J Oral Maxillofac Surg 66:973-986, 2008

Evidence-Based Oral and Maxillofacial Surgery

Panayiotis A. Kyzas, PhD*
Purpose: The amount and quality of research evidence in oral and maxillofacial surgery (OMFS)

journals have never been evaluated. The current study aims to empirically assess the evidence available in this literature. Materials and Methods: The main (Database 1) and neighboring (Database 2) journals of OMFS were manually screened over a 3-year period (2004 to 2006). The types and designs of articles were recorded. The identied randomized, controlled trials (RCTs) were further evaluated for issues of reported methodological quality. Results: In total, 3,487 articles were analyzed. Meta-analyses and RCTs were very rare. Only 2 meta-analyses of RCTs were identied, and RCTs represented a mere 1.3% in each database. Case series and case reports were the dominant article types (1,388, or 59%, for Database 1; 686, or 60.1%, for Database 2). Basic research, laboratory and animal studies, had an important share of 19% and 15.4% in both databases, respectively. An equally high percentage was recorded for nonsystematic reviews, personal views, expert opinions, and editorials (15.9% and 19% for Database 1 and Database 2, respectively). Of the 46 identied RCTs, most of them enrolled less than 100 patients (37 studies, or 80.5%). The majority of them did not describe the randomization mode (27 studies, or 59%), did not present power calculations (31 studies, or 67.4%), and did not report allocation concealment (38 studies, or 79.5%). Almost half of them made no mention of masking (22 studies, or 48%), and only one third described withdrawals during follow-up (15 studies, or 32.6%). Conclusion: The OMFS literature suffers from a relative shortage of high-quality evidence. More, larger, adequately powered, and better reported RCTs are warranted. 2008 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 66:973-986, 2008 Oral and maxillofacial surgery (OMFS) is a unique specialty that deals with the gentle structures of the facial skeleton, the oral cavity, and the neck and that requires a dual qualication in medicine and in dentistry in many countries.1-5 It is a demanding specialty that covers a broad spectrum extending from oral malignancies, facial injuries, facial deformities, and facial reconstruction to impacted third molars, dental implants, and generally minor oral surgery.2,3,6 Evidence-based medicine is the conscientious, explicit, and judicious use of the current best evidence in decision-making about patients care.7-11 Its practice means integrating the best available external evidence
*Senior House Ofcer, Department of Oral and Maxillofacial Surgery, Ninewells Hospital, National Health System Tayside, Dundee, Scotland, United Kingdom. Address correspondence and reprint requests to Dr Kyzas: Department of Oral and Maxillofacial Surgery, Ninewells Hospital, National Health System Tayside, Simpson Ave 67, DD2 1UZ Dundee, Scotland, United Kingdom; e-mail: kyzasp@hol.gr
2008 American Association of Oral and Maxillofacial Surgeons

0278-2391/08/6605-0022$34.00/0 doi:10.1016/j.joms.2008.01.024

from research with an astute clinicians assessment of the individual patients circumstances.8,10-12 Doctors should use both clinical expertise and external research evidence; neither alone is enough.8,10-13 Otherwise, practice risks becoming tyrannized by evidence, because even excellent external average evidence may be inappropriate for an individual patient. Without the current best evidence, practice risks becoming unjustied and entirely subjective, to the detriment of patients. Studies that provide external evidence for clinical practice applications can be grouped according to their design.14-17 Although the design to get the best evidence depends mainly on the question we want to answer,10 it is generally accepted that meta-analyses and systematic reviews of randomized, controlled trials (RCTs), and RCTs themselves, have the greatest relevance to the clinical setting.14,16-18 Randomized, controlled trials and meta-analyses, when designed, executed, and reported properly, are considered to provide the highest-quality evidence for the majority of clinical or interventional questions. Cohort studies, case-control studies, case series, basic and laboratory research, expert opinions, and nonsystematic reviews comprise the remaining research designs.17,18 973

974 The amount and quality of the evidence used in OMFS have not been previously evaluated. The purpose of the present study was to generate empirical evidence for the research evidence available in OMFS journals.

WE CAN DO BETTER

Materials and Methods

TARGETED JOURNAL POPULATION

The main journal population included in the current study consists of the 5 main specialty journals in OMFS (Database 1), listed according to their Index Medicus abbreviations (Br J Oral Maxillofac Surg, Int J Oral Maxillofac Surg, J Craniomaxillofac Surg, J Oral Maxillofac Surg, and Oral Oncol). Other journals that often publish OMFS-related articles, according to the ISI/Thompson Scientic classication, were also considered (Database 2), listed according to their Index Medicus abbreviations (Br Dental J, Cleft Palate, Cranio, Int J Oral Maxillofac Implants, J Am Dent Assoc, J Oral Pathol Med, and Oral Surg Oral Med Oral Pathol). One journal from the allied specialties of plastic surgery and otolaryngology was randomly selected and included in Database 2, to serve as a control (Plast Reconstr Surg).
DATA EXTRACTION

The contents of every issue of the journals in Database 1 were screened manually. The screening covered a 3-year period from January 1, 2004, to December 31, 2006. The types of articles included in each issue were recorded. The following types were considered: meta-analyses of RCTs, other meta-analyses, RCTs per se, practice guidelines, cohort studies, casecontrol studies, case series, case reports, basic research, laboratory studies, animal studies, articles not presenting data (personal views, editorials, and opinions), and nonsystematic reviews. Because the distinction between some of the epidemiologic designs and basic or laboratory research is difcult, when a study presented patients data, it was included in the relevant epidemiologic design, regardless of whether it also addressed basic research questions. Inclusion in each category was usually done based on the article title and abstract. However, when this was not sufciently clear, the full text was used for clarication. Notices, announcements, memorials, advertisements, letters to the editor, and summaries of conference abstracts were excluded. The same evaluation was performed for Database 2, but this was limited to the OMFS parts of these journal issues.
DATA ANALYSIS

summed up for each database. Studies considered to present the best clinical evidence (meta-analyses and RCTs) were further evaluated. In particular, in each of these studies, the question of interest, the specialty subcategory (minor oral surgery, trauma, orthognathic surgery, oncology, clefts, temporomandibular joint, and reconstruction), and the study conclusion, as stated in the article, were recorded. Randomized, controlled trials were further assessed for their reported quality. Items that were used in previous studies19-22 were examined. These included a report of the study sample size, a description of inclusion and exclusion criteria, a description of the randomization mode, the performance of power calculations, allocation concealment (whether the sequence of allocation was concealed from those assigning participants to intervention groups), reports on withdrawals and reasons for withdrawing, and masking (blinding of patients, surgeons, or assessors of outcomes). In addition, the results of each RCT were categorized as showing statistically signicant efcacy, no difference between arms, or signicant harm for a tested experimental intervention versus the intervention of the control arm. In theory, more, larger, and adequately powered and better reported RCTs in OMFS may have been published in general surgical and medical journals, with a wider audience, rather than in the specialty journals. To account for this possibility, 5 leading journals in surgery (Ann Surg, Ann Surg Oncol, Arch Surg, Br J Surg, and Surgery) and in medicine (Ann Intern Med, Br Med J, JAMA, Lancet, and N Engl J Med) were screened for the same time period. The purpose was to identify RCTs in OMFS-relevant topics (if any), and compare them with the RCTs published in specialty journals.

