Caries-preventive effect of glass ionomer and resin-based fissure sealants on permanent teeth: An update of systematic review evidence Retention and caries preventive effects of a GIC and a resin-based fissure sealant. Use of Pit-and-Fissure Sealants. Evidence-based Clinical Practice Guideline for the Use of Pit-and-Fissure Sealants. Effects of glass ionomer cement, resin-based pit and fissure sealant and HF applications on occlusal caries in a developing country field trial. The success rates of a glass ionomer cement and a resin-based fissure sealant placed by fifth-year undergraduate dental students Systematic reviews in public health: old chestnuts and new challenges. Pit and fissure sealants in high-caries-risk individuals. Research gaps identified during systematic reviews of clinical trials: glass-ionomer cements The use of systematic reviews in the planning, design and conduct of randomised trials: a retrospective cohort of NIHR HTA funded trials All in the Family: systematic reviews, rapid reviews, scoping reviews, realist reviews, and more Comparing the caries-preventive effect of two fissure sealing modalities in public health care: a single application of glass ionomer and a routine resin-based sealant programme. A randomized split-mouth clinical trial. Balancing the strengths of systematic and narrative reviews. Randomized Trial on Fluorides and Sealants for Fissure Caries Prevention Retention of a glass ionomer cement and a resin-based fissure sealant and effect on carious outcome after 7 years. Sealing versus partial caries removal in primary molars: a randomized clinical trial Caries-Preventive Effect of a One-Time Application of Composite Resin and Glass Ionomer Sealants after 5 Years Fissure sealing with a light-cured resin-reinforced glass-ionomer cement (Vitrebond) compared with a resin sealant. Clinical evaluation of three different materials used as pit and fissure sealant: 24-months results. Clinical evaluation of sealants and preventive resin restorations in a group of environmentally homogeneous children. Seeing the forests and the trees—innovative approaches to exploring heterogeneity in systematic reviews of complex interventions to enhance health system decision-making: a protocol PROBAST: A Tool to Assess Risk of Bias and Applicability of Prediction Model Studies: Explanation and Elaboration Do light cured ART conventional high-viscosity glass-ionomer sealants perform better than resin-composite sealants: a 4-year randomized clinical trial.
Background This article constitutes a partial up date of the original systematic review evidence by Yengopal et al. from 15 January 2008 ( published in the Journal of Oral Science in 2009 ) with primary focus on research quality in regard to bias risk in trials . Its aim is to up date the existing systematic review evidence from the English literature as to whether caries occurrence on pits and fissures of teeth sealed with either GIC or resin is the same . Methods In addition to the 12 trials included during the original systematic review , 5 new trials were identified during the data base search ( up to 26 August 2010 ) and 2 further trials were included from a h and search and reference check . Of these , 3 trials were excluded and 16 were accepted for data extraction and quality assessment . The quality of accepted trials was assessed , using up date d quality criteria , and the risk of bias was investigated in more depth than previously reported . In addition , the focus of quantitative synthesis was shifted to single data sets that were extracted from the accepted trials . Results Twenty-six dichotomous and 4 continuous data sets were extracted . Meta- analysis and cumulative meta- analysis were used in combining clinical ly homogenous data sets . The overall outcome of the computed data sets suggest no difference between the caries-preventive effects of GIC- and resin-based fissure sealants . Conclusions This overall outcome is in agreement with the conclusions of the original systematic review . Although the findings of the trials identified in this up date may be considered to be less affected by attrition- and publication bias , their risk of selection - and detection-/performance bias is high . Thus , verification of the currently available results requires further high quality r and omised control trials Abstract Fissure sealing using partially filled resins is an established caries preventive practice . Glass ionomer cement ( GIC ) sealants may offer additional advantages due to their ability to bond chemically to enamel and release fluoride . The aim of this study was to compare the caries preventive effect and retention of a GIC and a resin-based sealant . Ketac-fil ® was tested against a chemically cured resin-based material ( Delton ® ) using a split mouth design . Perth ( Western Australia ) schoolchildren ( n= 465 ) , mean age 7 yr±0.72 ( S.D. ) , received sealants  on the occlusal surfaces of sound homologous permanent first molar pairs .  Test ( GIC ) and control ( resin ) sealants were systematic ally allocated to left and right sides based on the child 's month of birth , and were placed by dental therapists . After 3.64±0.11 yr , 415 children were examined by different clinicians , and the clinical status of the teeth and the extent of sealant retention recorded . Sealants were deemed retained when at least 2/3 of the fissure pattern was still sealed . In 252 tooth pairs , neither sealant was retained to this extent . In 71 pairs , the GIC was not retained and the resin sealant retained . In 40 pairs the reverse occurred ( McNemar 's test , χ2= 8.66 , P < 0.005 ) . Net gain ( additional lesions prevented by the test agent per 100 treatments ) was 6.1%(95 % CI 3.3 % , 8.9 % ) . Effectiveness of the GIC was 80.6 % ( 95 % CI 59.6 % , 90.7 % ) . The relative risk of caries in test teeth was 0.19 ( 95 % CI 0.09 , 0.40 ) . The study suggests that complete retention of GIC sealant is not necessary for caries prevention in newly erupted permanent first molars BACKGROUND This article presents evidence -based clinical recommendations for the use of pit- and -fissure sealants on the occlusal surfaces of primary and permanent molars in children and adolescents . A guideline panel convened by the American Dental Association ( ADA ) Council on Scientific Affairs and the American Academy of Pediatric Dentistry conducted a systematic review and formulated recommendations to address clinical questions in relation to the efficacy , retention , and potential side effects of sealants to prevent dental caries ; their efficacy compared with fluoride varnishes ; and a head-to-head comparison of the different types of sealant material used to prevent caries on pits- and -fissures of occlusal surfaces . TYPES OF STUDIES REVIEW ED This is an up date of the ADA 2008 recommendations on the use of pit- and -fissure sealants on the occlusal surfaces of primary and permanent molars . The authors conducted a systematic search in MEDLINE , Embase , Cochrane Central Register of Controlled Trials , and other sources to identify r and omized controlled trials reporting on the effect of sealants ( available on the U.S. market ) when applied to the occlusal surfaces of primary and permanent molars . The authors used the Grading of Recommendations Assessment , Development , and Evaluation approach to assess the quality of the evidence and to move from the evidence to the decisions . RESULTS The guideline panel formulated 3 main recommendations . They concluded that sealants are effective in preventing and arresting pit- and -fissure occlusal carious lesions of primary and permanent molars in children and adolescents compared with the nonuse of sealants or use of fluoride varnishes . They also concluded that sealants could minimize the progression of non-cavitated