Date: January 30, 2001

To,

Phil Alderson, Associate Director (Training)
UK Cochrane Centre, Summertown Pavilion,
Middle Way, Oxford OX2 7LG, UK

Sub: Application for The Cochrane Collaboration Sheiham Public Health and Primary Care Scholarship

Sir,

I am very keen to learn the skills required to do a Cochrane Systematic Review. Since there is no such training available in India, the Sheiham Scholarship would enable me to get it right where it is all happening- the Mecca of EBD, Oxford. Hence I would like to submit my candidature for this scholarship. I have enclosed all the required documents and information as mentioned in the scholarship leaflet. These include:
1. Full curriculum vitae.
2. Full names and addresses (including e-mail address) of three referees.
3. A detailed outline of work already done on systematic reviews or clinical trials, including an outline of experience with quantitative data
4. The suggested topic for review, with a write-up explaining the relevance to public health and primary care.
5. Confirmation from Cochrane Oral Health CRG that the topic has been agreed.

While assessing my eligibility for the scholarship, I request consideration of the following:
Ø The concept of a Cochrane review is almost unheard of in India, at least in the field of oral health care. In the field of general health care, only 13 reviews have been done or are under different stages of completion (by an Indian reviewer). None exists, however, in the field of oral health care. The patients needing oral health care stand to benefit greatly from such reviews. A beginning has to be made to make these skills available in India.
Ø Even though I lack previous experience in doing a systematic review or dealing with quantitative data (which I suppose is a pre-requisite for gaining the scholarship), my conviction and enthusiasm to do one should make me eligible for gaining the scholarship. Further, the Oral Health Group at Oxford has been very supportive in my attempt to get involved in the process of doing a Cochrane Systematic Review. In fact, the words of Emma Tavender, the Group Co-ordinator, go much more beyond that. To quote her "Whilst you are based here in the UK we would be happy to support you through the review process and maybe you would like to work here in Manchester for a period of time?" She adds, "…you have the support of the Cochrane Oral Health Group editorial team who have offered their assistance in the completion of a systematic review and subsequent training".
Ø Moreover, I am actively involved (as one of the founding directors) in the activities of our Centre for Evidence-Based Dentistry and Informatics (more information at http://www.cods.net/cebd/). We shall be conducting the first ever workshop on EBD on the 10th & 11th of March 2001 (details at http://www.cods.net/cebd/workshop.htm). Dr. Derek Richards (Director, CEBD, Oxford, UK) and Dr. Osbjorn Jokstad (Assoc. Editor, EBD Journal, Norway) shall be conducting this workshop for our centre. Prior to the workshop, they shall conduct an instructional course for some of us at the centre. This course shall cover systematic reviews as well as other evidence-based dentistry topics.
Ø About 100 senior teachers are expected to attend the workshop. The Vice-Chancellor of our state's health university and his senior staff, and the President of the central regulatory authority 'Dental Council of India' will also be attending. Their presence is an acknowledgement that EBD has arrived in India and that the activity generated by us shall be sustained on a wider scale. This is surely going to create a lot of interest in things like systematic review. If I get trained in the skills required to do systematic reviews, the same can be imparted to others locally. The Oxford team can even come here to do the good deed themselves.

Sir, I hope this information gives a better perspective when looking at my application.

Although it may seem a little premature to mention, I must make it known that the period between June to September is the most suitable for me to avail the scholarship (at least as far as the year 2001 is concerned). The full set of application documents is also being faxed to you. I shall be eager to provide any more information with regard to this application.

