no abstract available

This article provides a brief overview of the UTHSCSA CATs Library. This searchable online database provides oral health care practitioners with evidence-based answers to common clinical questions. The library contains over 1,000 concise answers to focused clinical questions that have been researched by UTHSCSA students, residents, and faculty teams as part of the school's Evidence- Based Practice Program. The CATs online database allows visitors to browse or search by keyword, print or email the document, and comment on the conclusions of the CAT. This provides a mechanism to keep the CATs up to date by incorporating the latest evidence. The UT CATs have become a worldwide resource for up-to-date, concise answers to focused oral health questions, and they provide a mechanism to bridge the gap between published clinical research and clinical practice. Selected CATs from the UTHSCSA CATs Library will be published in the International Journal of Evidence-Based Practice for the Dental Hygienist.

Keywords: academic detailing, Critically Appraised Topics, evidence-based dentistry, evidencebased practice, teaching EBD, Trip Database, UTHSCSA

• Research is the process by which we generate knowledge.
• Different research questions require different study designs.
• Bias is the systematic deviation of the findings of studies from the truth. All studies can be subject to bias, but some study designs are more prone to bias than others.
• It is important that researchers take steps to reduce bias so that studies are valid and their results trustworthy. When testing whether a treatment is effective, a randomized controlled trial is the best design to minimize bias.
• Odds ratios, risk ratios, and number needed to treat are ways of expressing results in quantitative studies.
• Critical appraisal is the process of carefully and systematically examining a research report to judge its trustworthiness, make sense of the results, and assess the relevance of the findings in a particular context.
• Systematic reviews systematically collect, appraise, report, and, where appropriate, combine all the trustworthy scientific evidence from individual studies. They are therefore the best study design to choose to inform decisions.
• The Critical Appraisal Skills Programme aims to help people develop the necessary skills to make sense of scientific evidence and has produced appraisal checklists covering the validity, results, and relevance of different study designs, including systematic reviews. You can download these free of charge at www.casp-uk.net.

Periodontal disease is a multifactorial infection that is initiated by bacteria and is influenced by the host response and risk factors. The primary goal of prevention is to remove the causative agent and prevent an inflammatory reaction. Daily biofilm control is the responsibility of the individual. However, the dental professional is a key factor in the success of good oral hygiene through evidence-based recommendations and adequate and effective counseling. Toothbrushes have evolved with several choices that provide a favorable outcome when used correctly and consistently. Power brushes have a slight edge over manual brushes, and the bristle design does not seem to be significant overall. Interdental cleaning is a key factor in reducing inflammation. People who can achieve a high standard of flossing technique may see benefits, but there are other devices that have shown effectiveness and in some cases superiority, such as interdental brushes, wood sticks, and water flossers. Interdental brushes are currently the best choice for periodontal maintenance patients with spacing that can accommodate the brush design. The addition of a chemical mouthrinse or dentifrice is also beneficial when added to an oral care regimen. Although there is statistical evidence for most products, in some cases the clinical impact is unknown based on the relatively small changes or differences in gingival inflammation over the course of the study. This article reviews and summarizes the evidence of recent systematic reviews and meta-analysis that have provided information on the effectiveness of products and formulations that achieve the desired outcome of reduction of inflammation as measured by the absence of bleeding.

Keywords: antigingivitis, antiplaque, behavior change, floss, interdental brushes, toothbrushes, mouthrinse, psychologic approaches, toothpaste, water flosser, wood sticks

Lasers are used in medicine and dentistry for a variety of indications. They have also been suggested as an adjunct to scaling and root planing in patients with periodontitis. Based on clinical research, it has been shown that there is no evidence to support the adjunctive use of the water-cooled Nd:YAG laser. The effect of subgingival debridement as performed in the initial phase of periodontal therapy as well as during periodontal maintenance care was not improved when followed by the application of this laser. Extensive literature reviews supported these findings regarding several laser types. The results taken together support a firm statement to refute the use of laser technologies as adjuncts to nonsurgical periodontal treatment based on the lack of additional clinical efficacy and the considerable investment involved.