Results
In total, 3,487 published articles were screened (2,355 in Database 1, and 1,132 in Database 2). As seen in Figure 1 and Table 1, articles presenting highquality evidence (meta-analyses and RCTs) were very rare exceptions. Only 2 meta-analyses of RCTs were identied. Individual RCTs represented a mere 1.3% in each database. Case series and case reports were the dominant article types (1,388, or 59%, for Database 1; 686, or 60.1%, for Database 2) (Table 1, Fig 1). Basic research, and laboratory and animal studies, had an important share of 19% and 15.4% in both databases; an equally high percentage was devoted to nonsystematic reviews, personal views, expert opinions, and editorials (15.9% and 19% for Database 1 and Database 2, respectively). There was no statistically signicant difference for any article type between the

Results for the examined time period were entered in a table for each journal separately, and afterwards, results from different journals were

PANAYIOTIS A. KYZAS

975

FIGURE 1. Evidence pyramid for the main specialty journals (Database 1) and for the close neighboring journals (Database 2). Numbers and percentages of individual article types are listed in Table 1. RCT, randomized, controlled trial. Panayiotis A. Kyzas. We Can Do Better. J Oral Maxillofac Surg 2008.

2 databases (in all cases, 2 P .05). The percentage of article types published in the control journal (Plast Reconstr Surg) was no different from the overall ndings for Database 2 (Appendix). Also, a significant number of letters to the editor were noted and excluded from analysis (data not shown). A detailed list of article types per journal is included in the Appendix. One of the 11 identied meta-analyses overlapped with another meta-analysis, and this reduced even more the percentage of these studies. Four metaanalyses (40%) were inconclusive (according to the conclusions of the articles) because of an insufcient amount and quality of primary studies (Appendix). Minor oral surgery, clefts, and oncology were the most common specialty subcategories employing meta-analyses, with the same percentage for each (27.3%) (Table 2). The vast majority of the identied RCTs referred to minor oral surgery (32 articles, 70%), followed

by trauma (4 articles, 9%) and orthognathic surgery (3 articles, 7%) (Table 2). Most RCTs were of limited sample size (median, 50 patients); only 9 (19.5%) enrolled more than 100 patients. A few trials did not mention in detail their inclusion and exclusion criteria (6 studies, 13%). The majority of RCTs did not describe their randomization mode (27 studies, 59%), did not present power calculations for the necessary sample size (31 studies, 67.4%), and did not report allocation concealment (38 studies, 79.5%). Double-blind masking was applied in 18 studies (39%), whereas almost half of the RCTs did not mention anything about masking (22 studies, 48%). Twenty studies (43.5%) showed signicant efcacy for the intervention examined. However, more studies (24 studies, 52%) showed no difference between the examined interventions. Table 3 summarizes the quality characteristics of the identied RCTs; data per study are given in the Appendix.

Table 1. DISTRIBUTION OF ARTICLE TYPES AMONG THE 2 JOURNAL DATABASES

Type of Study Meta-analyses of RCTs Meta-analyses (other) RCTs Practice guidelines Cohort studies Case-control studies Case series and case reports Basic research, laboratory and animal studies Personal views, editorials, and expert opinions Nonsystematic reviews Unclassied Total
Abbreviation: RCTs, randomized, controlled trials. Panayiotis A. Kyzas. We Can Do Better. J Oral Maxillofac Surg 2008.

Database 1 (%) 1 (0) 5 (0.2) 31 (1.3) 5 (0.2) 10 (0.4) 52 (2.2) 1,388 (59) 446 (19) 244 (10.4) 130 (5.5) 43 (1.8) 2,355

Database 2 (%) 1 (0.01) 4 (0.7) 15 (1.3) 1 (0.01) 4 (0.7) 24 (2.1) 686 (60.1) 175 (15.4) 156 (13.7) 60 (5.3) 6 (0.6) 1,132

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WE CAN DO BETTER

Table 2. SPECIALTY SUBCATEGORIES IN WHICH THE IDENTIFIED RCTS AND META-ANALYSES CAN BE INCLUDED

Specialty Subcategory Minor oral surgery Trauma Orthognathic surgery Clefts TMJ Oncology Reconstruction Unclassied

RCTs (n

46)

Meta-Analyses (n 11) 3 (27.3) 1 (9%) 1 (9%) 3 (27.3) 3 (27.3)

32 (70%) 4 (10%) 3 (6%) 1 (2%) 1 (2%) 3 (6%) 1 (2%) 1 (2%)

Abbreviation: RCTs, randomized, controlled trials; TMJ, temporomandibular joint. Panayiotis A. Kyzas. We Can Do Better. J Oral Maxillofac Surg 2008.

Only 1 OMFS-related RCT was identied across the screened general medical and surgical journals. Therefore, a comparison with the RCTs published in the specialty journals would be of little importance.

Discussion
The present study points to the rare presentation of hard and solid evidence among articles published in both the main and the neighboring journals of OMFS. Observational studies (case series, case reports, and laboratory studies) dominate this literature, whereas expert opinions (including nonsystematic reviews and editorials) appear 10 times more often than RCTs. The RCTs published in the examined journals tend to be limited in number, small, and underpowered, and they suffer from a number of methodological shortcomings. This might be an expected consequence, because less than half of the journals in both databases have endorsed the Consolidated Standards for Reporting of Trials (CONSORT)22 statement (Br Dental J, J Oral Maxillofacial Surg, J Oral Pathol Med, and Oral Oncol). The interpretation of ndings of the current study is quite difcult. Only 2 meta-analyses of RCTs could be identied out of 3,487 articles. Overall, almost half of the identied meta-analyses were inconclusive because of an insufcient amount and quality of primary studies. The vast majority of screened articles presented observations on case series, usually of limited sample. Observational studies are susceptible to major biases that limit their credibility, such as inadequate and selective reporting, a lack of power calculations, and poor design and execution.23-26 Ideally, data from large, well-designed, and well-presented case series are only sufcient to justify performing a randomized clinical trial.17,27 Usually the direct incorporation of such observational data into clinical prac-

tice is the exception,23,27 because nonrandomized studies, even with large sample sizes, may still introduce biases in assessing therapeutic interventions.28,29 The reader would expect a countable proportion of RCTs within the screened articles population to conrm or reject the issues raised by observational studies. However, the percentage of RCTs was negligible, and their reported quality was not optimal. Instead, the specialty journals host a signicant number of experts opinions. Individual clinical expertise alone is not enough to ensure the provision of the best possible care for patients.12,13 The number of RCTs published in this literature during the covered time period is very limited, considering the very broad spectrum of the specialty. These studies tended to be small and underpowered to detect differences between the compared arms, especially in the subcategory of minor oral surgery, where the examined outcomes are usually soft and susceptible to misinterpretation. Furthermore, several other quality parameters were not adequately reported in these RCTs. Allocation concealment was rarely ensured, power calculations were uncommon, the mode of randomization was inadequately described, and almost half of the studies mentioned nothing about masking. Similar problems, to the same extent, were previously described in the broader eld of surgery.20,30,31 In regard to another important issue, half of the published RCTs found no difference between the compared groups. This was often misinterpreted as evidence of equivalence (Appendix), as if both interventions seemed to be equally good in clinical practice. However, in a small trial, a lack of