occlusal carious lesions ( also referred to as initial lesions ) that receive a sealant . Finally , based on the available limited evidence , the panel was unable to provide specific recommendations on the relative merits of 1 type of sealant material over the others . Conclusions and practical implication s : These recommendations are design ed to inform practitioners during the clinical decision-making process in relation to the prevention of occlusal carious lesions in children and adolescents . Clinicians are encouraged to discuss the information in this guideline with patients or the parents of patients . The authors recommend that clinicians re-orient their efforts toward increasing the use of sealants on the occlusal surfaces of primary and permanent molars in children and adolescents BACKGROUND This article presents evidence -based clinical recommendations for the use of pit- and -fissure sealants on the occlusal surfaces of primary and permanent molars in children and adolescents . A guideline panel convened by the American Dental Association ( ADA ) Council on Scientific Affairs and the American Academy of Pediatric Dentistry conducted a systematic review and formulated recommendations to address clinical questions in relation to the efficacy , retention , and potential side effects of sealants to prevent dental caries ; their efficacy compared with fluoride varnishes ; and a head-to-head comparison of the different types of sealant material used to prevent caries on pits- and -fissures of occlusal surfaces . TYPES OF STUDIES REVIEW ED This is an up date of the ADA 2008 recommendations on the use of pit- and -fissure sealants on the occlusal surfaces of primary and permanent molars . The authors conducted a systematic search in MEDLINE , Embase , Cochrane Central Register of Controlled Trials , and other sources to identify r and omized controlled trials reporting on the effect of sealants ( available on the U.S. market ) when applied to the occlusal surfaces of primary and permanent molars . The authors used the Grading of Recommendations Assessment , Development , and Evaluation approach to assess the quality of the evidence and to move from the evidence to the decisions . RESULTS The guideline panel formulated 3 main recommendations . They concluded that sealants are effective in preventing and arresting pit- and -fissure occlusal carious lesions of primary and permanent molars in children and adolescents compared with the nonuse of sealants or use of fluoride varnishes . They also concluded that sealants could minimize the progression of non-cavitated occlusal carious lesions ( also referred to as initial lesions ) that receive a sealant . Finally , based on the available limited evidence , the panel was unable to provide specific recommendations on the relative merits of 1 type of sealant material over the others . Conclusions and practical implication s : These recommendations are design ed to inform practitioners during the clinical decision-making process in relation to the prevention of occlusal carious lesions in children and adolescents . Clinicians are encouraged to discuss the information in this guideline with patients or the parents of patients . The authors recommend that clinicians re-orient their efforts toward increasing the use of sealants on the occlusal surfaces of primary and permanent molars in children and adolescents The aim of this community-oriented study was to evaluate different methods to prevent fissure caries . The following products and measures were tested : 1 ) glass ionomer cement ( GIC ) applied by dentist ; 2 ) same material applied by short term ( 3 days ) trained personnel ( teachers ) ; 3 ) application of a 0.5 % HF solution three times ; 4 ) an established autopolymerized resin based sealant ( Delton ) . The study was performed in Bangkok , Thail and , a city in a developing country experiencing increasing caries prevalence . Children with at least three sound permanent molars from two age groups , 7 - 8 and 12 - 13-yr-olds respectively were chosen from very low to medium socioeconomic level families . 1264 children were systematic ally assigned to experiment or control groups based on school and DMFT . For the younger age group , the 2 yr mean DFS occlusal increment in the Control group was 0.66 surfaces . Significantly lower increments were observed in the GIC experimental group : 0.17 surfaces applied by the teachers and 0.32 applied by dentist , corresponding to 74 % and 52 % reductions , respectively . The mean increment in the HF group was 0.44 surfaces , a 33 % reduction in relation to the Control group . For the 12 - 13-yr-olds , the mean occlusal surface DF increment was 0.70 surfaces in the Control group . Almost no occlusal increment was found in the Delton group , 0.05 DFS , a 93 % reduction . In the GIC Dentist group , the DFS increment was 0.48 and in the Teacher group 0.56 , corresponding to 31 % and 20 % reduction , respectively . A slight and nonsignificant increase of caries in relation to the Control group was observed in the HF group . ( ABSTRACT TRUNCATED AT 250 WORDS AIM : To evaluate retention and caries prevention of a glass-ionomer cement ( GIC ) and a resin-based fissure sealant placed by fifth-year undergraduate dental students . METHODS : The study was conducted according to a split-mouth , r and omised clinical trial . Children with at least one pair of caries-free permanent first molars with deep pits and fissures were included in the study . The children were selected from a population that had a high risk for dental caries .  Sealant material s were applied by fifth-year undergraduate dental students on 346  fissures of the first permanent molars in 173 children . The ages of the children ranged from 7–15 years ( mean 9.4 ) . Two research ers at the clinics supervised all of the procedures . Intra-examiner reproducibility and inter-examiner reproducibility were 0.90 and 0.86 , respectively , for the clinical assessment of sealant retention and caries evaluation . RESULTS :  GIC sealants were completely lost in 31.9 % and resin-based sealants in 16.6 % ( p<0.05 ) . The total retention rates of GIC sealants and resin-based sealants were 13.8 % and 20.8 % , respectively . After 24 months , the caries increment was 3.4 % for GIC sealants and 4.8 % for resin-based sealants ( p>0.05 ) . CONCLUSIONS : The retention of GIC sealants was markedly inferior to the retention of resin-based sealants ; however , GIC when used as a pit and fissure sealant was slightly more effective in preventing occlusal caries The Bulletin ’s editorial team has decided to encourage systematic review s. This is an important decision and is to be welcomed . However it is possible that it will not be received positively by all . Some may feel that systematic review s are not suitable for answering wider public health questions , and that the new section will simply result in the publication of systematic review s addressing narrowly focused , clinical questions with a focus on r and omized controlled trials alone.1 There is no reason why this should be so , and there are far too many examples of systematic review s of non- clinical interventions ( including government policies ) , which include non-r and omized studies , to list.2 Systematic review s of qualitative research are also becoming more common.3 Nonetheless misconceptions about the scope and flexibility of systematic review s still surface occasionally and it never fails to surprise me when I stumble across one of these hoary old chestnuts . If it really were true that systematic review s were only for simple , individual-level interventions , systematic review ers working in public health would be very concerned . After all , public health problems require us to draw on complex sets of qualitative as