I await your decision. With regards,

Yours truly,

Dr. Shailesh Lele

(Total number of pages faxed including this application= 9)

Professional Designation & Address:
Senior Professor & Head, Department of Oral Medicine & Radiology, College of Dental Sciences, Davangere-577004
Tel. No.: 91-8192-31285 Fax: 91-8192-51070
e-mail: lelesgs@vsnl.com

Residential Address:
A-5, Indragiri, BEA Staff Quarters, Anjaneya Layout, Davangere-577004
Tel. No.: 91-8192-20023 e-mail: lelesgs@vsnl.com

Professional Qualification:
B.D.S.: University of Bombay, June 1983 *1st Rank in two subjects: Oral Medicine & Radiology, Pedodontia
M.D.S.: University of Bombay, June 1986
Certificate Course in Computer Fundamentals: 1991

Other Skills:
Ø Sufficient knowledge and experience of computer applications such as word processor (MS Word), presentations (PowerPoint, Macromedia Director), graphics (CorelDraw, PhotoImapct, Photo Editor), spreadsheet (Excel), HTML (Macromedia Dreamweaver, FrontPage), WS_FTP, Sound Forge.
Ø Created about 60 presentations for undergraduate curriculum.
Ø Created (using Macromedia Dreamweaver) a web site for the department with about 26 web pages and 90 images (and still growing) depicting the faculty, facilities and activities of the department. The archive on the site hosts interesting case studies with clinical, laboratory, radiographic and histological records, and articles of interest (https://omr-cods.tripod.com/).
Ø Created (using Macromedia Dreamweaver) a web site for the Centre for Evidence-Based Dentistry & Informatics with about 40 web pages and several graphical images (self-created) depicting the Centre- and EBD-related information (http://www.cods.net/cebd/). The site is still under development.
Ø Clinical photography

Teaching Experience: 11 years teaching experience at
1. Bapuji Dental College & Hospital, Davangere
2. Government Dental College & Hospital, Bombay
3. Bharati Vidyapeeth's Dental College & Hospital, Pune
4. College of Dental Sciences, Davangere since 23rd August 1997 to-date.

Academic Activities:
Published 4 scientific papers
1. "Goals for oral health by 2000 AD- A review", Dental Dialogue, 14:1, 1989
2. "Resorption of permanent teeth- An overview", Journal of Indian Dental Association, 62:7, 1991
3. "Whose radiograph is it anyway" (editorial), Dental Dialogue, 16:1 & 2, 1991
4. "Gestant odontome- A case report", Dental Dialogue, 20:3, 1995

Attended 5 continuing education programs

Conducted a state level 'Hands-on' Course on Oral Digital Radiography & Photography, College of Dental Sciences, Davangere, September 1998

Guest Speaker presentations on
1. 'Computers in Public Health Dentistry' at the 4th National Conference of Indian Association of Public Health Dentistry, November 1998
2. 'Digital Imaging in Dentistry' at
Ø The 2nd Continuing Education Programme of Bapuji Dental Colleges Alumni Association, June 1999 and
Ø The Continuing Education Programme of Krupa Continuing Dental Education Wing, Bangalore, September 1999 3. 'Digital Imaging in Endodontics' at the National Endodontic Workshop at College of Dental Sciences, Davangere, November 2000

Best Paper Presentation Award for the presentation on 'Computer-Aided-Education' at the X National Conference of Indian Academy of Oral Medicine & Radiology, Mangalore, December 1998

Scientific paper presentation on 'X-ray Tube Head- The Inside Out story' at the XI National Conference of Indian Academy of Oral Medicine & Radiology, Navi Mumbai, December 1999 (also available in the archive at https://omr-cods.tripod.com/)

Lectures on 'Dissertation Writing' and 'Computers in Research' for postgraduate students of College of Dental Sciences, Davangere

Special Interests:
~ Science of higher education
~ Evidence-based dentistry
~ Computer and Internet applications in dental education
~ Photography

UP

Full names and addresses (e-mail address if possible) of three referees:

1. Dr. Anmol S. Kalha, Sr. Professor & Head, Department of Orthodontics, College of Dental Sciences, Pavilion Road, Davangere-577004, Karnataka, India
e-mail address: anmolkalha@hotmail.com

2. Dr. Ravindranath Sable, Professor & Head, Department of Orthodontics, B. V. Deemed University Dental College & Hospital, Dhanakawadi, Pune-411043, Maharashtra, India
e-mail address: avantis@pn2.vsnl.net.in