Table 3. QUALITY CHARACTERISTICS OF THE REPORTING OF THE IDENTIFIED RCTS

Quality Characteristics Sample size 100 patients 100 patients Inclusion and exclusion criteria Randomization mode Power calculations Allocation concealment Withdrawals described Masking Double-blind Single-blind Not reported Results of experimental intervention Signicant efcacy No difference Signicant harm

All Trials (n 9 (19.5%) 37 (80.5%) 40 (87%) 19 (41%) 15 (32.6%) 8 (20.5%) 15 (32.6%) 18 (39%) 6 (13%) 22 (48%) 20 (43.5%) 24 (52%) 2 (4.5%)

46)

Abbreviation: RCTs, randomized, controlled trials. Panayiotis A. Kyzas. We Can Do Better. J Oral Maxillofac Surg 2008.

PANAYIOTIS A. KYZAS

977 audience of the publication of OMFS-related leading articles in other journals or databases. Some journals are already moving in this direction by reprinting abstracts of OMFS-related articles published elsewhere. Readers should be aware of the shortage of solid evidence within the specialty journals, and should expand their weekly journal list. The whole community of oral and maxillofacial surgeons should develop a novel research culture. We should turn away from the sterile presentation of the results of our practice and from debates and personal opinions. We should aim for the creation of collaborations that will set the questions, and will organize the design and execution of large-scale studies to provide the best possible research evidence. Other medical elds have already made signicant progress in this direction.36 In conclusion, the OMFS literature suffers from a relative shortage of high-quality evidence. More, larger, adequately powered, and better reported RCTs are warranted. Journals, authors, editors, and oral and maxillofacial surgeons should all cooperate in the achievement of this objective.

statistically signicant differences does not necessarily mean that the compared arms are equivalent.32,33 This is a common misunderstanding that leads to the adoption of potentially suboptimal treatments. There are several possible explanations about the lack of RCTs and other high-quality articles in the OMFS literature. Oral and maxillofacial surgery is a specialty with a very long training pathway and with heavy clinical duties for the surgeon after the completion of training. Thus, time demands during training and beyond are frequently overwhelming, and do not allow time for research, even for interested surgeons. Furthermore, in the majority of countries, there is no integrated PhD track available to most surgeons as is the case in medicine. Moreover, obtaining a research grant is a daunting task. Therefore, most of the effort is placed in clinical practice, and not in research. Some limitations of the current study should be noted. First, data extraction and interpretation were performed by only one person. However, the strict criterion of patients data presentation was applied for the separation of studies at the borders of epidemiology and basic research; thus, large misclassication bias is unlikely. Second, the evaluation was journal-centric, and a number of journals in allied specialties (eg, otolaryngology and plastic surgery) known to publish OMFS-related articles were unavoidably not screened. Searching for all OMFS-related articles would not be a realistic option, and the comparison of the 2 databases and the results for the control journal shows that one would expect no signicant differences. Furthermore, the search of leading journals in general surgery and medicine revealed only 1 OMFS-related RCT. It seems that these RCTs usually nd their way into the specialty journals. This comes as an indirect conrmation that the evaluation performed in the current study is representative of the OMFS literature in general, despite its journalcentric design. The results of the present study may lead to some recommendations on how to improve this situation. Editors should encourage both the execution and publication of studies that provide hard evidence and discourage opportunistic observational studies.26 Encouragement of prepublication protocol registration, endorsement of CONSORT,22 and other consortia such as the Quality of Reporting of Meta-analyses (QUOROM),34 reporting recommendations for tumor marker prognostic studies (REMARK),35 and Meta-analysis of Observational Studies in Epidemiology (MOOSE) is necessary now more than ever. Fast peer-review, rapid publication, and extended coverage of RCTs might motivate authors who seek immediate and broad visibility for their work. Moreover, editors should shoulder the responsibility to inform their

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philia by using tranexamic acid mouthwash. Br Dent J 198:33, 2005 Abu-Serriah M, Critchlow H, Whitters CJ, Ayoub A: Removal of partially erupted third molars using an erbium (Er):YAG laser: A randomised controlled clinical trial. Br J Oral Maxillofac Surg 42:203, 2004 Joshi A, Parara E, Macfarlane TV: A double-blind randomised controlled clinical trial of the effect of preoperative ibuprofen, diclofenac, paracetamol with codeine and placebo tablets for relief of postoperative pain after removal of impacted third molars. Br J Oral Maxillofac Surg 42:299, 2004 Buchter A, Meyer U, Kruse-Losler B, Joos U, Kleinheinz J: Sustained release of doxycycline for the treatment of periimplantitis: Randomised controlled trial. Br J Oral Maxillofac Surg 42:439, 2004 Baqain ZH, Hyde N, Patrikidou A, Harris M: Antibiotic prophylaxis for orthognathic surgery: A prospective, randomised clinical trial. Br J Oral Maxillofac Surg 42:506, 2004 Bergdahl M, Hedstrom L: Metronidazole for the prevention of dry socket after removal of partially impacted mandibular third molar: A randomised controlled trial. Br J Oral Maxillofac Surg 42:555, 2004 Renton T, Hankins M, Sproate C, McGurk M: A randomised controlled clinical trial to compare the incidence of injury to the inferior alveolar nerve as a result of coronectomy and removal of mandibular third molars. Br J Oral Maxillofac Surg 43:7, 2005 Nayyar MS, Yates C: Bupivacaine as pre-emptive analgesia in third molar surgery: Randomised controlled trial. Br J Oral Maxillofac Surg 44:501, 2006 Richard B, Russell J, McMahon S, Pigott R: Results of randomized controlled trial of soft palate rst versus hard palate rst repair in unilateral complete cleft lip and palate. Cleft Palate Craniofac J 43:329, 2006 Kreisler MB, Haj HA, Noroozi N, Willershausen B: Efcacy of low level laser therapy in reducing postoperative pain after endodontic surgeryA randomized double blind clinical study. Int J Oral Maxillofac Surg 33:38, 2004 Norholt SE, Pedersen TK, Jensen J: Le Fort I miniplate osteosynthesis: A randomized, prospective study comparing resorbable PLLA/PGA with titanium. Int J Oral Maxillofac Surg 33: 245, 2004 van der Westhuijzen AJ, Becker PJ, Morkel J, Roelse JA: A randomized observer blind comparison of bilateral facial ice pack therapy with no ice therapy following third molar surgery. Int J Oral Maxillofac Surg 34:281, 2005 Scardina GA, Messina P, Carini F, Maresi E: A randomized trial assessing the effectiveness of different concentrations of isotretinoin in the management of lichen planus. Int J Oral Maxillofac Surg 35:67, 2006 Graziani F, DAiuto F, Arduino PG, Tonelli M, Gabriele M: Perioperative dexamethasone reduces post-surgical sequelae of wisdom tooth removal. A split-mouth randomized doublemasked clinical trial. Int J Oral Maxillofac Surg 35:241, 2006 Torres-Lagares D, Gutierrez-Perez JL, Infante-Cossio P, GarciaCalderon M, Romero-Ruiz MM, Serrera-Figallo MA: Randomized, double-blind study on effectiveness of intra-alveolar chlorhexidine gel in reducing the incidence of alveolar osteitis in mandibular third molar surgery. Int J Oral Maxillofac Surg 35:348, 2006 Lindeboom JA, Frenken JW, Tuk JG, Kroon FH: A randomized prospective controlled trial of antibiotic prophylaxis in intraoral bone-grafting procedures: Preoperative single-dose penicillin versus preoperative single-dose clindamycin. Int J Oral Maxillofac Surg 35:433, 2006 Venchard GR, Thomson PJ, Boys R: Improved sedation for oral surgery by combining nitrous oxide and intravenous midazolam: A randomized, controlled trial. Int J Oral Maxillofac Surg 35:522, 2006 de Lange J, van den Akker HP, Veldhuijzen van Zanten GO, Engelshove HA, van den Berg H, Klip H: Calcitonin therapy in central giant cell granuloma of the jaw: A randomized doubleblind placebo-controlled study. Int J Oral Maxillofac Surg 35: 791, 2006