well as quantitative evidence ; and some policy interventions have never been subjected to r and omized controlled trials ( RCTs ) but have been evaluated using other approaches ; everything from controlled and uncontrolled before- and -after studies , to time series analyses , to qualitative methods . In such cases , systematic review s that focused on RCTs alone would have little to say and we would end up producing many “ empty review s ” , which contain no studies at all . These would be undoubtedly quicker to do and quicker to read than the typical systematic review , but would be of limited use for making policy . However this is not the case . In public health we already have a wealth of review s that prioritize RCTs where they are available , but which draw upon a range of other evidence where they are appropriate to answering the review question .2 Take , as an example , transport policies , an important social determinant of health.4 Public health decision-makers have been interested in the effects on health of building new roads for decades , but there has never been a r and omized controlled trial , for obvious reasons . Yet it would make no sense to cl aim that there is no evidence to be review ed ; rather , there have been many controlled and uncontrolled studies that have examined the effects of new roads on respiratory symptoms , injuries , community severance , disturbance and a variety of other outcomes of public health importance . These studies have in fact been systematic ally review ed.5 Many other examples of review s of complex interventions that impact on public health could be given , which appear on the Cochrane Data base and elsewhere,6,7 and such review s are the main focus of the recently-established Cochrane Public Health Review Group . It is also worth noting that both the Cochrane and Campbell Collaboration include increasing numbers of review s that are relevant to low- and middle- income countries,8 though there is a particular need for more systematic review s that consider the effects on equity of the interventions that they include.9 Currently systematic review s have a “ utilitarian bias ” – they tend to be concerned more with the effects on population s and average effects than with distributional effects and impacts in disadvantaged subgroups . It is to be hoped that systematic review s su bmi tted to the Bulletin will routinely consider the effects of interventions on health inequities . The Cochrane Health Equity Field ( http://equity.cochrane.org/en/index.html ) was set up explicitly to further this agenda , to encourage systematic review authors to explicitly assess the effects of interventions not only on the whole population , but on the disadvantaged . So where does this leave non- systematic review s ? Should every review be a systematic review ? This is a difficult question to answer in a short editorial . My own view is that not all review s need to be systematic review s ; there is still a place for review papers that provide a broad overview , and that discuss a range of evidence and make a contribution to wider debates about what might work in particular setting s. However , while such discussion s help place evidence in context and suggest how it may be used , they should not be confused with the evidence -based conclusions of a transparent , scientific review , which systematic ally attempts to find all the relevant evidence , appraises its strengths and limitations in a transparent fashion , and draws that evidence together in such a way that the more robust studies are given greater weight . Finally , the challenges are many . Evidence on interventions to improve public health is in short supply , particularly evidence on social determinants . Systematic review ers therefore face a real challenge in making best use of the sometimes poor , often sparse and usually heterogeneous evidence available to them . It is easy to set narrow inclusion criteria for a review and then sift through the evidence before concluding that there is n’t enough – and what there is , is n’t very good anyway . Such “ evidential nihilism ” is probably not helpful to decision-makers , and public health systematic review ers need to continue to develop new methods and better frameworks within which different types of research evidence can be integrated to inform decision-making . Publishing systematic review s in the Bulletin should give an added impetus to this ongoing work . This paper examines the evidence demonstrating the effectiveness of sealants in high-caries-risk children and discusses the Research Triangle Institute/University of North Carolina 's ( RTI/UNC ) systematic review . The strict RTI/UNC protocol limited the number of sealant studies that could be included . This analysis exp and ed their criteria to permit additional methods of determining caries risk ( for example , past caries experience , less than two pairs of sound first permanent molars available/child in half-mouth design s ) and outcome measures in addition to DMFS ( that is , percent sealant retention , survival rates , cost-effectiveness , changes in salivary S. mutans levels ) . Nine clinical studies with a r and omized , half-mouth , clinical trial design and seven studies with observational study design s were included . There is good evidence that  sealants can be used efficaciously and effectively in high-risk  children as long as the sealant is retained . Sealants are more effective in preventing further caries and providing cost savings in a shorter time span if placed in children who have high rather than low caries risk Background To report the results of an audit concerning research gaps in clinical trials that were accepted for appraisal in authored and published systematic review s regarding the application of glass-ionomer cements ( GIC ) in dental practice Methods Information concerning research gaps in trial precision was extracted , following a framework that included classification of the research gap reasons : ‘ imprecision of information ( results ) ’ , ‘ biased information ’ , ‘ inconsistency or unknown consistency ’ and ‘ not the right information ’ , as well as research gap characterization using PICOS elements : population ( P ) , intervention ( I ) , comparison ( C ) , outcomes ( O ) and setting ( S ) . Internal trial validity assessment was based on the underst and ing that successful control for systematic error can not be assured on the basis of inclusion of adequate methods alone , but also requires empirical evidence about whether such attempt was successful . Results A comprehensive and interconnected coverage of GIC-related clinical topics was established . The most common reasons found for gaps in trial precision were lack of sufficient trials and lack of sufficient large sample size . Only a few research gaps were ascribed to ‘ Lack of information ’ caused by focus on mainly surrogate trial outcomes . According to the chosen assessment criteria , a lack of adequate r and omisation , allocation concealment and blinding/masking in trials covering all review ed GIC topics was noted ( selection - and detection/performance bias risk ) . Trial results appear to be less affected by loss-to-follow-up ( attrition bias risk ) . Conclusion This audit represents an adjunct of the systematic review articles it has covered . Its results do not change the systematic review ’s conclusions but highlight existing research gaps concerning the precision and internal validity of review ed trials in detail . These gaps should be addressed in future GIC-related clinical research Background A systematic review , with or without a meta- analysis , should be undertaken to determine if the research question of interest has already been answered before a new trial begins . There has been limited