Dental Statistics Made Easy 3rd Edition
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Contents
Preface to the Third Edition vii
Preface to the Second Edition xi
Preface to the First Edition xiii
1 Introduction 1
2 Planning a Study 9
3 Types of Study in Dental Research 23
4 Sampling 31
5 Randomized Controlled Trials 37
6 Ethical Considerations 47
7 The Normal Distribution 55
8 Diagnostic Tests 59
9 Sampling Variation 69
10 Introduction to Hypothesis Tests 81
11 Comparing Two Means 89
12 Dealing with Proportions and Categorical Data 97
13 Comparing Several Means 107
14 Regression, Correlation, and Agreement 117
15 Non-Normally Distributed Data 129
16 The Choice of Sample Size 135
v
vi CONTENTS
17 Evidence-based Dentistry 141
18 Statistical Refereeing 149
Appendix 159
Solutions to Exercises 169
References 187
Index 191
Preface to the Third Edition
My background in teaching dental statistics goes back to the early
1990s, when I became engaged in introducing the basics of study
design and data analysis to undergraduate dental students at the very
start of their professional training. This experience was supplemented
by visits to dental practical sessions (complete with lab coat) where I
was able to see first hand the collection of data such as salivary flow
rates. At that time, medical students were able to choose from a range
of medical statistics texts, whereas there were few introductory statistics
books written specifically with dental training in mind. In addition,
it was not uncommon for dental students to feel challenged by the
mathematical approach then in common use.
This gap in student learning resources was initially addressed
through the development of tailored course notes that included guided
tutorials along with detailed solutions. In addition, students were
introduced to dental journal literature through articles on major issues
such as the fluoridation of public water supplies and dental health pro-
vision in areas of deprivation. The material was well received by dental
students and staff alike, and it became clear that there was a need for a
textbook in dental statistics which cut through the algebra and focused
directly on the issues that bring dentistry and statistics together. The
encouragement of my colleagues and dental students at King’s College
London brought about the publication of Dental Statistics Made Easy
in 2005, with a second edition in 2012.
The needs of qualified dentists and those engaged in dental research
have not been overlooked. The collection and interpretation of infor-
mation is essential in, for instance, the development of new treatments,
the delivery of dental care in the community, and the administration of
patient records at a dental practice. This book provides an introduction
to how this information is collected and analyzed, and the role that
academic publication plays in the dissemination of research findings.
There is an emphasis on underlying principles, illustrated by draw-
ing from published dental studies and realistic examples rather than
through recourse to algebraic formulae.
The first chapter explains why familiarity with dental statistics is
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viii PREFACE TO THE THIRD EDITION
important. The next chapters provide a broad overview of study design.
Attention is given to the use of pilot studies, public and patient involve-
ment in research, and ethical considerations, as well as to the common
types of design and most widely used methods of sampling. The reader
is then introduced to the Normal distribution, diagnostic testing, and
the concept of sampling variation. Subsequent chapters cover the
analysis of dental data, with an emphasis on the use of null hypotheses
and the interpretation of confidence intervals (details of some of the
calculations are provided in the Appendix). The book concludes with
a description of how a review of the dental literature can be applied to
modify everyday dental practice, followed by an account of the process
involved in the development of a dental paper from the initial drafting
of a report to its eventual publication in an academic journal.
This text has been written with a wide audience in mind, including
dental students, qualified dentists, those engaged in dental research,
and health-care professionals in general. No previous knowledge of
statistics is required, and, importantly for readers who are not dentists,
the illustrative examples are accessible to those involved in other areas
of health care. Its style makes the book suitable not only as a class
text but also for self-directed learning. The main text provides a gentle
introduction to dental statistics, with exercises and solutions available
for readers taking an in-depth approach. The numerous key messages
allow the time-pressured dentist to benefit from a superficial reading
and enable the most important principles to be located quickly. The
articles used in the book, along with the associated cited and citing
papers, will aid in identifying up-to-date subject-specific literature for
student dissertations, library projects, and dental research.
NEW TO THIS EDITION
Some of the features of the present edition are the following:
➤ A new chapter on evidence-based dentistry. This material
covers the “why” and “how” of systematic reviews along
with a very basic introduction to meta-analysis. Emphasis is
placed on sources of information, the hierarchy of research
and the concept of research quality. This chapter also covers
the neglected area of publications in languages other than
English. An intriguing question that has received scant
attention is addressed: Do dentists actually implement what
they discover through evidence-based dentistry in their
routine dental care?
PREFACE TO THE THIRD EDITION ix
➤ The selection of dental journal articles used in the examples and
exercises has been broadened and updated. The perspective of the
book is much more international, particularly, but not exclusively,
with regard to the United States, and examples have been drawn
from a range of cultures around the world.
➤ The assumption of independence of observations required for
most basic statistical techniques has been highlighted.
➤ The conduct of pilot studies is explained in greater detail. In
addition, the use of public and patient involvement (PPI) in
research is described as funding organizations increasingly expect
proposed studies to include PPI input.
➤ In the description of cohort studies, retrospective as well as
prospective designs are discussed.