3. Dr. S. Madhava Murthy, Manager- Dental Division, Technical Department, Birla 3M Limited, Plot No. 48-51, Electronics City Hosur Road, Bangalore-561229, Karnataka, India e-mail: msmadhav@mmm.com

UP

Detailed outline of work already done on systematic reviews or clinical trials, including an outline of experience with quantitative data

Systematic reviews: None

Non-systematic reviews:
Ø As part of my dissertation work (in 1985-86, see below), I was required to do a review of literature relevant to the hypothesis of the study. All the studies cited in the bibliographies of textbook chapters, journal articles were hand-searched. The Index Medicus (Medline was unheard of in those days) and dental index were similarly hand-searched. Wherever full articles could be accessed, the contents were analyzed (not statistically, though) for their relevance to my study. The results of these relevant studies were summarized and included in the 'Review of Literature' section of the dissertation.
Ø I did a similar exercise prior to publication of an article titled "Resorption of permanent teeth- An overview" (in Journal of Indian Dental Association, 62:7, 1991).
Ø I have done similar reviews on digital imaging prior to conducting a 'Hands-on course of oral digital radiography & photography' and giving lectures on the same topic for various audiences.

Clinical trials and experience with quantitative data:
Ø "A comparative study of automatic processing versus manual" was the title of the dissertation that I submitted to University of Bombay in partial fulfillment of the requirements of the postgraduate course (Master of Dental Surgery).
Two identical periapical exposures of a site were made in 100 patients (after obtaining an informed consent). One film was processed in automatic processor, the other processed by the standard manual method. The radiographs so obtained were shown in a random order to three observers (who were blinded as to the method of processing) for critical evaluation along certain criteria. Their valuations were tabulated and analyzed statistically. The image quality was concluded to be equal in radiographs processed by the two methods (non-parametric test of significance was employed). A cost-benefit evaluation was also made.
Ø As a university examiner for the Master of Dental Surgery examinations, I am required to critically evaluate the submitted dissertations for methodology and statistical handling of data.

Bottom line:
Experience: Limited

Knowledge: Some! I have read the following resources on systematic reviews, clinical trials and quantitative data:

1. Cochrane Reviewers' Handbook 4.1 including the Appendices and Glossary
2. Style Guidelines for Cochrane Reviews
3. Randomized Controlled Trials: A User's Guide by Alejandro Jadad, BMJ Books, 1998.
4. Evidence-based practice Handbook, Dr. Anthony Staines, Department of Public Health Medicine and Epidemiology, University College Dublin.
5. Critical appraisal and using the literature, From the resources of School of Health and Related Research, The University of Sheffield
6. Systematic reviews: what are they and why are they useful? From the resources of School of Health and Related Research, The University of Sheffield

1. Systematic Reviews: Rationale for systematic reviews, C D Mulrow, BMJ 1994;309:597-599 (3 September)
2. Systematic Reviews: Reporting, updating, and correcting systematic reviews of the effects of health care, I Chalmers, B Haynes, BMJ 1994;309:862-865 (1 October)
3. Anticonvulsant drugs for management of pain: a systematic review, Henry McQuay, Dawn Carroll, Alejandro R Jadad, Philip Wiffen, Andrew Moore, BMJ 1995;311:1047-1052 (21 October) 4. Analgesic efficacy and safety of paracetamol-codeine combinations versus paracetamol alone: a systematic review, Anton J M de Craen, Giuseppe Di Giulio, Angela J E M Lampe-Schoenmaeckers, Alphons G H Kessels, Jos Kleijnen, Angela J E M Lampe-Schoenmaeckers, BMJ 1996;313:321-325 (10 August)
5. Letters to the editor: Systematic reviews provide information not contained in traditional narrative reviews, David Henry, BMJ 1997;314:1832 (21 June)
6. How to read a paper: Papers that report drug trials, Trisha Greenhalgh, BMJ 1997;315:480-483 (23 August)
7. How to read a paper: Papers that report diagnostic or screening tests, Trisha Greenhalgh, BMJ 1997;315:540-543 (30 August)
8. How to read a paper: Papers that summarise other papers (systematic reviews and meta-analyses), Trisha Greenhalgh, BMJ 1997;315:672-675 (13 September)
9. How to read a paper: Papers that go beyond numbers (qualitative research), Trisha Greenhalgh, Rod Taylor, BMJ 1997;315:740-743 (20 September)
10. Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy, Sally Green, Rachelle Buchbinder, Richard Glazier, Andrew Forbes, BMJ 1998;316:354-360 (31 January)
11. Letters to the editor: Medline and Embase complement each other in literature searches, David Woods, Kate Trewheellar, BMJ 1998;316:1166 ( 11 April )
12. Letters to the editor: Research questions for systematic reviews must be unambiguous from protocol stage, Gunther Eysenbach, BMJ 1999;319:1265 ( 6 November )