Keywords: diode lasers, Nd:YAG, nonsurgical therapy, periodontitis

Background: This article is a critical appraisal of a 2015 systematic review with meta-analysis updating a 2002 review on the efficacy of fluoride gels for preventing dental caries in children and adolescents.
Clinical question: How effective and safe is the use of fluoride gel for the prevention of tooth decay in children and adolescents compared with placebo or no treatment?
Summary of methods: Studies were obtained from the Cochrane Oral Health Group Trials Register, both MEDLINE and EMBASE via OVID, CINHAL via EBSCO, LILACS and BBO via BIREME Virtual Health Library, ProQuest Dissertations and Theses, and Web of Science Conference Proceedings. Issue 11 of the 2014 Cochrane Library was found via Cochrane Central Register of Controlled Trials (CENTRAL). Ongoing trials were searched using the WHO International Clinical Trials Registry Platform and ClinicalTrials. gov (2014). References within the articles generated from searching the aforementioned databases were searched, and select contact was made for the initial review (2002) but not this update (2015). Evidence quality was assessed utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Meta-analyses were conducted.
Critical appraisal: This was a well-conducted systematic review based on current standards. The AMSTAR tool showed that all necessary characteristics for a review of acceptable quality were present. Selection, data extraction, and bias assessment were done in duplicate. Publication bias was found to be high in 71% of studies or otherwise unclear.
Practical implications: Conclusions remain the same in 2015 as in 2002. There is a 28% decrease in the risk for caries in the permanent dentition with the application of fluoride gel, though the evidence is of moderate quality at best.

Background: This systematic review updates the bruxism management review by Lobbezoo et al published in 2008 and focuses on the most recent literature on the management of sleep bruxism.
Clinical question: Is there currently enough statistically significant evidence to support a standard of care approach for sleep bruxism management in adult bruxers?
Summary of methods: A systematic review of randomized controlled trials (RCTs) published in English from June 2008 to March 2015 was conducted using the medical databases MEDLINE and Scopus.
Critical appraisal: Structured reading of the included articles showed a high variability of topics, designs, and findings. The risk of bias for RCTs was low to unclear, but the before-and-after studies had methodologic limitations.
Practical implications: Clinicians should be cautious and utilize a conservative approach, as current evidence reviews show that there is no standard of care protocol for the management of sleep bruxism in adults.

Background: This article critically appraises a Cochrane systematic review that was conducted in 2012 to identify and evaluate the different interventions for treating peri-implantitis around dental implants.
Clinical question: What are the most effective interventions for the management of peri-implantitis?
Summary of methods and results: Comprehensive electronic (Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE, and EMBASE) and manual searches without time or language restrictions were conducted. Two authors independently screened titles and abstracts, assessed the methodologic quality of the trials, and performed data extraction of the identified studies. Excluded studies were recorded with reasons for exclusion. Nine randomized controlled trials (RCTs) were included: Five trials compared different nonsurgical interventions, one trial compared adjunctive treatments to nonsurgical interventions, two trials compared different surgical interventions, and one trial compared adjunctive treatments to surgical interventions.
Critical appraisal: The review met all requirements on the AMSTAR checklist. Of the nine RCTs included, three trials were judged to be at an unclear risk of bias and six trials were judged to be at high risk of bias. Thus, the result of this review should be interpreted with caution.
Practical implications: The management of peri-implant infections should focus both on control of infection in the lesion (decontamination of the implant surface) and surgical regeneration of lost supporting tissue depending on the clinical situation. Devoting more interest to the prevention of peri-implant disease will save time and effort.

Background: Despite the recognition that periodontitis and its cofactors are known to be associated with coronary heart disease (CHD) and stroke, there is limited knowledge regarding these associations in new cardiovascular events among patients with existing CHD.
Clinical question: Are periodontitis, or particular associated confounders, independent risk factors for new cardiovascular events in patients with coronary heart disease?
Summary of methods: The authors conducted a cohort study of 942 inpatients with CHD with 1-year follow-up to determine the strength of associations between periodontitis, associated confounders, and new cardiovascular events. Adjusted hazard ratios (HRs) used for cofactors were age, sex, body mass index, smoking, oral health, systemic diseases, bacterial species, and expression of IL-6c.-174G/C genotypes.
Critical appraisal: Evidence for associations between periodontal disease and associated confounding factors with CHD has been well established. This study finds no significant association between these factors and new cardiovascular events apart from the association between the lack of interproximal cleaning and new cardiovascular events. These results should be considered with some caution.
Practical implications: This study further highlights the multifactorial influences on cardiovascular events and in particular the impact of oral health on general health. Practitioners should promote the benefits of interproximal cleaning as an adjunct to other oral hygiene practices.