16. 17. 18. 19. 20. 21. 22.

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23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34.

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35. 36.

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Further Reading
1. Alkan A, Metin M, Arici S, Sener I: A prospective randomised cross-over study of the effect of local haemostasis after third molar surgery on facial swelling: An exploratory trial. Br Dent J 197:42, 2004 2. Lee AP, Boyle CA, Savidge GF, Fiske J: Effectiveness in controlling haemorrhage after dental scaling in people with haemo19.

PANAYIOTIS A. KYZAS
20. Coulthard P, Rolfe S, Mackie IC, Gazal G, Morton M, JacksonLeech D: Intraoperative local anaesthesia for paediatric postoperative oral surgery painA randomized controlled trial. Int J Oral Maxillofac Surg 35:1114, 2006 21. Szabo G, Huys L, Coulthard P, et al: A prospective multicenter randomized clinical trial of autogenous bone versus beta-tricalcium phosphate graft alone for bilateral sinus elevation: Histologic and histomorphometric evaluation. Int J Oral Maxillofac Implants 20:371, 2005 22. Eckelt U, Schneider M, Erasmus F, et al: Open versus closed treatment of fractures of the mandibular condylar processA prospective randomized multi-centre study. J Craniomaxillofac Surg 34:306, 2006 23. Downie IP, Umar T, Boote DJ, Mellor TK, Hoffman GR, Brennan PA: Does administration of isosorbide mononitrate affect cellular proliferation in oral squamous cell carcinoma? A prospective randomized clinical study. J Oral Maxillofac Surg 62: 1064, 2004 24. Dodson TB: Management of mandibular third molar extraction sites to prevent periodontal defects. J Oral Maxillofac Surg 62:1213, 2004 25. Collins CP, Pirinjian-Leonard G, Tolas A, Alcalde R: A prospective randomized clinical trial comparing 2.0-mm locking plates to 2.0-mm standard plates in treatment of mandible fractures. J Oral Maxillofac Surg 62:1392, 2004 26. Adeyemo WL, Ogunlewe MO, Ladeinde AL, Bamgbose BO: Are sterile gloves necessary in nonsurgical dental extractions? J Oral Maxillofac Surg 63:936, 2005 27. Sittitavornwong S, Waite PD, Holmes JD, Klapow JC: The necessity of routine clinic follow-up visits after third molar removal. J Oral Maxillofac Surg 63:1278, 2005 28. Schmitter M, Zahran M, Duc JM, Henschel V, Rammelsberg P: Conservative therapy in patients with anterior disc displacement without reduction using 2 common splints: A randomized clinical trial. J Oral Maxillofac Surg 63:1295, 2005 29. Gomes AC, Vasconcelos BC, de Oliveira e Silva ED, da Silva LC: Lingual nerve damage after mandibular third molar surgery: A randomized clinical trial. J Oral Maxillofac Surg 63:1443, 2005 30. Ersin NK, Oncag O, Cogulu D, Cicek S, Balcioglu ST, Cokmez B: Postoperative morbidities following dental care under daystay general anesthesia in intellectually disabled children. J Oral Maxillofac Surg 63:1731, 2005 31. Lacombe GF, Leake JL, Clokie CM, Haas DA: Comparison of remifentanil with fentanyl for deep sedation in oral surgery. J Oral Maxillofac Surg 64:215, 2006 32. Taschieri S, Del Fabbro M, Testori T, Francetti L, Weinstein R: Endodontic surgery using 2 different magnication devices: Preliminary results of a randomized controlled study. J Oral Maxillofac Surg 64:235, 2006 33. Miles BA, Potter JK, Ellis E III: The efcacy of postoperative antibiotic regimens in the open treatment of mandibular fractures: a prospective randomized trial. J Oral Maxillofac Surg 64:576, 2006 34. Lindeboom JA, Frenken JW, Dubois L, Frank M, Abbink I, Kroon FH: Immediate loading versus immediate provisionalization of maxillary single-tooth replacements: A prospective randomized study with BioComp implants. J Oral Maxillofac Surg 64:936, 2006 35. Humphris GM, Freeman R, Clarke HM: Risk perception of oral cancer in smokers attending primary care: A randomised controlled trial. Oral Oncol 40:916, 2004 36. Nusstein J, Burns Y, Reader A, et al: Injection pain and postinjection pain of the palatal-anterior superior alveolar injection, administered with the Wand Plus system, comparing 2% lidocaine with 1:100,000 epinephrine to 3% mepivacaine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 97:164 2004 37. Cheung LK, Chow LK, Chiu WK: A randomized controlled trial of resorbable versus titanium xation for orthognathic surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:386, 2004 38. Ong KS, Seymour RA, Tan JM: A prospective randomized crossover study of the preemptive analgesic effect of nitrous oxide

