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This article is the first in a four-part series designed to help readers build skills in finding scientific evidence and understanding how to use evidence-based knowledge to support decisions in clinical practice. This first paper explains how to use two quality resources, the Trip Database and the Clinical Queries feature in PubMed, to answer patients' questions. A case scenario is provided to explain how to use each resource, and figures illustrate each step in the search process. The paper concludes with a clinical decision based on the scientific evidence discovered.

Schlagwörter: clinical decision-making, levels of evidence, PubMed Clinical Queries, secondary evidence, Trip database

Searching PubMed and other citation resources is an essential component of evidencebased practice. The inability to create effective searches can impact the ability of clinicians to incorporate evidence into their decision-making processes. This paper describes four strategies to help clinicians find evidence efficiently through targeted, well-designed literature searches.

Schlagwörter: Boolean, evidence-based practice, Google Scholar, PICO, PubMed

A well-designed question in a search for clinical information maximizes the potential for discovering the most useful and relevant information. The PICO format was designed for exactly this purpose-to make the search for answers easier and faster, especially for those times when questions arise in the context of a patient visit. PICO (patient/population, intervention, control/ comparison, outcome) is the most well-known framework for designing good questions, with PIO, PIC, and PICOT as common adaptations of the basic PICO structure. Several examples of question development and framing are provided that are drawn from the clinical literature, as well as suggested best practices for integration with the patient record.

Schlagwörter: clinical decision-making, clinical information needs, evidence-based dentistry, evidence-based health care, PICO, question development, search filters, searching skills, systematic review methods

Diabetes mellitus has reached epidemic proportions in many countries. In the United States, more than 8 million cases remain undiagnosed. Current research demonstrates that the addition of blood glucose testing in the dental office has the ability to detect a clinically significant number of undiagnosed cases of diabetes. Studies have also shown that patients are generally accepting of the practice and may be willing to pay nominal out-of-pocket fees to have the screening performed within a dental setting. Since dental practitioners may have access to patients who do not seek out regular medical care, incorporating blood glucose screenings into dental practice may assist in earlier detection of diabetes. Earlier detection may help improve patients' overall health, reduce morbidity and mortality rates, and reduce health care costs associated with diabetes and comorbid conditions.

Schlagwörter: diabetes, blood glucose testing, medical testing in dental practice

Background: Dental caries is a chronic oral disease that continues to be highly prevalent in the United States and globally, and it remains a public health concern. Community water fluoridation, considered a key public health strategy for the prevention of dental caries, was initiated in the United States in 1945 and is currently practiced in approximately 25 countries.
Clinical question: What is the effect of water fluoridation (artificial or natural) on tooth decay prevention and on fluorosis of tooth enamel?
Summary and methods: A wide range of databases were searched from 1975 to February 2015 by two review authors, independently and in duplicate, who screened the titles and abstracts using a selection criteria and a validity assessment checklist.
Critical appraisal: The review process met the criteria of a well-conducted systematic review following established research requirements. The data for this review were extracted from prospective studies. The majority of the studies were conducted prior to 1975. The applicability of the results to current lifestyles is unclear because 71% of the studies examining tooth decay were conducted before fluoride toothpastes and other preventive measures were widely used in many US communities. The review for risk of bias showed 97% of the studies were at high risk for bias, which reduces the overall validity of the results.
Practical implications: Although findings from studies have demonstrated the effectiveness of fluoride at reducing the level of dental caries in adults and children, the studies in this review provided insufficient data to determine the effect that stopping water fluoridation programs would have on caries levels. More research is needed to understand the contribution of fluoride from sources other than water.

