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Background: Medical education has experienced important changes in recent times. The concern for patient's safety is one of the key reasons for the change in medical curricula. Innovative instructional methods like simulation-based medical education (SBME) has evolved to address this problem. SBME has become an essential part of education and training for health professionals in many parts of the world. There are evidences that support that high-fidelity simulation (HPS) training has enhanced clinical knowledge among medical students. Aims: The objective of this study was to note the differences in the knowledge made by high-fidelity simulation-based medical education among undergraduate medical education. Study Design: It was a quasi-experimental time series study with Pre-test and Post-test interventions. Place and Duration of Study: Clinical Skills Lab, Faculty of Medicine, Manipal University College Malaysia, Melaka, between October 2015 and September 2017. Methodology: The study involved 347 final year undergraduate medical students. The participants were divided into groups during the simulation sessions and their knowledge was assessed individually with Multiple Choice Questions (MCQ) and also self-reported Pre-test and Post-tests. Paired t-test was used to determine the difference of MCQ scores between pre and post simulation sessions. One-way repeated measure ANOVA was performed to determine the significant difference in knowledge assessment of self-reported Pre-test and Post-test scores. P value < .001 was taken to be of statistical significance. Results: In the unpaired t-test, Post-test MCQ scores were higher than Pre-test scores but not statistically significant (P = .013). A one-way repeated measured ANOVA with Bonferroni post hoc analysis demonstrated that the total scores of the self-reported knowledge tests were significantly increased over time (P < .001). Conclusion: There is enhancement of knowledge as perceived by the students with self-reported knowledge tests but not statistically significant as revealed by the MCQ scores.

Background: Oral Health Programme, Ministry of health, Malaysia highlights the need to enhance oral health promotion and prevention of oral disease for preschool children. Developing and exploring engaging methods of education that enable young children in dental hygiene practices is a way forward in oral health promotion. Objectives: To develop novel activity based tooth brushing teaching method for preschool children using egg cartons as simulated teeth models and evaluate effectiveness of the same Methods: Two methods of teaching tooth brushing technique to preschool children in the age 4 to 6 years were compared through a Randomized Control Trial.: (i) Conventional method (N=32): Instructions on study model (ii) Egg carton simulation method (N=34): Hands on activity on egg cartons as simulated models. Outcome assessed was plaque index (Silness and Loe, 1964) Results: Plaque scores compared using Dependent t-test shows significant improvement in both groups after the teaching sessions (P.01). Conclusion: Egg carton simulation method is as good as the conventional approach as there is significant plaque score reduction in children after the teaching session.

BackgroundExcessive ultraviolet light (UV) can cause premature skin aging and potentially skin cancer. This study evaluated the knowledge, attitude of sunscreen, and skin cancer among Malaysian medical students.MethodsThis cross-sectional study was conducted from October 2022 to November 2022 among the clinical year medical students in a private medical university in Malaysia. The respondents were recruited by purposive sampling method. The content validated questionnaire was used to collect the data, and the data collection was done via online platform.ResultsThere are a total of 117 responses that we collected through an online questionnaire via Google Forms. Among the respondents, 59.8% of the respondents reported of having a poor knowledge about sunscreen. However, 64.96% reported to have good knowledge about skin cancer. Approximately half of the respondents (48.7%) had a good attitude towards sunscreen. Females are more likely to use them compared to men (OR: 9.12, 95% CI: 3.52, 23.64) and there is a difference between ethnicity and the usage of sunscreen.ConclusionThis study demonstrated limited knowledge of sunscreen among medical students. However, they are having better knowledge of skin cancer. Our results spotted the need for education about sunscreen among Malaysian medical students.

The aim of this study was to assess the prevalence of depression, anxiety, and stress among dental students and its association with factors such as gender, year of study, phase of the course, and ethnicity.A questionnaire-based cross-sectional study was conducted among medical students in a medical institute in Malaysia. Prevalence of depression, anxiety, and stress was assessed by Depression, Anxiety, and Stress Scale-21 (DASS-21).A total of 351 students took part in the study with a mean age of 22.38 (+1.69) years. The overall prevalence of depression, anxiety, and stress with varying severity among the study population was 60.4, 75.2, and 50.4%, respectively. The prevalence of symptoms of depression among the study population appears to be independent of gender, ethnicity, and academic year of study. Our results show that stress and anxiety may be influenced by gender with more prevalence in females.Early detection of symptoms of depression, anxiety and stress is of great importance to take timely remedial action to keep the mental well-being of individuals. Maintaining the mental health of young medical professionals is a need of society in the present world. Further studies are suggested to recognize other factors associated with depression, anxiety, and stress among dental students.Considering the students who experience depression, anxiety, or stress during undergraduate schooling, appropriate measures shall be taken to ensure effective learning. Students who have shown higher scores shall be advised for further follow-up and treatment strategies or appropriate counseling programs.

Context: Primary teeth and dermal ridges form around the same time in utero. Hereditary and intrauterine factors affecting the formation of primary teeth may affect dermal ridge formation also. Aims: This pilot study was conducted to see the association between dermatoglyphics and dental caries among preschool children Settings and Design: Cross sectional, case–control design. Materials and Methods: One hundred, healthy preschool children aged 3–6 years attending private kindergarten participated. They were divided equally into caries active and caries free group based on the oral examination. The fingerprint patterns were collected for all the fingers of both hands of children and categorized as loop, whorl or arch for each finger of the right and left hand. Statistical Analysis Used: Statistical analysis was performed using the Chi-square test and Independent t-test to compare the dermatoglyphics patterns between the caries-free group and the caries active group for each variable. Results: (1) Dental caries susceptibility of an individual decreases with an increase in the incidence of loop pattern, followed by whorl pattern and arch pattern; (2) Left hand loop was found statistically significant (P = 0.03); (3) Presence of loop pattern in left hand thumb predicts significantly lower risk of caries, whereas the presence of arch pattern in left hand thumb predicts significantly high risk of early childhood caries (P = 0.01). Conclusions: The caries free status of a preschool child increased with the presence of loop on the left thumb.