research on how systematic review s are used within the design of new trials , the aims of this study were to investigate how systematic review s of earlier trials are used in the planning and design of new r and omised trials . Methods Documentation from the application process for all r and omised trials funded by the National Institute for Health Research Health Technology Assessment ( NIHR HTA ) between 2006 and 2008 were obtained . This included the : commissioning brief ( if appropriate ) , outline application , minutes of the Board meeting in which the outline application was discussed , full application , detailed project description , referee comments , investigator response to referee comments , Board minutes on the full application and the trial protocol . Data were extracted on references to systematic review s and how any such review s had been used in the planning and design of the trial . Results 50 r and omised trials were funded by NIHR HTA during this period and documentation was available for 48 of these . The cohort was predominately individually r and omised parallel trials aim ing to detect superiority between two treatments for a single primary outcome . 37 trials ( 77.1 % ) referenced a systematic review within the application and 20 of these ( i.e. 41.7 % of the total ) used information contained in the systematic review in the design or planning of the new trial . The main areas in which systematic review s were used were in the selection or definition of an outcome to be measured in the trial ( 7 of 37 , 18.9 % ) , the sample size calculation ( 7 , 18.9 % ) , the duration of follow up ( 8 , 21.6 % ) and the approach to describing adverse events ( 9 , 24.3 % ) . Boards did not comment on the presence/absence or use of systematic review s in any application . Conclusions Systematic review s were referenced in most funded applications but just over half of these used the review to inform the design . There is an expectation from funders that applicants will use a systematic review to justify the need for a new trial but no expectation regarding further use of a systematic review to aid planning and design of the trial . Guidelines for applicants and funders should be developed to promote the use of systematic review s in the design and planning of r and omised trials , to optimise delivery of new studies informed by the most up-to- date evidence base and to minimise waste in research Three years ago , we founded this journal focusing on publishing systematic review s , systematic review protocol s , and associated method ological development papers . Systematic review s , which developed in the social sciences in the 1970s , began to gain rapid momentum during the 1990s in response to concerns by policymakers and clinicians about the scientific validity of the prevailing paradigm of traditional narrative review s written by authoritative experts . What distinguished systematic review s was the use of formal explicit methods , in other words pre-specification , of what exactly was the question to be answered , how evidence was search ed for and assessed , and how it was synthesized in order to reach the conclusion . Importantly , these formal methods were described as part of the review itself in a Methods section . In turn , these methods themselves became the subject of hypothesis-testing studies , as investigators sought how best to search for evidence , assess studies for quality or risk of bias , determine under what conditions meta- analysis was justified , and how to best determine and characterize our confidence in the conclusions . The results of these hypothesis-testing studies led over time to improvements in the methods we use for systematic review s. Thus , systematic review s and this journal are part of an ever-evolving process whose foundations are rooted in the scientific method . Today , new forms of review s are appearing . These have emerged in response to policymakers and other stakeholders ’ needs for information , sometimes emergently or urgently , for which the existing systematic review model does not quite fit . Hence , the rapid review , when time is of the essence ; the scoping review , when what is needed is not detailed answers to specific questions but rather an overview of a broad field ; the evidence map , a cousin of scoping review s that commonly has a specific visual presentation of the evidence across a broad field ; and the realist review , where the question of interest includes how and why complex social interventions work in certain situations , rather than assume they either do or do not work at all . As Editors , we regularly get contacted by prospect i ve authors asking whether realist review s , or scoping review s , etc . , are “ within the scope ” for Systematic Review s , and therefore we judge it an opportune time to state our position on this matter . It is our view that all of these new forms of review s are related to systematic review s , similar to the way that different biological Species within the same Family are related to each other . We consider “ systematic review s ” to be the Family and the different forms of review s to be the different species . Just as in the biological classification , where the related organisms must share certain characteristics , so too must the different types of review s share a common characteristic . In this case , what is shared is their foundation in the scientific method , with their methods articulated in advance in sufficient detail that the review can be reproduced by others . A further defining feature is that there are scholars devoted to improving the methods over time via hypothesis-testing studies . Systematic Review s has responded to these emerging techniques and already publishes papers reporting methods and findings from the systematic review family and has for example published an extremely popular series on rapid review s. We would like to consoli date this position and invite su bmi ssion of these new species of review s , as long as they meet the qualifications just listed . We expect this process of evolution to continue and to refine the methods such that in 10 years ’ time , there will appear new , as yet unimagined species of review s— and perhaps some current species of review will become extinct . Thus , it is with the scientific method , which we believe is the foundation that unites the Family of systematic review AIM The aim of this study was to compare the caries-preventive effect of two types of sealant modalities and to evaluate whether the caries-preventive effect is related to sealant retention . A hypothesis was tested in which a glass ionomer sealant , once applied to the occlusal surface , was able to protect the fissure from caries even if the sealant appeared lost at visual inspection . DESIGN A 3-year r and omized split-mouth trial evaluating two sealant modalities was performed at a public health centre in Finl and . A chemically curing glass ionomer cement ( GIC ) and light-curing resin-based ( RB ) sealant material were applied r and omly to the permanent second molars . Sealant application as a routine treatment procedure was carried out to 599 children in the age group of 12 - 16 years .  