QUESTION 1

QUESTION 1

Step 1: Formulating a specific question (PICO)

a. What is the participants disorder/disease? What are the participants main

characteristics you may want to pay attention to?
808 participants, ages 4-13years, mixed deciduous and permanent teeth
b. What is the intervention? Overall and in details.
Dental flossing
In one study, professional flossing was performed for 1.7 years on school
days
In another study, three-monthly professional flossing for 3 years
In another study, self-performed flossing for 2 years
c. Is there a comparison?
Comparison of flossing and non-flossing groups
d. What are the outcomes the authors are examining?
Whether dental flossing reduces interproximal caries

QUESTION 2

Step 2: Literature review

a. What was the main research theme of the review? State three research
questions that relate to the review.
Whether dental flossing reduces interproximal caries
1: Whether professional flossing on patients aged 4-13 years reduces
interproximal caries
2: Whether unsupervised self-flossing on patients aged 4-13 years reduces
interproximal caries
3: What is the effect of dental flossing on primary vs permanent teeth?
b. What are the aims? Were they clearly defined?
Assess, systematically, the effect of flossing on interproximal caries risk

QUESTION 3

Step 3: Critically appraising the evidence to assess its validity

a. What type of publication was this? Is that primary or secondary research?

Secondary systematic review
b. Were the inclusion/exclusion criteria appropriate?
The treatment comparisons of interest included flossing vs. no flossing, or
a comparison of different frequencies of flossing use. Studies where the
effect of flossing could not be separated from the effects of other
treatments were excluded. The primary study outcome was a measure of
caries incidence. There were no restrictions with respect to the study
population. Study designs included in this synthesis were limited to
controlled clinical trials
c. Was a comprehensive literature search done? Was publication bias
assessed? What was the finding? Where would you search for information
apart from those sources searched by the authors?
 d. Was the validity of the primary studies assessed?
Trials were excluded from this review for the following reasons: no
assessment of the effect of flossing, absence of caries outcomes, no
control group that would have allowed flossing effects to be estimated, or
preliminary reports of the included studies
The quality assessment of the controlled trials revealed generally poor
reporting of the studies and the presence of a moderate to high risk of
bias
Whether they had random allocation, treatment allocation concealment,
blinding of outcomes assessors, presentation of point estimates with a
measure of variability for the primary outcome measure, eligibility criteria,
loss to follow-up, and missing values
e. Was the assessment of the studies reproducible?
Yes, the review states how the studies were included and summarised, and
also how the statistical data was calculated using an I^2 statistic
f. Were the results similar between studies?
4/6 studies were not statistically significant
4/6 studies reported that flossing decreased the relative caries risk by 19-
54%
g. Were the findings of the studies combined appropriately?
Used fixed effects model and random effects model to compare results
Stated weaknesses in the studies, and difficulty in interpreting the results
h. What is meta-analysis? When meta-analysis can be performed? i. What
were the main findings of the review?
Analysing combined findings from systematic reviews

QUESTION 4

Step 4: Applying the evidence

a. Were valid conclusions drawn from the findings in the review?

b. You are clinical leaders of a major dental health service agency. You are
developing clinical guidelines for clinicians in your agency. Patient advice
 on home care is being considered. How would you develop a guideline on
advising patients about flossing? Explain your decision.

c. What are the clinical implications (i.e., from a practice point of view) of this
systematic review?