➤ Cluster randomized trials have been included as part of the
material on randomized controlled trials.
➤ In the comparison of several means, a caution is given regarding
the use of the Bonferroni technique.
➤ Illustrative examples have been modified. In part, this is to ensure
that the data are appropriate for the statistical methods described.
In addition, a caution has been given regarding current opinion
on the benefits of water fluoridation. Increasing public concern
regarding patient home to dental practice distance explains the
choice of this issue for several examples.
ACKNOWLEDGMENTS
I wish to thank the many readers and reviewers who have provided
detailed constructive feedback on the earlier editions, and my col-
leagues at the Centre for Research in Primary and Community Care,
University of Hertfordshire, for their encouragement in my commit-
ment to making statistics accessible to all. Any imperfections in the
text are, of course, my responsibility.
Nigel Smeeton
August 2016
Preface to the Second Edition
This text was developed for the dental student or practitioner who
wishes to discover the rationale behind the application of statistics to
dentistry. Practical dental examples were employed to illustrate these
concepts without the need to resort to algebraic formulae. Feedback
received since its publication in 2005 has shown that readers, includ-
ing some from outside the dental community, have found this book
helpful as a first step on their pathway to understanding and using
statistics.
The content of the original text was chosen to reflect the current
key statistical issues at the time of writing. Although the importance
of these core principles remains unquestioned, the range of statistical
methods routinely found in the dental literature has subsequently
broadened and study findings are frequently presented in greater detail
than in the past. This edition covers some of the additional issues that
these advances have raised, whilst retaining the original focus on the
understanding of statistical concepts rather than the performance of
routine calculations.
The text has been supplemented by a chapter on one-way analysis of
variance. This topic forms a natural extension of the unpaired t-test to
the case of three or more independent groups. The role of confidence
intervals in the presentation of results has been given much greater
emphasis and the use of confidence intervals in diagnostic testing,
regression and correlation, and the analysis of observer agreement is
discussed. The original chapter on non-Normally distributed data has
been extended in order to introduce the use of analysis of variance and
correlation in situations where the data cannot be assumed to follow
a Normal distribution.
The choice of the dental journal papers used for the examples and
exercises has been updated. It is intended that these papers, along with
their cited references, will not only be helpful in the study of dental
statistics in its own right but will also aid in locating appropriate
subject-specific literature for student dissertations, library projects and
dental research. Advances in technology are transforming many aspects
of the research process from data entry to the way in which journals
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xii PREFACE TO THE SECOND EDITION
handle potential papers for publication. These developments have also
been reflected in this edition.
Finally, I wish to thank the many colleagues and dental students
who provided the original motivation for this book. The students
engaged in the Master of Public Health course at King’s College
London have, by their enthusiastic feedback, aided in encouraging me
to write this updated edition. Regarding the exercises, I am particularly
grateful to King’s College London for permitting the use of several
dental undergraduate examination questions, as indicated in the text.
Any imperfections in the text are, of course, my responsibility.
Nigel Smeeton
April 2012
Preface to the First Edition
Throughout my experience of teaching the basic principles of statistics
to dental undergraduates and researchers, students and colleagues
have remarked on the need for a textbook in dental statistics that
cuts through the algebra and focuses directly on the issues that bring
dentistry and statistics together. It is in this spirit that this text has
been developed, drawing from the course in dental statistics at King’s
College, London. It is intended for the dental student or practitioner
who wishes to discover the rationale behind the application of sta-
tistics to dentistry. These concepts are illustrated by practical dental
examples without the reader having to contend with formulae or even
mathematical symbols. To assist the reader in gaining rapid reference
to specific concepts, use has been made of highlighted key points.
As for the concepts themselves, statistics is a huge field in its own
right and those chosen represent what are in my view the key issues.
The scope of the book is wide and covers such areas as research ethics,
dealing with statistical referees and a simplified introduction to sample
size calculation. Hence, basic methods of data presentation and the use
of statistical techniques have been given a much less important place
than in the traditional statistics text.
There are several ways open for these basic concepts to be explored
more closely. The Appendix has been designed so that some of the
simpler calculations can be followed through. Where the discussion
shows signs that it might become technical, references to texts and
journal articles have been given so that these issues can be followed
further. Finally, at the end of most chapters there is a wide range of
exercises. Some of these are in a multiple-choice form, whereas others
require a few sentences in response. There are several longer problems
based on studies published in dental journals and an extended case
study around research design. All questions have been provided with
solutions. For some there is a straightforward answer, for others a well-
reasoned argument might be presented from more than one position;
problems in research are usually of the latter kind so it is only fair to
give the reader due warning.
In writing this book I wish to thank the many colleagues and dental
xiii
xiv PREFACE TO THE FIRST EDITION
students who have been involved in the development of the King’s
College dental statistics course over the years. Any imperfections in the
text are, of course, totally my responsibility. I am also grateful to King’s
College, London, for permitting the use of several dental undergradu-
ate examination questions, as indicated in the text.