Caries rate of the sealed teeth and sealant retention with both material s were analysed by a modified McNemar 's test . The effectiveness , rate difference , and relative risk with both sealant material s were measured . RESULTS The difference in caries rate between the two modalities was highly significant . When compared to the GIC sealant method , the effectiveness of  RB sealant method was 74.1 % and the rate difference 3.2 % ( 95 % CI 1.44 % , 4.98 % ) . The relative risk for RB-sealed surfaces vs. GIC-sealed surfaces of having detectable dentin caries was 0.26 ( 95 % CI 0.12 , 0.57 ) . The retention rate of sealants was higher with RB than GIC ( P < 0.001 ) . The effectiveness of the retention rate for RB sealants was 94.8 % and the rate difference 87.2 % ( 95 % CI 83.86 % , 90.50 % ) . The relative risk during the 3-year study period of having a defective or lost RB sealant  was 0.052 ( 95 % CI 0.036 , 0.075 ) when compared to having a defective or lost GIC sealant . CONCLUSION It is concluded that in preventing dentin caries a RB sealant programme including resealing when necessary was more effective than a single application of GIC . The original hypothesis was thus falsified The m and ate of Human Reproduction Up date involves several roles : ( i ) to provide a synthesis of evidence that can aid scientists and clinicians in their daily work ; ( ii ) to help reproductive specialists underst and concepts from related disciplines ; and ( iii ) to summarize current knowledge generated by basic science as the foundation of future scientific and clinical advancement . Given that review and synthesis are central to good scientific and clinical practice , and that a grasp of the current state of knowledge is a prerequisite to design ing new studies , it is pertinent to ask which review s are most likely to fulfil the needs of readers . A related question concerns whether systematic review s meet the needs of all review topics and all readers . Summarizing evidence or knowledge is a difficult problem in reproductive medicine , as in other branches of science and medical care ( Eddy et al. , 1992 ) . For each question there may be multiple studies that use different design s and inclusion criteria . For clinical questions , the interventions , outcomes and measures of effect may vary : the effect measures in treatment studies include odds ratios , relative risks and absolute differences . For scientific questions , the experimental species , models and design s may differ . Moreover , it is always uncertain whether all of the relevant evidence has been evaluated . Even when the search has been exhaustive , there are no simple guides on how to interpret conflicting results and whether to accept apparently outlying studies . The choices that the review er makes to address the variable conditions and uncertainties may be conservative , strict and exclusive , or liberal , open and inclusive . The decisions made by the review er may not be consistent throughout and these choices may or may not satisfy the reader who seeks out the review to address a clinical or research question . Faced with uncertainty and doubt , readers nonetheless must form an impression of the evidence and synthesize the state of knowledge in order to address the clinical or research question that stimulated their interest in the review . We argue that the reader is better served when the choices made in the review , regardless of whether they are strict or open , should be explicit , transparent , clearly stated and reproducible by interested readers . This list of objectives for review s is more easily satisfied by systematic review s , which use explicit methods to method ically search , critically appraise and synthesize the available literature on a specific issue . The question or issue need not be clinical : indeed , the concept evolved primarily in psychology studies ( Light and Pillemer , 1984 ) . The systematic review attempts to reduce review er bias through the use of objective , reproducible criteria to select relevant individual publications and assess their validity . A systematic review may include a meta- analysis or statistical summary of the individual study results : the aggregate of effects from several studies yields an average treatment effect that is more precise than the individual study results ( Schlesselman and Collins , 2003 ) . Thus , the systematic review involves explicit , transparent methods which are clearly stated , and reproducible by others . Whether a systematic review of r and omized controlled trials adheres to the guidelines can easily be evaluated by means of a widely used checklist ( the QUORUM statement ) ( Moher et al. , 1999 ) . The strengths of the systematic review include the narrow focus of the question , the comprehensive search for evidence , the criterion-based selection of relevant evidence , the rigorous appraisal of validity , the objective or quantitative summary , and the evidence -based inferences ( Cook et al. , 1997 ) . For some review topics , however , the strengths of the systematic review may turn into weaknesses . The primary problem is that the narrow focus and prescribed methods of the systematic review do not allow for comprehensive coverage . For example , the historical review is an irreplaceable means of tracing the development of a scientific principle or clinical concept , but the narrative thread could be lost in the strict rules of systematic review . As other examples , it would be burdensome to apply systematic methods to a survey on  aneuploidy and fertility in the aging female or to an assessment of mouse knockout models and polycystic ovarian phenotype . Such topics would require the wider scope of a traditional narrative review , in Human Reproduction Up date , Vol.11 , No.2 pp . 103–104 , 2005 doi:10.1093/humupd/dmh058 Advance Access publication December 23 , To investigate the effectiveness of topical fluorides in preventing fissure caries , we conducted a r and omized controlled trial with parallel groups . In total , 501 children ( 1,539 molars , 3,078 sites ) , mean age 9.1 years , who had at least one sound permanent first molar with deep fissures or fissures with signs of early caries were recruited . They were r and omly allocated among four groups : ( 1 ) resin sealant , single placement ; ( 2 ) 5 % NaF varnish , semi-annual application ; ( 3 ) 38 % silver diamine fluoride ( SDF ) solution , annual application ; and ( 4 ) placebo control . Follow-up examinations were conducted every 6 months by a masked examiner . After 24 months , 485 children ( 97 % ) were examined . Proportions of pit/fissure sites with dentin caries in the sealant , NaF , SDF , and control groups were 1.6 % , 2.4 % , 2.2 % , and 4.6 % , respectively . A multi-level logistic regression analysis accounting for the effects of data clustering and confounding factors showed that fissures in any of the three treatment groups had significantly lower risks of carious cavity development into dentin than did controls ( p < 0.05 ) . We concluded that placement of resin sealant , semi-annual application of NaF varnish , and annual application of SDF solution are all effective in preventing pit and fissure caries in permanent molars ( Clinical Trials.gov number CT01446107 ) The aim of this study was to compare the retention and caries preventive efficacy of glass ionomer ( Fuji III ; GIC ) and light-cured resin-based ( Delton ; LCR ) fissure sealants .  