Background: This article is a summary and critical appraisal of a systematic review published in 2015 on nonsurgical treatment of dentin caries in preschool children.
Clinical question: What is the effect of nonsurgical treatment of dentin caries in primary teeth of preschool children?
Summary of methods: The authors conducted a systematic review searching three databases for studies from 1947 to June 2014. Screening, quality assessment, data extraction, and grading of the evidence were done in duplicate.
Critical appraisal: There was limited evidence, based on three randomized controlled trials, that silver diamine fluoride applied once or twice a year was substantially more effective in arresting dentin caries in primary teeth when compared to fluoride varnish applied four times a year, glass-ionomer fillings placed once a year, or no intervention. There was also limited evidence that a school program of oral health education and daily brushing with fluoridated toothpaste was more effective in arresting caries than no intervention.
Practical implications: The evidence for arresting tooth decay in preschoolers is limited. Because early decay can have serious consequences for the health and development of young children worldwide, there is a great need to identify ways to treat tooth decay that are effective, affordable, and appropriate for as many settings as possible. Silver diamine fluoride, a therapy used for several decades in many countries outside of the United States, might increase the options for effective management of tooth decay in very young children who face multiple barriers to dental care.

Background: Nonsurgical treatment options for patients with moderate periodontitis include traditional scaling and root planing performed via quadrants at weekly intervals (SRP-Q) or full-mouth disinfection (FMD) to prevent local reinfection of treated sites. Current evidence suggests that clinical outcomes are similar for SRP-Q and FMD. However, differences in fear and anxiety among patients undergoing SRP-Q compared with FMD are unknown.
Clinical question: In patients with moderate chronic periodontitis, does one-stage full-mouth disinfection compared with scaling and root planing by quadrant impact fear, anxiety, and pain?
Summary of methods and results: A 6-month randomized clinical trial was conducted in Brazil to evaluate differences in clinical outcomes (probing pocket depth [PD], clinical attachment level [CAL], plaque index [PI], gingival index [GI]), fear, anxiety, and pain among patients with moderate periodontitis treated with SRP-Q or FMD. There were no significant differences between SRP-Q and FMD in fear, anxiety, pain, or clinical outcomes.
Critical appraisal: This study was adequately designed and powered to detect differences between SRP-Q and FMD. However, there are methodologic uncertainties regarding blinding, recall bias, and measurement of fear and anxiety. In addition, other studies report conflicting results regarding pain resulting from FMD.
Practical implications: Given that this study reports similar clinical outcomes as well as similar levels of fear, anxiety, and pain for both SRP-Q and FMD, patient preferences should be considered, especially in regard to time constraints and compliance in completing the therapies.

Background: Mouthwashes are a safe and effective delivery system for antimicrobials. They have also been evaluated for antiplaque properties and as such have been the subject of considerable research. There is clinically relevant evidence to suggest that mouthrinses containing active agents can be effective against dental caries. However, there is a lack of studies determining the comparative effect of these mouthrinses in patients with and without dental caries.
Clinical question: What is the effectiveness of fluoride-, essential oils (EO)-, and chlorhexidine (CHX)-containing mouthrinses on dental plaque and gingivitis and what is their relative efficacy in patients with and without dental caries?
Summary of methods: The authors conducted a randomized, controlled, double-blind crossover clinical trial to assess the effect of mouthwashes on dental plaque accumulation and gingivitis. The primary interest was the comparison between fluoride, EO, CHX, and saline as a negative control in dental caries and cariesfree groups. Participants used the products for 7 days.
Critical appraisal: The population ranged from 12 to 44 years, with both adolescent and adult participants who most likely had different dental profiles and needs. Furthermore, the study with only 15 participants per group can be considered as poorly powered. No details on the number and location of caries lesions were provided. Relevant references are also missing. Evaluating the data, it seems unlikely that no carryover effects occurred because large differences at the start of each leg were observed for both plaque index and gingival index scores.
Practical implications: All three mouthrinses had a significant impact on plaque accumulation and gingival inflammation, but due to several significant weaknesses of the study design, the results of the study are questionable. The effect was more pronounced in caries-free subjects. It is therefore recommended to treat caries before a chemical antiseptic therapy is initiated.