979
in oral surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:637, 2004 Kondoh T, Hamada Y, Kamei K, et al: Comparative study of intra-articular irrigation and corticosteroid injection versus closed reduction with intermaxillary xation for the management of mandibular condyle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 98:651, 2004 Jerjes W, Jerjes WK, Swinson B, et al: Midazolam in the reduction of surgical stress: A randomized clinical trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100:564, 2005 Branco FP, Ranali J, Ambrosano GM, Volpato MC: A doubleblind comparison of 0.5% bupivacaine with 1:200,000 epinephrine and 0.5% levobupivacaine with 1:200,000 epinephrine for the inferior alveolar nerve block. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 101:442, 2006 Lindeboom JA, Tjiook Y, Kroon FH: Immediate placement of implants in periapical infected sites: A prospective randomized study in 50 patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 101:705, 2006 Colombini BL, Modena KC, Calvo AM, et al: Articaine and mepivacaine efcacy in postoperative analgesia for lower third molar removal: A double-blind, randomized, crossover study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 102:169, 2006 Deo S, Hazarika S, Shukla NK, Kar M, Samaiya A: A prospective randomized trial comparing harmonic scalpel versus electrocautery for pectoralis major myocutaneous ap dissection. Plast Reconstr Surg 115:1006, 2005 Borodic G, Bartley M, Slattery W, et al: Botulinum toxin for aberrant facial nerve regeneration: Double-blind, placebo-controlled trial using subjective endpoints. Plast Reconstr Surg 116:36, 2005 Singer AJ, Gulla J, Hein M, Marchini S, Chale S, Arora BP: Single-layer versus double-layer closure of facial lacerations: A randomized controlled trial. Plast Reconstr Surg 116:363, 2005 Zeiger JS, Beaty TH, Liang KY: Oral clefts, maternal smoking, and TGFA: A meta-analysis of gene-environment interaction. Cleft Palate Craniofac J 42:58, 2005 Cheung LK, Chua HD: A meta-analysis of cleft maxillary osteotomy and distraction osteogenesis. Int J Oral Maxillofac Surg 35:14, 2006 Lau SL, Samman N: Recurrence related to treatment modalities of unicystic ameloblastoma: A systematic review. Int J Oral Maxillofac Surg 35:681, 2006 Andreasen JO, Jensen SS, Schwartz O, Hillerup Y: A systematic review of prophylactic antibiotics in the surgical treatment of maxillofacial fractures. J Oral Maxillofac Surg 64:1664, 2006 Lagravre MO, Heo G, Major PW, Flores-Mir C: Meta-analysis of immediate changes with rapid maxillary expansion treatment. J Am Dent Assoc 137:44, 2006 Downer MC, Moles DR, Palmer S, Speight PM: A systematic review of test performance in screening for oral cancer and precancer. Oral Oncol 40:264, 2004 Dijkstra PU, Kalk WW, Roodenburg JL: Trismus in head and neck oncology: A systematic review. Oral Oncol 40:879, 2004 Downer MC, Moles DR, Palmer S, Speight PM: A systematic review of measures of effectiveness in screening for oral cancer and precancer. Oral Oncol 42:551, 2006 Caso A, Hung LK, Beirne OR: Prevention of alveolar osteitis with chlorhexidine: A meta-analytic review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 99:155, 2005 Richardson DT, Dodson TB: Risk of periodontal defects after third molar surgery: An exercise in evidence-based clinical decision-making. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100:133, 2005 Nollet PJ, Katsaros C, Vant Hof MA, Kuijpers-Jagtman AM: Treatment outcome in unilateral cleft lip and palate evaluated with the GOSLON yardstick: A meta-analysis of 1236 patients. Plast Reconstr Surg 116:1255 2005

39.

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

50.

51.

52.

53. 54.

55.

56.

57.

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APPENDIX

Appendix Table 1. DISTRIBUTION OF ARTICLE TYPES PER JOURNAL IN DATABASE 1

Type of Study Meta-analyses of RCTs Meta-analyses (other) RCTs Practice guidelines Cohort studies Case-control studies Case series and case reports Basic research and animal studies Personal views, editorials, and opinions Nonsystematic reviews Unclassied Total

Journal Database 1 (%) 1 (0) 5 (0.2) 31 (1.3) 5 (0.2) 10 (0.4) 52 (2.2) 1,388 (59) 446 (19) 244 (10.4) 130 (5.5) 43 (1.8) 2,355

Br J Oral Maxillofac Surg

Int J Oral Maxillofac Surg 2 10 1 4 290 123 21 34 485

J Craniomaxillofac Surg

J Oral Maxillofac Surg 1

Oral Oncol 3 1 29 163 135 22 62 12 427

7 1 2 275 41 37 7 24 394

1 1 134 51 30 11 2 230

12 4 8 17 526 96 134 16 5 819

Abbreviation: RCTs, randomized, controlled trials. Journal titles are given as Index Medicus abbreviations. Panayiotis A. Kyzas. We Can Do Better. J Oral Maxillofac Surg 2008. Appendix Table 2. DISTRIBUTION OF ARTICLE TYPES PER JOURNAL IN DATABASE 2

Type of Study

Oral Surg Int J Oral J Am J Oral Oral Med Plast Database 2 Br Dent Cleft Maxillofac Dent Pathol Oral Reconstr (%) J Palate Cranio Implants Assoc Med Pathol Surg 1 1 1 15 4 1 3 25 1 10 94 9 15 4 135 1 4 88 4 26 5 128 46 14 14 3 1 79 1 21 2 2 2 29 9 70 60 8 147 124 47 15 18 1 216 2 228 39 80 19 1 373 1 1 1 1 8 1 3

Meta-analyses of RCTs 1 (0.01) Meta-analyses (other) 4 (0.7) RCTs 15 (1.3) Practice guidelines 1 (0.01) Cohort studies 4 (0.7) Case-control studies 24 (2.1) Case series and case reports 686 (60.1) Basic research and animal studies 175 (15.4) Personal views, editorials, and opinions 156 (13.7) Nonsystematic reviews 60 (5.3) Unclassied 6 (0.5) Total 1,132

Abbreviation: RCTs, randomized, controlled trials. Journal titles are given as Index Medicus abbreviations. Panayiotis A. Kyzas. We Can Do Better. J Oral Maxillofac Surg 2008. Appendix Table 3. QUALITY CHARACTERISTICS OF RCTS INCLUDED IN SURVEY
Inclusion and Exclusion Criteria Yes Yes Yes No No Results of Experimental Intervention No difference No difference Signicant efcacy Signicant efcacy Signicant efcacy

Article Alkan et al1/Br Dent J/2004 Lee et al2/Br Dent J/2005 Abu-Serriah et al3/Br J Oral Maxillofac Surg/2004 Joshi et al4/Br J Oral Maxillofac Surg/2004 Buchter et al5/Br J Oral Maxillofac Surg/2004

Sample Size 25 16 42 119 28

Randomization Mode No Yes No No No

Power Calculations No No No No No

Allocation Concealment No No No No No

Withdrawals Described No No No No No

Masking NR DB NR DB SB

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Appendix Table 3. QUALITY CHARACTERISTICS OF RCTS INCLUDED IN SURVEY (Contd)

Inclusion and Exclusion Criteria Yes Yes Results of Experimental Intervention Signicant efcacy No difference