One hundred and sixty-six 5 - 14-year-old schoolchildren received sealants on their newly erupted first or second molars ; a split mouth design was used . Previously reported 2-year results showed low retention rates for GIC sealants , but no difference in the caries increment between the groups . The same persons were invited to a dental check-up 6.1 to 7.8 ( mean 7.1 ) years after the application of sealants ;  111 persons ( 66.8 % of the original group ) participated in the study . The retention of sealants , and the caries status of occlusal surfaces and adjacent proximal surfaces was recorded . On the sealed occlusal surfaces , 10 % of GIC and 45 % of LCR sealants were totally and 9 % of GIC and 20 % of LCR sealants partially present . Twenty-three ( 23.5 % ) of the occlusal surfaces sealed with GIC and 16 ( 16.5 % ) of those sealed with LCR were carious or filled . Compared to LCR sealants , the effectiveness of GIC sealants  was -44 % ( 95 % CI -71 % , -16 % ) and net gain -7 % ( 95 % CI -18 % , 4 % ) . The relative risk of caries occurring was 1.44 ( 95 % CI 0.96 , 2.14 ) Background The resin-based pit and fissure sealant is considered a successful tool in caries prevention , however there is a growing evidence of its use in controlling already established caries in posterior teeth . The aim of this clinical trial is to verify the efficacy of pit and fissure sealants in arresting dentinal caries lesions compared to partial excavation and restorative treatment in primary molar teeth . Methods Thirty six patients with occlusal cavitated primary molar reaching outer half of dentin were selected . The patients were r and omly allocated into two groups : sealant application ( experimental group – n = 17 ) and restoration with composite resin ( control group – n = 19 ) . Clinical and radiograph evaluation were performed after 6 , 12 and 18 months . The chi-square test was used to verify the distribution of characteristics variables of the sample among the groups . The survival rate of treatments was evaluated using Kaplan – Meier survival and log-rank test . Fisher ’s Exact and logistic regression tests were calculated in each evaluation period ( α = 5 % ) . Results The control group showed significantly better clinical survival after 18 months ( p = 0.0025 ) . In both groups , no caries progression was registered on the radiographic evaluations . Conclusions Sealing had similar efficacy in the arrestment of caries progression of cavitated occlusal lesions compared to partial excavation of the lesions , even though the frequency of re-treatments was significantly higher in sealed lesions . Trial registration Registro Brasileiro de Ensaios Clínicos ( ReBEC ) : The aim of the present trial was to ( 1 ) compare the caries-preventive effect of glass ionomer sealants , placed according to the atraumatic restorative treatment ( ART ) procedure , with composite resin sealants over time and ( 2 ) investigate the caries-preventive effect after complete disappearance of sealant material . Forty-six boys and 57 girls , mean age 7.8 years , were r and omly divided into two treatment groups in a parallel-group study design . A light-polymerized composite resin sealant material and a high-viscosity glass ionomer were each placed in 180 fully erupted first molars in their respective treatment groups . Evaluation took place annually for 5 years by calibrated examiners . After 5 years , 86 % composite resin and 88 % glass ionomer sealants did not survive . Three categories of re-exposure periods for caries development in pits and fissures after complete loss of sealants were distinguished : 0–1 , 1–2 and 2–3 years . In the 2- to 3-year group , 13 and 3 % of pits and fissures previously sealed with composite resin and glass ionomer , respectively , were diagnosed as having developed a dentine lesion . The relative risks ( 95 % CI ) of dentine lesion development in surfaces sealed with glass ionomer compared to those sealed with composite resin after 3 , 4 and 5 years were 0.22 ( 0.06–0.82 ) , 0.32 ( 0.14–0.73 ) and 0.28 ( 0.13–0.61 ) , respectively . The relative risks of dentine lesion development in pits and fissures previously sealed with glass ionomer compared with composite resin over re-exposure periods of 1–2 and 2–3 years were 0.26 ( 0.14–0.48 ) and 0.25 ( 0.09–0.68 ) , respectively . We conclude that the caries-preventive effect of high-viscosity glass ionomer sealants , placed using the ART procedure , was between 3.1 and 4.5 times higher than that of composite resin sealants after 3–5 years . Furthermore , high-viscosity ( ART ) glass ionomer sealants appear to have a four times higher chance of preventing caries development in re-exposed pits and fissures of occlusal surfaces in first molars than light-cured composite resin sealant material over a 1- to 3-year period . A well- design ed clinical trial using different types of oral health personnel should be implemented to confirm these initial results The aims of the present study were to evaluate the retention and caries-preventive effect of a single application of a light-cured resin-reinforced glass-ionomer cement ( Vitrebond ) in pits and fissures of newly erupted permanent first and second molars , when compared with a single application of a resin-based sealant ( Concise White Sealant ) during a 3-year period . The study group comprised 73 pairs of contralateral newly erupted permanent first and second molars ( 136 fissure sites ) in 53 children ( 29 girls , 24 boys ) . A split-mouth experimental design was used in which the two sealants were r and omly allocated to one of the teeth within each pair . Acid etching was not used before application of the glass-ionomer cement . The sealed teeth were checked for retention and caries after 1 , 6 , 12 , 24 and 36 months . The resin-based sealant was almost totally retained after 3 years ( 97 % ) and there was no caries in these teeth . The glass-ionomer cement was increasingly lost and could be observed in only 9 % of the sealed sites after 3 years . Carious lesions developed in 10 ( 7.4 % ) sites ( nine teeth , seven children ) . It was concluded that the resin-based sealant is superior to the glass-ionomer cement in preventing caries , and that the superior retention of the resin probably is an important factor for this To evaluate the retention and caries experience effects of three different material s used as fissure sealants after 24 months of clinical application : a resin-modified glass ionomer cement ( A ) , a flowable resin composite ( B ) and a compomer ( C ) .  One hundred and seventeen ( 117 ) teeth were sealed with material A , 119 teeth with material B and 120 teeth with material C. Children were r and omly assigned . Each one received only one of the material s studied .  Plaque index , dmft score and socioeconomic level were scored at baseline . The clinical exams were conducted 6 , 12 and 24 months after application of the sealant . Statistical analysis ( Kruskal-Wallis ) revealed that there were statistically significant differences between the retention rates of groups A and B and between groups B and C after 2 years , with material B showing better results . After 2 years , 3.1 % of the teeth of group A , 4.3 % of group B and 6.7 % of group C were Carious+Filled . There was no evidence of association between caries presence after 2 years and plaque index , dmft score and socioeconomic level . These results suggest that flowable resin composite had a satisfactory retention after this period of evaluation and all three material s were effective on occlusal caries prevention PURPOSE Pit and fissure sealants reduce occlusal caries when proper patient selection and application techniques are followed . To increase retention rate of sealants over time , good adaptation and deep sealant penetration are important . Studies remain inconclusive , however , as to determining if the bur preparation of pits and fissures would increase the adaptation and penetration thus improving sealant retention . The aim of this study was to assess if tooth preparation prior to sealant application improves sealant retention . METHODS In this prospect i ve cohort study , 43 children and adolescents from 4 Hutterites colonies were , for 3 years , bussed to the University of Manitoba pediatric dental clinic , Winnipeg , Manitoba , Canada , for comprehensive dental care including  sealant placement  using st and ard procedures . These came from a community with homogeneous social economical status , dietary habits , fluoride intake , and lifestyles . The decision of tooth preparation prior to sealant application was made ad hoc . Of 122 treated permanent posterior teeth , 54 had been treated as preventive resin restorations ( PRRs , type A or B ) and 68 were nonprepared sealants .  