Background: This article critically appraises a systematic review that was conducted in 2015 to evaluate implant survival, postoperative infection, and marginal bone loss (MBL) in smokers compared with nonsmokers.
Clinical question: In patients undergoing implant placement, are smokers at higher risk than nonsmokers for implant failure, postoperative infection, and MBL?
Summary of methods: An electronic search was conducted in three databases in addition to hand searching without date or language restrictions. All studies, including randomized controlled trials, nonrandomized controlled trials, and retrospective studies, were included in this review. Results were expressed as risk ratios for dichotomous outcomes (implant failure and postoperative infection) and as mean differences for continuous outcomes (MBL). A fixed-effects model was used in meta-analysis for studies with low homogeneity, while a random-effects model was used for those with high heterogeneity.
Critical appraisal: The review met all requirements on the AMSTAR checklist. The overall quality of evidence is low, as the review includes both randomized and nonrandomized trials in addition to retrospective studies. Due to the many uncontrolled confounders, the results should be interpreted with caution.
Practical implications: Because of the possible association between smoking and increased rates of implant failure, postoperative infection, and MBL, caution is warranted when considering dental implants in patients who smoke.

Background: This article critically appraises a systematic review that was conducted in 2014 to investigate the effects of prophylactic antibiotic regimen on implant failure rates and postoperative infection when performing dental implant treatment in healthy individuals.
Clinical question: Does a prophylactic antibiotic regimen before implant placement in healthy patients have an effect on the prevention of implant failure and postoperative infection in comparison with those not receiving an antibiotic?
Summary of methods and results: Manual, ongoing trials and electronic searches without time or language restrictions were conducted. Three authors independently screened titles and abstracts of the identified studies. Related data were extracted by the review authors. The risk of bias of the studies was assessed. Implant failure and postoperative infection were the outcomes measured. The meta-analysis revealed that use of antibiotic prophylaxis significantly affected the implant failure rates (relative risk [RR] of 0.55, P = .0002). The number needed to treat (NNT) to prevent one patient having an implant failure was 50. There were no significant effects of prophylactic antibiotics on the occurrence of postoperative infections in healthy patients receiving implants (P = .520).
Critical appraisal: The results of this review should be interpreted with caution, as they include seven studies that were considered at high risk of bias with the presence of uncontrolled confounding factors.
Practical implications: The use of prophylactic antibiotics may decrease the rate of implant failure, but care should be taken as the emergence of resistant pathogens may result from indiscriminate use of antibiotics in addition to potential adverse effects.

Background: This article critically appraises a cross-sectional study that was conducted to investigate whether an association exists between dental utilization and Oral Health Literacy (OHL).
Clinical question: In participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in North Carolina, is dental utilization associated with OHL?
Summary of methods: The authors conducted a cross-sectional study using data collected through the Carolina Oral Health Literacy Project from nine sites of the WIC Program in seven North Carolina counties. OHL was determined by the validated 30-item Rapid Estimate of Adult Literacy in Dentistry test. A question from the National Health and Nutrition Examination Survey was employed to assess dental utilization. Multiple linear regression was used to analyze the association between OHL and covariates. Ordinary least square regression was performed to determine whether an association exists between dental utilization and OHL.
Critical appraisal: This was a well-constructed cross-sectional study employing validated survey techniques. The strength of the findings was considered low to moderate given the size of the study and its design. The generalizability is limited due to selection bias, as only females of low socioeconomic status and who spoke English were included in the study. Another limitation was that there was no distinction made for the nature of the dental utilization (emergency versus regular maintenance).
Practical implications: The results showed no association between dental utilization and OHL. These findings are of importance as there are no other studies showing this directional relationship, or lack thereof, explicitly. Further research is needed to analyze this relationship while taking the nature of the dental utilization into consideration.