Article
6

Sample Size

Randomization Mode No Yes

Power Calculations No Yes

Allocation Concealment No Yes

Withdrawals Described Yes Yes

Masking DB DB

34 Baqain et al /Br J Oral Maxillofac Surg/2004 7 Bergdahl and Hedstrom / 119 Br J Oral Maxillofac Surg/2004 128 Renton et al8/Br J Oral Maxillofac Surg/2005 9 Nayyar and Yates /Br J 45 Oral Maxillofac Surg/ 2006 47 Richard et al10/Cleft Palate/ 2006 11 Kreisler et al /Int J Oral 52 Maxillofac Surg/2004 12 60 Norholt et al /Int J Oral Maxillofac Surg/2004 Van der Westhuijzen et 60 al13/Int J Oral Maxillofac Surg/2005 70 Scardina et al14/Int J Oral Maxillofac Surg/2006 15 Graziani et al /Int J Oral 43 Maxillofac Surg/2006 16 Torres-Lagares et al /Int 103 J Oral Maxillofac Surg/ 2006 150 Lindeboom et al17/Int J Oral Maxillofac Surg/ 2006 60 Venchard et al18/Int J Oral Maxillofac Surg/2006 19 de Lange et al /Int J Oral 14 Maxillofac Surg/2006 20 142 Coulthard et al /Int J Oral Maxillofac Surg/2006 21 Szabo et al /Int J Oral 20 Maxillofac Implants/ 2005 88 Eckelt et al22/J Craniomaxillofac Surg/ 2006 31 Downie et al23/J Oral Maxillofac Surg/2004 24 Dodson /J Oral Maxillofac 24 Surg/2004 25 Collins et al /J Oral 90 Maxillofac Surg/2004 26 Adeyemo et al /J Oral 269 Maxillofac Surg/2005 Sittitavornwong et 60 al27/J Oral Maxillofac Surg/2005 74 Schmitter et al28/J Oral Maxillofac Surg/2005 29 Gomes et al /J Oral 55 Maxillofac Surg/2005 30 Ersin et al /J Oral 86 Maxillofac Surg/2005 31 47 Lacombe et al /J Oral Maxillofac Surg/2006 32 Taschieri et al /J Oral 71 (teeth) Maxillofac Surg/2006 33 Miles et al /J Oral 181 Maxillofac Surg/2006 34 Lindeboom et al /J Oral 48 Maxillofac Surg/2006 35 Humphris et al /Oral 995 Oncol/2004 36 Nusstein et al /Oral Surg 40 Oral Med Oral Pathol/ 2004 60 Cheung et al37/Oral Surg Oral Med Oral Pathol/ 2004

Yes Yes

Yes Yes

No No

No No

No No

Signicant efcacy Signicant efcacy

SB NR

Yes Yes Yes Yes

No No No Yes

No No No Yes

No No No No

Yes Yes Yes No

No difference Signicant efcacy No difference No difference

NR DB NR SB

Yes Yes Yes

No Yes Yes

No No No

No Yes Yes

No No No

Signicant efcacy Signicant efcacy Signicant efcacy

NR DB DB

Yes

Yes

Yes

Yes

No

No difference

DB

No Yes Yes Yes

No No No No

No Yes Yes

No No No No

No No No

Signicant efcacy No difference No difference No difference

NR DB DB NR

Yes

No

No

No

Yes

Signicant efcacy

NR

Yes Yes Yes Yes Yes

Yes Yes No No No

No Yes No No No

No No No No No

No No No No Yes

No difference No difference No difference No difference No difference

DB SB NR NR NR

Yes Yes No Yes Yes Yes Yes Yes Yes

No No No No Yes Yes No Yes Yes

No No No Yes Yes No Yes Yes Yes

No No No No No No No Yes Yes

No No No Yes Yes Yes No Yes No

Signicant efcacy Signicant harm Signicant harm Signicant efcacy No difference No difference No difference Signicant efcacy No difference

NR SB NR SB DB NR NR NR DB

Yes

Yes

Yes

No

Yes

No difference

NR

Panayiotis A. Kyzas. We Can Do Better. J Oral Maxillofac Surg 2008.

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Appendix Table 3. QUALITY CHARACTERISTICS OF RCTS INCLUDED IN SURVEY (Contd)

Inclusion and Exclusion Criteria Yes No Results of Experimental Intervention No difference Signicant efcacy

Article Ong et al /Oral Surg Oral Med Oral Pathol/2004 Kondoh et al39/Oral Surg Oral Med Oral Pathol/ 2004 Jerjes et al40/Oral Surg Oral Med Oral Pathol/ 2005 Branco et al41/Oral Surg Oral Med Oral Pathol/ 2006 Lindeboom et al42/Oral Surg Oral Med Oral Pathol/2006 Colombini et al43/Oral Surg Oral Med Oral Pathol/ 2006 Deo et al44/Plast Reconstr Surg/2005 Borodic et al45/Plast Reconstr Surg/2005 Singer et al46/Plast Reconstr Surg/2005
38

Sample Size 36 26

Randomization Mode Yes No

Power Calculations Yes No

Allocation Concealment Yes No

Withdrawals Described Yes No

Masking NR NR

38

Yes

No

No

No

Yes

Signicant efcacy

DB

30

Yes

No

No

No

No

No difference

DB

50

Yes

Yes

Yes

No

No

No difference

NR

20

Yes

No

No

No

No

Signicant efcacy

DB

30 30 65

No Yes Yes

Yes No Yes

No No Yes

No No Yes

No No Yes

Signicant efcacy Signicant efcacy No difference

NR DB DB

Abbreviations: DB, double-blind; SB, single-blind; NR, not reported; RCTs, randomized, controlled trials. Journal titles are given as Index Medicus abbreviations. Panayiotis A. Kyzas. We Can Do Better. J Oral Maxillofac Surg 2008.

Appendix Table 4. SURGICAL SUBSPECIALTY AND ISSUE ADDRESSED BY RCTS INCLUDED IN THE SURVEY

Article Alkan et al /Br Dent J/2004 Lee et al2/Br Dent J/2005 Abu-Serriah et al3/Br J Oral Maxillofac Surg/2004 Joshi et al4/Br J Oral Maxillofac Surg/2004 Buchter et al5/Br J Oral Maxillofac Surg/2004 Baqain et al6/Br J Oral Maxillofac Surg/2004 Bergdahl and Hedstrom7/ Br J Oral Maxillofac Surg/2004 Renton et al8/Br J Oral Maxillofac Surg/2005 Nayyar and Yates9/Br J Oral Maxillofac Surg/ 2006 Richard et al10/Cleft Palate/ 2006 Kreisler et al11/Int J Oral Maxillofac Surg/2004 Norholt et al12/Int J Oral Maxillofac Surg/2004
1

Issue Addressed Effect of local hemostasis on facial swelling after the surgical removal of impacted wisdom teeth. To compare the effectiveness of tranexamic acid mouthwash in controlling hemorrhage with that of using factor replacement therapy before dental scaling in people with hemophilia. Comparison of erbium YAG laser with a surgical bur for removal of partially erupted lower third molars. Effect of preoperative ibuprofen, diclofenac, paracetamol with codeine, and placebo tablets for relief of postoperative pain after removal of impacted third molars. Sustained release of doxycycline for the treatment of periimplantitis. Short-term (1-day) and long-term (5-day) antibiotic prophylaxis after orthognathic surgery were compared. Metronidazole for the prevention of dry socket after removal of partially impacted mandibular third molar. To compare incidence of injury to the inferior alveolar nerve as a result of coronectomy and removal of mandibular third molars. Bupivacaine as pre-emptive analgesia in third molar surgery. To compare outcomes for primary repair of unilateral cleft lip and palate, operating on the soft palate rst vs the hard palate rst. To evaluate the effect of low-level laser application on postoperative pain after endodontic surgery. To compare the use of resorbable osteosynthesis material (LactoSorb) with titanium osteosynthesis for the xation of Le Fort I osteotomies.