RESULTS After 1 year , teeth prepared ( type B PRRs ) and restored with flowable composite resins had significantly ( P<.01 ) lower retention rates ( 27 % vs 63 % ) than did teeth with nonprepared sealants or typeA PRRs . Teeth prepared ( type B PRRs ) were also significantly ( P<.001 ) more likely to have caries on follow-up examination ( 50 % vs 11 % ) than were teeth with nonprepared sealants or type A PRRs . CONCLUSIONS These results suggest that preventive resin type B restorations restored with flowable composites are not helpful in terms of retention or caries reduction Background To improve quality of care and patient outcomes , health system decision-makers need to identify and implement effective interventions . An increasing number of systematic review s document the effects of quality improvement programs to assist decision-makers in developing new initiatives . However , limitations in the reporting of primary studies and current meta- analysis methods ( including approaches for exploring heterogeneity ) reduce the utility of existing syntheses for health system decision-makers . This study will explore the role of innovative meta- analysis approaches and the added value of enriched and up date d data for increasing the utility of systematic review s of complex interventions . Methods / Design We will use the data set from our recent systematic review of 142 r and omized trials of diabetes quality improvement programs  to evaluate novel approaches for exploring heterogeneity . These will include exploratory methods , such as multivariate meta-regression analyses and all-subsets combinatorial meta- analysis . We will then up date our systematic review to include new trials and enrich the data set by surveying authors of all included trials . In doing so , we will explore the impact of variables not , reported in previous publications , such as details of study context , on the effectiveness of the intervention . We will use innovative analytical methods on the enriched and up date d data set to identify key success factors in the implementation of  quality improvement interventions  for diabetes . Decision-makers will be involved throughout to help identify and prioritize variables to be explored and to aid in the interpretation and dissemination of results . Discussion This study will inform future systematic review s of complex interventions and describe the value of enriching and updating data for exploring heterogeneity in meta- analysis . It will also result in an up date d comprehensive systematic review of diabetes quality improvement interventions that will be useful to health system decision-makers in developing interventions to improve outcomes for people with diabetes . Systematic review registration PROSPERO registration no. Prediction models in health care aim to predict for an individual whether a particular outcome , such as disease , is present ( diagnostic models ) or whether it will occur in the future ( prognostic models ) ( 16 ) . Diagnostic models can be used to refer patients for further testing , to initiate treatment , or to inform patients . Prognostic models can be used to aid decisions about preventive lifestyle changes , therapeutic interventions , or monitoring strategies or to stratify risk in r and omized trial design and analysis ( 7 , 8) . Potential users of prediction models include health care professionals , policymakers , guideline developers , patients , and the general public . The medical literature contains thous and s of studies developing and validating prediction models and often has numerous prediction models for the same target population and outcomes . For example , more than 60 models address breast cancer prognosis ( 9 ) , more than 250 exist in obstetrics ( 10 ) , and nearly 800 predict outcomes in patients with cardiovascular disease ( 11 ) . This proliferation of prediction models will increase further with the growth of personalized or precision medicine . Systematic review s are considered the most reliable form of evidence when addressing r and omized therapeutic studies and studies of diagnostic test accuracy ( 12 ) . In the era of personalized and precision medicine , interest in systematic review s of prediction model studies is rapidly growing , as exemplified by the formation of the Cochrane Prognosis Methods Group to support systematic review s of prognosis , including prediction model studies ( 13 , 14 ) . Guidance to facilitate systematic review s of prediction models has been developed ( Table 1 ) , including for search strategies ( 15 , 4143 ) , formulation of the review question ( 16 , 17 ) , data extraction ( 16 ) , and meta- analysis ( 17 , 2225 , 40 , 44 , 45 ) . Table 1 . Guidance on Conducting Systematic Review s of Prediction Model Studies  Assessment of risk of bias ( ROB ) is an essential step in any systematic review . Shortcomings in study design , conduct , and analysis can result in study estimates being at ROBthat is , at risk of results being flawed or distorted . When interpreting results from a systematic review , readers can draw stronger conclusions from a review based on primary studies at low ROB than from one based on studies at high or unclear ROB ( 46 ) . Identifying the studies most relevant to the setting s and population s targeted in the review ( based on the applicability of primary studies to the review question ) is also important . We therefore developed PROBAST ( Prediction model Risk Of Bias ASsessment Tool ) to address the lack of suitable tools design ed specifically to assess ROB and applicability of primary prediction model studies . PROBAST consists of 4 domains containing 20 signaling questions to facilitate ROB assessment ( 39 ) . The structure and rating system are similar to those in tools design ed to assess ROB in r and omized trials ( revised Cochrane ROB Tool [ ROB 2.0 ] ) , diagnostic accuracy studies ( QUADAS-2 [ Quality Assessment of Diagnostic Accuracy Studies 2 ] ) , and systematic review s ( ROBIS ) ( 37 , 47 , 48 ) . Although PROBAST was design ed for use in systematic review s of prediction model studies , it can also be used as a general tool for critical appraisal of ( primary ) prediction model studies . Here , we describe the rationale behind the domains and signaling questions , how to use them , and how to reach domain-level and overall judgments about ROB and applicability of primary studies to a review question . At the Web site ( www.probast.org ) , 5 filled-in examples from across the medical field illustrate these processes . Because this is an area of active research , the tool , examples , and accompanying guidance will be up date d when needed , and the latest version of PROBAST should always be downloaded from the Web site . Focus of PROBAST PROBAST is design ed to assess primary studies that develop , vali date , or up date ( for example , extend ) multivariable prediction models for diagnosis or prognosis ( Boxes 1 and 2 ) . A multivariable prediction model is defined as any combination or equation of 2 or more predictors ( such as age , sex , symptoms , signs , disease stage , or biomarkers ) for estimating for an individual the probability or risk of having ( diagnosis ) or developing ( prognosis ) a particular outcome ( 1 , 4 , 68 , 49 , 50 ) . Other names for prediction model include risk prediction model , predictive model , prediction index or rule , and risk score ( 1 , 38 , 4951 ) . Box 1 . Types of diagnostic and prognostic modeling studies or reports addressed by PROBAST . Adopted from the TRIPOD ( Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis ) and CHARMS ( CHecklist for critical Appraisal and data extraction for systematic Review s of prediction Modelling Studies ) guidance ( 8 , 16 ) . Box 2 . Differences