Nigel Smeeton
December 2004
C HAPTER 1
Introduction
Dentistry is a rapidly evolving profession. Methods of patient manage-
ment are under constant scrutiny and there is a wide range of views
about the funding of dental care. New methods of diagnosis and
treatment continue to be developed. The current rapid advances in
technology will without doubt accelerate this process.
Before new methods can be considered suitable for general imple-
mentation, they need to be compared with current techniques. Such
studies often yield much detailed information that has to be evaluated.
For example: Is the new technique “better”? Are there any side effects?
What are the cost implications? In order to resolve these questions
properly, a multidisciplinary team is required that includes (for exam-
ple) psychologists, sociologists, economists, and statisticians. Dental
statistics plays a crucial role in the design and evaluation of such stud-
ies. Once the findings have been summarized, they need to be applied
to the practice of dentistry in general. Statistical methods are essential
in order to achieve this goal.
It is the responsibility of the qualified dentist to keep abreast of
developments in dental practice, particularly those that are relevant to
the quality of patient care. In many countries, practicing dentists are
required to undertake continuing professional development (CPD)
in order to remain registered. Information about dental care is more
readily available to the general public than ever before (e.g., on the
Internet), and some patients will ask their dentist detailed questions
about their treatment. A basic knowledge of statistics can enable the
dentist to become better informed about dental issues. In particular,
it can assist in the following.
1
2 DENTAL STATISTICS MADE EASY
THE UNDERSTANDING OF PAPERS IN JOURNALS
One component of many CPD programs is the critical reading of a
number of dental articles. Dentists might also need to evaluate papers
on themes related to their particular specialty. Articles of general inter-
est to dentists appear in high-circulation dental periodicals such as the
British Dental Journal and the Journal of the American Dental Association.
Papers of interest to a particular field of dentistry tend to appear in
specialist journals such as Community Dental Health, the International
Journal of Paediatric Dentistry, and the Journal of Oral and Maxillofacial
Surgery. Occasionally, dental articles of potential interest to all clini-
cians are published in high-circulation medical journals such as the
British Medical Journal, the Journal of the American Medical Association,
and The Lancet. Many papers (both general and specialist) make use
of statistical terms; some knowledge of statistics will therefore make
it much easier to glean useful information from them. It is unwise to
have blind faith in everything that is published; journal articles can
contain errors and a little knowledge of dental statistics can assist in
the detection of some of them.
Day-to-day clinical decisions should be based on the current evi-
dence (this is known as evidence-based dentistry). To facilitate this
process, the journal Evidence-Based Dentistry publishes abstracts of
important advances in the practice of dentistry. Many of these sum-
marize the results of a comprehensive search of literature databases
such as MEDLINE, a continually updated source of information on
articles from medical, dental, and biological journals (see Chapter 17).
This relieves the busy dental practitioner of what can be a very time-
consuming task.
CLINICAL AUDIT
In many dental practices, patients complete a short information sheet
when they register. This usually requests the patient’s name, address,
gender, date of birth, current medical conditions, and medications
prescribed. A dental record is created for that patient. Information
regarding the condition of the patient’s teeth, investigative procedures,
and treatment received is added after each visit by the patient. It is good
practice to audit dental records to assess (for instance) procedures per-
formed, patient referrals, and methods of payment for care. In many
countries, dental practices operate in a free market and careful financial
auditing is essential.
Suppose that a new method of treatment is adopted at a dental
practice. The partners will need to evaluate its success (or otherwise)
INTRODUCTION 3
from the records of patients in the practice. If the findings are in the
form of numbers, the use of statistical methods is the most appropriate
form of evaluation.
HEALTH SERVICES RESEARCH
Increasingly, general dental practices are being linked to dental schools
for the purpose of research studies in the community. Practices can act
as data-collecting centers for projects based, for instance, in a dental
school. In addition, if they so wish, dentists can learn about research
methods and gain assistance with the planning of their own investiga-
tions, thus becoming active researchers in their own right.
The view that few dental students or practitioners are interested in
participating in research is becoming increasingly outdated. Dental
practice research networks have developed into a major resource
(Heasman et al. 2015) at local, regional, and national dental practice
levels. Some involvement in research activities is becoming increas-
ingly commonplace. The origin of one of the earliest general dental
practice networks in the United Kingdom (UK) is described below.
Example 1.1
Kay, Ward, and Locker (2003) describe the development of a gen-
eral dental practice research network in the northwest of England.
Some general dental practitioners in the region were interested in
participating in research in an active way beyond data collection
alone. Following funding from a research and development initiative
for primary dental care, a series of workshops was organized. These
were aimed at developing the research skills of practitioners in areas
such as literature retrieval, critical appraisal of articles, questionnaire
design, applying for research funding, and data analysis. A further
goal was to stimulate the practitioners’ own research ideas, so that the
network could undertake a research program leading to publications
in refereed journals.
Fifteen dentists, each from a different practice, joined the network.
The scheme was judged to be highly successful with all the aims being
met, including the publication of research papers. Participant feed-
back highlighted a strong sense of belonging to a group, considerable
personal educational development, and increased job satisfaction.
Most practitioners thought that their involvement in the network
would improve the standard of their patient care.