These and some other readings have convinced me that preparing systematic reviews is the need of the times. The patients stand to benefit greatly from them. So I am very keen to obtain training and experience in preparing systematic reviews. And what better place than Oxford to get that!

UP

The agreed topic for review: Pharmacological interventions for pain in patients with temporomandibular disorders (TMD)

Relevance of the review to public health and primary care

A sizeable number of patients in a hospital setting such as ours (a teaching institute with hospital services in dentistry) comprise TMD patients. The complex, multi-factorial and poorly understood pathogenesis and clinical course of TMD has led to appearance of a variety of management methods. Most of these methods are picked up from the senior teachers, from narrated experiences of colleagues or from a stray article in a journal. Little thought is given to validity and applicability of these methods in one's own patients. Mostly the outcome of such arbitrary management is unsatisfactory and patients suffer from the psychosocial and economic impact of the maltreated disorder.

One of the mainstays of management of TMD patients is prescribing a pharmacological agent either singly, but mostly in combination with another. Relief from or reduction in pain intensity is usually the aim of this pharmacotherapy. These agents can be broadly grouped under: nonopioid analgesics, opioids, corticosteroids, antidepressants, benzodiazepines and muscle relaxants. How far are the benefits, if any, real and how far by chance or other factors is not well established.

The data supporting the effectiveness of these, either singly or in combination, is said to be limited. Apparently, so also is the data supporting their utility when used in combination with other management methods such as physical therapy. The ease with which a prescription can be filled out may be causing unnecessary use or overuse (on account of chronicity of pain) of these agents. Drug toxicity that may result from this action needs to be seriously taken into consideration. On the other hand, there is a possibility that some agents such as opioids may be underutilized, thus depriving the patient of their benefits.

Lack of a clear-cut picture as to the utility, or otherwise, of the pharmacological interventions in TMD is to the detriment of public health. Whether drugs such as of the types mentioned above have a role in the primary care of TMD needs to be ascertained. If they do, their benefits need to be balanced with the costs and toxicity. If they don't, the resources being expended on them can be better utilized on other methods of management. A systematic review is most likely to provide an answer to this area of concern in the management of TMD. The statement made above about the limited data can also be validated as true or false. If true, the systematic review shall throw up pointers for further clinical research that needs to be carried out. If false, it is likely we shall know the answers to many a question in the management of TMD.

Either way a problem area in public health and primary care shall get suitably addressed. Individual patient, and the society at large stand to gain.

UP

From: Emma Tavender
To: Dr. Shailesh Lele
Subject: RE: Title Registration
Date: Tuesday, January 30, 2001 3:58 PM

Dear Shailesh

I have discussed your title with the editorial team and the Cochrane Pain and Palliative Care Group and the title 'Pharmacological interventions for pain in patients with temporomandibular disorders (TMD)' has been accepted. The Cochrane Pain and Palliative Care Group have also offered their support when you are ready to start working on the protocol. I look forward to working with you in the future and good luck with the Sheiham Scholarship Best wishes

Emma

UP