between diagnostic and prognostic prediction model studies . PROBAST = Prediction model Risk Of Bias ASsessment Tool . Diagnostic and Prognostic Models Diagnostic prediction models estimate the probability that a certain outcome , the target condition , is currently present . Diagnostic prediction model studies typically include individuals who are suspectedbut not yet knownto have the target condition . Prognostic prediction models estimate the probability that a future outcome or event will occur , such as death , disease recurrence , disease complication , or therapy response . The time period of prediction can vary from hours ( for example , preoperatively predicting postoperative nausea and vomiting ) to years ( for example , predicting lifelong risk for a coronary event ) . Although many prognostic models enroll patients with an established diagnosis , this does not have to be the starting point , as seen in models for predicting development of diabetes in pregnant women ( 52 ) or of osteoporotic fractures in the general population ( 53 ) . Consistent with the TRIPOD ( Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis ) statement ( 7 , 8) , PROBAST thus broadly defines prognostic models as those predicting a future outcome in persons at risk for that outcome . Diagnostic and prognostic model studies often use different terms for predictors and outcomes ( Box 2 ) . The cancer literature frequently distinguishes between prognostic and predictive models , such that predictive models identify individuals with differential treatment effects ( 54 ) . These types of ( predictive ) models are outside the scope of this article . Types of Predictors , Outcomes , and Modeling Techniques PROBAST can be used to assess any type of diagnostic or prognostic prediction model aim ed at individualized predictions regardless of the predictors used ; outcomes being predicted ; or methods used to develop , vali date , or up date ( for example , extend ) the model . Predictors range from demographic characteristics , medical history , and physical examination results ; to imaging results , electrophysiology , blood , urine , or tissue measurements , and disease stages or characteristics ; to results from omics and other new biological measurements . Predictors are also called covariates , risk indicators , prognostic factors , determinants , index test results , or independent variables ( 4 , 68 , 49 , 50 , 55 , 56 , 57 ) . PROBAST distinguishes between c and i date predictors and predictors included in the final model ( 57 ) . C and i date predictors are variables considered potentially predictive of the outcome presence ( diagnosis ) or occurrence (prognosis)that is , all those evaluated in the study regardless of whether they are included in the final multivariable model . PROBAST primarily addresses prediction models for binary and time-to-event outcomes because these are the most common in medicine . However , the tool can also be used to assess models predicting nonbinary outcomes , such as continuous scores ( for example , pain scores or cholesterol levels ) or categorical outcomes ( for example , the Glasgow Coma Scale ) . Almost all PROBAST signaling questions apply equally to continuous and categorical outcomes , except questions addressing number of outcome events per predictor and certain measures of model performance ( such as the c-statistic ) , which are not relevant to continuous outcomes . Prediction models usually involve regression modeling techniques , such as logistic regression or survival models . Prediction models may also be developed or vali date d using nonregression techniques , such as neural networks , r and om forests , or support vector machines . As the use of routine care ( and big ) data increases , additional modeling techniques are becoming more common , including machine and artificial learning models . The main differences between studies using regression and other types of prediction modeling include the methods of data analysis ; nonregression development models can often have greater risks of overfitting when data are sparse , and the potential lack of transparency can affect the applicability and usability of the models . In the section on tailoring PROBAST with additional signaling questions , we provide guidance about how PROBAST can be adapted to address other types of outcomes and modeling techniques . Types of Review Questions PROBAST can be used to assess different types of systematic review questions . For some review questions , all prediction model studies are relevant ( including both development and validation ) , but for other questions only validation studies are relevant . Box 3 gives examples of potential review questions for both prognostic and diagnostic prediction models where PROBAST is applicable . CHARMS ( CHecklist for critical Appraisal and data extraction for systematic Review s of prediction Modelling Studies ) and Table 2 provide explicit guidance on how to frame a focused question for review s of prediction model studies ( 16 , 17 ) . Box 3 . Examples of systematic review questions for which PROBAST is suitable . There are various different questions that systematic review s OBJECTIVE The hypotheses tested were : the cumulative survival rates of dentin caries lesion-free pits and fissures of ART conventional high-viscosity glass-ionomer sealants with light-curing ( high-intensity LED ) and glass-carbomer sealants are higher than those of conventional ART sealants and resin-composite sealants after 4 years . METHODS The r and omized controlled clinical trial covered 405 children ( mean age 8-years ) . Three dentists placed sealants in pits and fissures of high caries-risk children . Evaluation by two independent evaluators was conducted after 0.5 , 1 , 2 , 3 and 4 years . The Kaplan-Meier survival method , ANOVA and t-test were used in data analyses . RESULTS 1304 first permanent molars were sealed . 12.3 % of children and 15.4 % of sealants dropped out . 46 re-exposed pits and fissures , 39 ( occlusal ) 7 ( free smooth surfaces ) , in 42 children developed a dentin carious lesion . The cumulative survival of dentin caries lesion-free occlusal pits and fissures in ART plus LED group ( 98 % ) was statistically significantly higher than in the resin-composite group ( 96.4 % ) and in the glass-carbomer group ( 94.5 % ) . The cumulative survival of dentin caries lesion-free occlusal pits and fissures in the glass-carbomer group was statistically significantly lower than that in the conventional ART group ( 97.3 % ) . For the free smooth surfaces , there was no statistically significantly difference among the four sealant groups . SIGNIFICANCE Light-cured ART conventional high-viscosity glass-ionomer sealants prevented the occurrence of dentin cavities best
The content of these signals suggest that higher precision of the current systematic review results might be achieved if an up date of the current review were conducted at this point in time .
However , these signals further indicate that such systematic review up date , despite its higher precision , would only confirm the existing review conclusion that no statistically significant difference exists in the caries-preventive effect of GIC and resin-based fissure sealants .
In conclusion , this study demonstrated the modified Ottawa method as an effective tool in establishing the up date need of the systematic review .
OBJECTIVE To demonstrate the application of the modified Ottawa method by establishing the up date need of a systematic review with focus on the caries preventive effect of GIC versus resin pit and fissure sealants ;  to answer the question as to whether the existing conclusions of this systematic review are still current ; to establish whether a new up date of this systematic review was needed .