Category Minor oral surgery Minor oral surgery Minor oral surgery Minor oral surgery Minor oral surgery Orthognathic surgery Minor oral surgery Minor oral surgery Minor oral surgery Clefts Minor oral surgery Orthognathic surgery

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Appendix Table 4. SURGICAL SUBSPECIALTY AND ISSUE ADDRESSED BY RCTS INCLUDED IN THE SURVEY (Contd)

Article Van der Westhuijzen et al13/Int J Oral Maxillofac Surg/2005 Scardina et al14/Int J Oral Maxillofac Surg/2006 Graziani et al15/Int J Oral Maxillofac Surg/2006 Torres-Lagares et al16/Int J Oral Maxillofac Surg/ 2006 Lindeboom et al17/Int J Oral Maxillofac Surg/ 2006 Venchard et al18/Int J Oral Maxillofac Surg/2006 de Lange et al19/Int J Oral Maxillofac Surg/2006 Coulthard et al20/Int J Oral Maxillofac Surg/2006 Szabo et al21/Int J Oral Maxillofac Implants/2005 Eckelt et al22/J Craniomaxillofac Surg/ 2006 Downie et al23/J Oral Maxillofac Surg/2004 Dodson24/J Oral Maxillofac Surg/2004 Collins et al25/J Oral Maxillofac Surg/2004 Adeyemo et al26/J Oral Maxillofac Surg/2005 Sittitavornwong et al27/J Oral Maxillofac Surg/2005 Schmitter et al28/J Oral Maxillofac Surg/2005 Gomes et al29/J Oral Maxillofac Surg/2005 Ersin et al30/J Oral Maxillofac Surg/2005 Lacombe et al31/J Oral Maxillofac Surg/2006 Taschieri et al32/J Oral Maxillofac Surg/2006 Miles et al33/J Oral Maxillofac Surg/2006

Issue Addressed To compare the efcacy of Tecnol bilateral facial icepacks with no cold therapy in reducing pain, swelling, and trismus during the rst 24 hours after third-molar surgery. To test the effectiveness of topical therapy of lichen planus based on 0.18% isotretinoin, compared with a 0.05% concentration. To study the effect of endo-alveolar and submucosal administration of dexamethasone sodium phosphate to prevent inammatory sequelae after surgical removal of lower third molars. To study the effectiveness of intra-alveolar chlorhexidine gel in reducing the incidence of alveolar osteitis in mandibular third-molar surgery. Comparison of preoperative single-dose penicillin vs preoperative single-dose clindamycin in intraoral bonegrafting procedures. To investigate whether sedation techniques for oral surgery can be improved by combining the use of inhalation of nitrous oxide/oxygen with intravenous midazolam. To evaluate the effectiveness of calcitonin therapy in central giant-cell granuloma of the jaw. The efcacy and safety of intraoperative local anesthetic (2% lidocaine with 1:200,000 epinephrine) for postoperative pain control were investigated. To determine whether donor-site morbidity could be avoided by using pure-phase -tricalcium phosphate. To compare operative and conservative treatments of displaced condylar fractures of the mandible. To examine the effect of oral administration of the NO donor drug isosorbide mononitrate on cellular proliferation in patients with oral squamous-cell carcinoma. To measure the efcacy of DBP or GTR therapy in preventing periodontal defects on the distal aspect of the M2 after M3 extraction. To compare standard 2.0-mm monocortical plates with 2.0-mm locking plates in the treatment of mandible fractures. To compare the incidence of healing complications of extraction socket with the use of sterile or clean, nonsterile gloves during nonsurgical dental extractions. To evaluate the clinical necessity of routine follow-up visits after third-molar removal under local anesthesia and intravenous sedation in patients aged 15 to 35 years. Comparative evaluation of different types of splint therapy for anterior disc displacement without reduction of the temporomandibular joint. To evaluate the frequency, type, and risk factors for lingual nerve damage after mandibular third-molar surgery, with reference to lingual ap retraction. To compare postoperative morbidities for 24 hours after dental care under day-stay general anesthesia using sevourane or halothane in intellectually disabled children. To compare recovery for oral surgery patients given a deep sedation regimen of midazolam, propofol, and remifentanil with a standard control of fentanyl in place of remifentanil. To monitor the outcomes of ultrasonic root-end preparation using magnication loupes or an endoscope. To determine the necessity and effectiveness of postoperative antibiotics in the treatment of mandible fractures.

Category Minor oral surgery Oral oncology Minor oral surgery

Minor oral surgery Minor oral surgery Minor oral surgery Minor oral surgery Minor oral surgery Minor oral surgery Trauma Oral oncology Minor oral surgery Trauma Minor oral surgery Minor oral surgery Temporomandibular joint Minor oral surgery Minor oral surgery Minor oral surgery Minor oral surgery Trauma

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Appendix Table 4. SURGICAL SUBSPECIALTY AND ISSUE ADDRESSED BY RCTS INCLUDED IN THE SURVEY (Contd)

Article Lindeboom et al34/J Oral Maxillofac Surg/2006 Humphris et al35/Oral Oncol/2004

Issue Addressed To evaluate the clinical outcomes of immediately loaded solid plasma sprayed implants vs immediate provisionalized but nonloaded implants in the anterior and premolar region of the maxilla. This study investigated three hypotheses: rst that a patient information leaet (PIL) would enhance risk perceptions, and second that the effect of the leaet on knowledge would be conrmed as in previous studies and third that these improvements would be associated with smoking behavior. To compare injection pain and postinjection pain of 2% lidocaine with 1:100,000 epinephrine and 3% mepivacaine, using the computer-assisted Wand Plus injection system to administer the palatal-anterior superior alveolar injection. To determine any differences in intra-operative and postoperative morbidities and complications between resorbable and titanium plating systems for xation in orthognathic surgery. To investigate the effects of preincisional vs postincisional nitrous oxide on postoperative oral surgical pain. To evaluate the clinical outcomes of a modied conservative treatment protocol involving intra-articular irrigation and corticosteroid injection into the superior joint compartment of patients with fresh mandibular condyle fractures. To assess the role of midazolam in reducing surgical stress, as measured using subjective and objective variables. To compare the anesthetic success and onset and duration of lip and pulpal anesthesia of 0.5% bupivacaine and levobupivacaine solutions, both with 1:200,000 epinephrine, when administered for inferior alveolar nerve anesthesia. To determine clinical success when implants are placed in chronic periapical infected sites. To compare the clinical efcacy of 4% articaine in relation to 2% mepivacaine, both with 1:100,000 epinephrine, in the prevention of postoperative pain after lower third-molar removal. To consider the feasibility of myocutaneous ap dissection using the harmonic scalpel, and to compare operative time, blood loss, drainage volume, and morbidity between patients undergoing ap dissection with the harmonic scalpel and those being treated with electrocautery. To assess the efcacy of Botulinum toxin for aberrant facialnerve regeneration. To compare the cosmetic outcomes of facial lacerations closed with a single or double layer of sutures.