Background: The rise of overweight and obesity has been a great concern in many countries among different professionals in medical and dental fields. This article critically appraises a 2015 systematic review with meta-analysis that investigates an association between overweight or obesity and the prevalence of periodontitis.
Clinical question: Is weight gain leading to overweight or obesity associated with the incidence of periodontitis in adults?
Summary of methods: Four databases were searched for eligible studies up to and including February 2015. After the screening, quality assessment and data extraction of evidence was done in duplicate. The authors conducted meta-analysis of five cohort studies.
Critical appraisal: Based on current research standards, this was a well-conducted systematic review with meta-analysis. Assessment using the AMSTAR critical appraisal tool indicated that most of the necessary qualities of a credible review were present. However, the search strategy did not include hand-searched journals or gray literature.
Practical implications: Although the study results are statistically significant, they lack the magnitude to show a strong association between overweight or obesity and the incidence of periodontitis.

Background: This article critically appraises a Cochrane systematic review that was conducted in 2013 to assess the benefit of preoperative antibiotics in preventing early implant failure and to determine which type of antibiotic and dosage is the most effective.
Clinical question: Are there beneficial or harmful effects of systemic prophylactic antibiotics at dental implant placement vs no antibiotic or placebo administration? If antibiotics are beneficial, which type, dosage, and duration is the most effective?
Summary of methods: The author performed a comprehensive search using the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE databases up to June 17, 2013 with no language or date restrictions. Assessment of the risk of bias of the trials and data extraction were conducted independently and in duplicate by two review authors. Results were expressed as risk ratios (RRs) using a random-effects model for dichotomous outcomes with 95% confidence intervals (CIs).
Critical appraisal: The review met all the requirements of the AMSTAR checklist. The overall evidence quality is moderate, as they included six RCTs, three of which were at high risk of bias. The other three RCTs were at low risk of bias. In addition, the results of all studies were homogeneous, and this strengthens confidence in the results.
Practical implications: Preoperative antibiotics as prophylaxis may be considered for dental implant treatment even for healthy persons because this will reduce the possibility of early implant failure.

Background: Bisphosphonates (BPs) improve the quality of life of cancer patients and reduce osteoporotic fractures. However, an adverse side effect of BPs is medication-related osteonecrosis of the jaws (MRONJ), which has been noted following tooth extraction with variable published occurrence rates. This systematic review evaluates the occurrence rate of MRONJ following tooth extraction during different BP treatments for oncology and osteoporosis.
Clinical question: In patients treated with an antiresorptive drug (ARD) for osteoporosis or oncologic reasons, what are the occurrence rate and risk indicators of MRONJ after dental extraction?
Summary of methods and results: An electronic search of three databases until June 4, 2014 with manual searches was made, and methods were adhered to standard guidelines (PRISMA). The occurrence rate of MRONJ was 3.2% for intravenous (IV) BPs treating cancers from 10 studies (564 patients) in contrast to 0.15% for oral BPs treating osteoporosis from 8 studies (2,098 patients). Possible risk indicators for MRONJ were IV zoledronic acid, chemotherapy, and previous bone infections. Adjusted extraction procedures, alveolectomy, or the use of a biologic membrane were suggested to lower the MRONJ occurrence rate for IV BPs treating cancer patients.
Critical appraisal: This was a well-conducted systematic review with limited evidence. The review estimates a higher MRONJ occurrence rate in BP treatment of cancer patients than in BP treatment of osteoporosis. The meta-analysis results may be weakened by the inclusion of different study types, which were mostly case series with a few prospective clinical trials and cohorts.
Practical implications: The management of patients treated with BPs, especially cancer patients, includes dental care and oral hygiene instructions to prevent bone infections. Dental extraction with an adjusted surgical protocol is suggested to reduce the occurrence of MRONJ in cancer patients taking BPs, especially if risk indicators are present.

The University of Texas Health Science Center at San Antonio (UTHSCSA) Oral Health CATs Library was established in 2011, with the aid of an NIH grant, as a component of the Dental School's Evidence-Based Practice Program. Each CAT provides a concise answer to a focused clinical question based on the most recent and highest level of evidence. This online searchable library contains over 950 CATs written by student/faculty teams, and about 150 new CATs are added annually. The CATs are indexed by the British Trip Database, which allows users to search over a large number of evidence-based sites. The journal is grateful to UTHSCSA for sharing these CATs with our readers.