Background: Uncontrolled diabetes is a known risk factor for periodontal disease, and evidence suggests that periodontal disease may have an adverse effect on glycemic control.
Clinical question: In patients with Type 1 or Type 2 diabetes, does periodontal therapy, compared with no active treatment or usual care, improve glycemic control?
Summary of methods and results: Seven databases were searched for randomized controlled trials (RCTs), and hand searching of journals and reference lists was performed. Two authors independently screened titles and abstracts, extracted data, and assessed risk of bias, with a third author arbitrating disagreements. Thirty-five RCTs were identified. These studies either compared nonsurgical periodontal therapy, defined as scaling and root planing (SRP) or mechanical therapy, with usual care or no active treatment, or compared different types of nonsurgical periodontal therapy. Low-quality evidence indicates that SRP reduces mean glycosylated hemoglobin (HbA1c) by 0.29 percentage points (95% confidence interval [CI]: 0.48% to 0.10% lower) at 3 to 4 months, and 0.02 percentage points (95% CI: 0.20% lower to 0.16% higher) at 6 months. The addition of antimicrobial therapy did not provide added benefit to SRP alone, with 0.00 percentage points change in HbA1c at 3 to 4 months (95% CI: 0.22% lower to 0.22% higher), and 0.04 percentage points lower HbA1c at 6 months (95% CI: 0.41% lower to 0.32% higher).
Critical appraisal: This was a well-conducted systematic review. However, pooling of data when comparing SRP with SRP + antimicrobial was questionable due to clinical heterogeneity (differing antimicrobial therapies). The overall evidence is of low quality. The magnitude of effect of SRP in reducing HbA1c is minor, short-term, and has unclear clinical relevance.
Practical implications: Because of concerns with the low quality of evidence and uncertain magnitude of effect, the results of this systematic review should be interpreted with caution. It remains prudent to manage periodontal disease in all patients, especially those with risk factors such as diabetes, as a recent American Dental Association (ADA) systematic review and guideline suggests that SRP is an effective management strategy for periodontal disease. However, it is uncertain if nonsurgical periodontal treatment will have a sustained and significant impact on glycemic control in patients with diabetes.

Background: This article critically appraises a systematic review conducted in 2015 that aimed to determine the antimicrobial efficacy of chlorhexidine varnishes (CHX-V) on mutans streptococci (MS) in patients undergoing orthodontic treatment with fixed appliances.
Clinical question: Does the application of CHX-V significantly decrease MS in patients undergoing orthodontic treatment with fixed appliances?
Summary of methods: An electronic systematic search up to September 2014 was conducted using Ovid MEDLINE, Scopus, and EMBASE. In addition, Google was searched for possible articles that met the inclusion criteria. Risk of bias was assessed independently by three reviewers.
Critical appraisal: This review met most requirements on the AMSTAR checklist. The overall quality of evidence was low as it included randomized and controlled studies as well as noncontrolled studies. Many confounding variables including CHX-V concentration, time of application, and frequency of application necessitate that the results be interpreted with caution.
Practical implications: The use of CHX-V to reduce the activity of cariogenic bacteria and caries incidence in patients with fixed orthodontic appliances may be beneficial despite weak evidence.

Background: This article critically appraises a systematic review conducted in 2015 that evaluated the efficacy of air polishing on peri-implant disease when compared with other nonsurgical treatments.
Clinical question: In patients with peri-implant disease, what is the efficacy of air polishing on changing signs of inflammation compared with other nonsurgical treatments?
Summary of methods and results: Electronic and manual searches in related journals were performed. Two authors independently screened titles and abstracts of the identified studies, assessed the methodologic quality, and performed data extraction of the identified studies. Prospective randomized controlled trials (RCTs) or nonrandomized controlled clinical trials (CCTs) that compared air polishing with control measures for the nonsurgical treatment of peri-implant disease were included. Bleeding on probing (BOP) score was defined as the primary outcome, and a secondary outcome was the change in pocket depth (PD). The pooled data of two RCTs revealed that the weighted mean difference in BOP reduction between the two groups was −23.83% ± 12.06 (P = .048; 95% confidence interval [CI] = −47.47 to −0.20). The weighted mean difference in PD reduction was −0.37 mm ± 0.23 (P = .119; CI = −0.84 to 0.096).
Critical appraisal: This systematic review had a limited number of trials, which were judged to be at high risk of bias with small sample size. Therefore, the results should be interpreted with caution.
Practical implication: To maintain healthy tissues around dental implants, it is important to institute an effective preventive program. When a pathologic condition of the tissues around implants is diagnosed, a therapeutic intervention starting with simple nonsurgical modalities (eg, air polishing) should be initiated as soon as possible.

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.