Category Minor oral surgery

Oncology (prevention)

Nusstein et al36/Oral Surg Oral Med Oral Pathol/ 2004 Cheung et al36/Oral Surg Oral Med Oral Pathol/ 2004 Ong et al38/Oral Surg Oral Med Oral Pathol/2004 Kondoh et al39/Oral Surg Oral Med Oral Pathol/ 2004 Jerjes et al40/Oral Surg Oral Med Oral Pathol/ 2005 Branco et al41/Oral Surg Oral Med Oral Pathol/ 2006 Lindeboom et al42/Oral Surg Oral Med Oral Pathol/2006 Colombini et al43/Oral Surg Oral Med Oral Pathol/ 2006 Deo et al44/Plast Reconstr Surg/2005

Minor oral surgery

Orthognathic surgery Minor oral surgery Trauma

Minor oral surgery Minor oral surgery

Minor oral surgery Minor oral surgery

Reconstruction

Borodic et al45/Plast Reconstr Surg/2005 Singer et al46/Plast Reconstr Surg/2005

Unclassied Minor oral surgery

Panayiotis A. Kyzas. We Can Do Better. J Oral Maxillofac Surg 2008.

Appendix Table 5. CHARACTERISTICS OF META-ANALYSES AND SYSTEMATIC REVIEWS

Article Type MA Number of Studies or Patients Five case-control studies.

Article Zeiger et al47/Cleft Palate/2005

Issue Addressed To examine the associations among maternal cigarette smoking, infant genotype at the Taq1 site in the TGFA locus, and risk of nonsyndromic oral clefts, both cleft palate and cleft lip with or without cleft palate.

Category Clefts

Results/Comments Signicant effect in the smoking group (ORsmokers 1.95; 95% CI, 1.22 to 3.10).

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Appendix Table 5. CHARACTERISTICS OF META-ANALYSES AND SYSTEMATIC REVIEWS (Contd)

Article Type MA Number of Studies or Patients Ninety-eight articles (72: 1,418 patients with osteotomies; and 26: 276 patients with distraction). Six articles (132 patients).

Article Cheung and Chua48/Int J Oral Maxillofac Surg/ 2006

Issue Addressed This meta-analysis aimed to provide evidence-based data to assist surgeons in making an informed choice between distraction osteogenesis or conventional osteotomy for cleft lip and palate patients. This systematic review aimed to identify all studies pertinent to the clinical question, Which treatment for unicystic ameloblastoma results in the lowest recurrence rate? To nd evidence for prophylactic administration of antibiotics in relation to treatment of maxillofacial fractures.

Category Clefts

Results/Comments No conclusive data. No syntheses, since RCTs with direct comparisons were not available.

Lau and Samman49/ Int J Oral Maxillofac Surg/ 2006 Andreasen et al50/ J Oral Maxillofac Surg/2006

SR

Minor oral surgery

It was concluded that there is only weak evidence that jaw resection resulted in the lowest recurrence rate, followed by enucleation with application of Carnoys solution. A one-shot or 1-day administration of prophylactic antibiotics seems to be best documented for reducing infections in the management of mandibular fractures not involving the condylar region. The greatest changes resulting from rapid maxillary expansion in the studies analyzed were dental and skeletal transverse changes. Few vertical and anteroposterior immediate changes were statistically signicant, though they probably are not clinically important. Meta-analysis regression showed no difference (P .99) in generally high level of discriminatory ability of the test.

SR

Trauma

Four studies (461 patients).

Lagravre et al51/ J Am Dent Assoc/ 2006

MA

To evaluate immediate transverse, anteroposterior, and vertical dental and skeletal changes produced by rapid maxillary expansion.

Orthognathic surgery

Fourteen studies (335 patients).

Downer et al52/Oral Oncol/2004

SR

To examine test performance in screening for oral cancer and precancer in primary care

Dijkstra et al53/Oral Oncol/2004

SR

To identify systematically the criteria for trismus in head and neck cancer, the evidence for risk factors for trismus, and the interventions to treat trismus.

Oral oncology: Diagnostic efcacy of screening tests Oral oncology

Eight studies (11,895 screened individuals).

Twelve studies (number of patients NR).

Downer et al54/Oral Oncol/2006

SR

To examine the effectiveness of screening for oral cancer and precancer in primary care.

Oral oncology: Diagnostic efcacy of screening tests

Twenty-eight studies, overlapping with Downer et al, 2004.52

Caso et al55/Oral Surg Oral Med Oral Pathol/2005

MA

To assess if chlorhexidine rinse decreased the occurrence of alveolar osteitis after third-molar removal.

Minor oral surgery

Seven studies (825 patients).

Richardson et al56/ Oral Surg Oral Med Oral Pathol/ 2005

SR

To answer the question, What is the risk of having periodontal defects on the distal aspect of the mandibular second molar after third-molar removal?

Minor oral surgery

Eight studies (total number of patients could not be retrieved).

Radiotherapy involving the structures of the temporomandibular joint or pterygoid muscles reduces mouth opening by 18% (SD, 17%). Exercises using a Therabite device or tongue blades increase mouth opening signicantly, with effect sizes of 2.6 and 1.5, respectively. Microcurrent electrotherapy and pentoxifylline increase mouth opening signicantly (effect sizes for both, 0.3). The review overall produced no evidence for or against the potential benets associated with an oral cancer screening program. It was concluded that there are insufcient available data to make an unequivocal determination about the effectiveness of oral cancer screening programs at present. The relative risk for the single-rinse group was 1.36 (95% CI, 0.80 to 2.33; P .05), whereas for the multiple-rinse group, the relative risk was 1.90 (95% CI, 1.46 to 2.47; P .05). Rinsing with chlorhexidine on day of surgery and several days afterward may reduce the incidence of alveolar osteitis. Commonly, the second-molar periodontal probing depth or attachment levels either remain unchanged or improve after thirdmolar removal. For subjects with healthy second-molar periodontium preoperatively, the indication for third-molar removal needs to be evaluated carefully, because these subjects are at increased risk for worsening of probing depths or attachment levels after third-molar removal.

Panayiotis A. Kyzas. We Can Do Better. J Oral Maxillofac Surg 2008.

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Appendix Table 5. CHARACTERISTICS OF META-ANALYSES AND SYSTEMATIC REVIEWS (Contd)

Article Type MA Number of Studies or Patients Fifteen studies (1,236 patients).

Article Nollet et al /Plast Reconstr Surg/ 2005

57

Issue Addressed To assess determinants for treatment outcome in unilateral cleft lip and palate, evaluated according to GOSLON yardstick and 5-year-index ratings by means of a meta-analysis.

Category Clefts

Results/Comments Patients whose soft and hard palates were closed before age 3 yr presented signicantly poorer (P .003) GOSLON scores (mean score, 2.9; SD, 0.4) than patients whose palates were closed at a later age (mean GOSLON score, 2.3; SD, 0.2). Delayed palatal closure generally results in better dental arch relationships than early palatal closure.

Abbreviations: CI, condence interval; GOSLON, Great Ormond Street London and Oslo; MA, meta-analysis; NR, not reported; OR, odds ratio; RCTs, randomized, controlled trials; SR, systematic review. Journal titles are given as Index Medicus abbreviations. Panayiotis A. Kyzas. We Can Do Better. J Oral Maxillofac Surg 2008.