Introduction: Medical simulation is a technique that allows interactive and immersive activity by recreating all or part of a clinical experience without exposing the patients to the antecedent risks. High-fidelity patient simulation-based teaching is an innovative and efficient method to address increasing student enrolment, faculty shortages and restricted clinical sites. Objective: To assess the effectiveness of high-fidelity patient simulation (HFPS) as compared to video-assisted lecture-based teaching method (VALB) among undergraduate medical students. Methods: The study was a Randomized Controlled Trial which involved 56 final year undergraduate medical students. The effectiveness of teaching based on HFPS (intervention group) and VALB (control group), on acquisition of knowledge, was assessed by multiple choice questions (MCQs) in the first and fourth week. Similarly, the skills competency was assessed by objective structured clinical examination (OSCE) in the second and fourth week. Mean and standard deviation (SD) for total score of knowledge and skills assessments were used as outcome measures. P value < 0.05 was considered to be statistically significant. Results: In both groups, students had significant higher mean MCQ scores at Post-tests. The intervention group had higher mean change score of MCQ marks than the control group but the difference was not statistically significant. In both the first and second skills assessments, mean OSCE scores for intervention group were higher than control group but this difference was not statistically significant. Conclusion: There was significant gain in knowledge in both methods of teaching but did not reach statistical difference in terms of skills enhancement in the intervention group as compared to the control group.

Aim: A variety of anthropometric techniques have been proposed to determine the correct vertical dimension of occlusion. However, none have reported correlating thumb length (TL) with vertical dimension at rest (VDR). This study aimed to correlate the VDR to measurements of the thumb in a multi-national, multi-centric trial in participants with and without orthodontic treatment and establish a regression equation for each region. Settings and Design: A cross-sectional multi-national, multi-centric correlation trial. Materials and Methods: A cross-sectional study was conducted in India and Malaysia with a total of 688 participants. Measurements of thumb and VDR were obtained using a modified Willi's gauge using a standard operating procedure. Statistical Analysis Used: Pearson's correlation coefficient was calculated to determine the correlation between TL and VDR. A multiple linear regression was done to correlate VDR from gender, orthodontic treatment, and length of thumb. Results: Correlation coefficient between TL and VDR in patients with orthodontic treatment was 0.829 and 0.774 in patients without orthodontic treatment. The correlation between TL and VDR in patients with orthodontic treatment in North India was 0.484, P = 0.010 and Malaysia was 0.946, P < 0.001. There were significant correlations between TL and VDR in patients without orthodontic treatment in all regions (P < 0.001). Regression equations were obtained for different ethnic groups for calculating the VDR. Conclusion: There was an overall positive correlation between TL and VDR in patients with and without orthodontic treatment. The regression equations presented in this article could help clinicians in their clinical practice and researchers to conduct future trials.

Herpes simplex encephalitis (HSE) is a medical emergency associated with high mortality and morbidity. Definitive diagnosis is established by history, clinical examination, neuroimaging studies, supportive electroencephalogram (EEG) findings, and cerebrospinal fluid (CSF) analysis. A 7-year-old Malay girl with known case of right hemiplegia secondary to herpes encephalitis presented to the neuropediatric ward, in General Hospital with refractory seizure. She had a moderate learning disability and diagnosed as right hemiparesis secondary to herpes encephalitis complicated with epilepsy. She was planned for the positron emission tomography (PET) scan and to undergo operation if PET scan was feasible (Hemispherectomy). However, the patient refused for operation. Prompt clinical recognition is important in the HSE to prevent progressive brain tissue damage, haemorrhagic changes, and worsening of the encephalitis. Diagnosis is usually confirmed through an extensive evaluation, including a thorough clinical examination with attention to findings on mental status changes, cerebrospinal fluid (CSF) analysis, electroencephalogram (EEG) testing and findings on neuroimaging. Once HSE is suspected, high-dose acyclovir should be started immediately before lumbar puncture (LP), and only stopped once a definitive alternate diagnosis has been established. This case is reported because the patient has generalized epilepsy with right hemiparesis secondary to herpes encephalitis. Herpes encephalitis with right hemiparesis cases are quite rare.

Introduction: The main cause of overweight and obesity is the imbalance between energy intake and expenditure. Obesity is the abnormal accumulation of ≥20% of body fat, over the individual's ideal body weight. Obesity is diagnosed by measuring the weight in relation to the height of an individual, thereby determining or calculating the body mass index (BMI). Methodology: This study is a cross-sectional study with the secondary data analysis of the health records of the patients who had attended the medical camps conducted in Melaka, Malaysia. All of the attendee’s body weight and height were measured. The blood pressure measurement was done according to the Clinical Practice Guidelines, Ministry of Health, Malaysia. Hypertension is defined as if the participant has systolic blood pressure (SBP) of > 140 mmHg and/ or diastolic blood pressure (DBP) of 90 mmHg or more. Some peoples were taking treatment of Hypertension. Results: The mean SBP among females was 11.64 units and mean DBP was 5.29 units lower compared to male participants. With an increase in age, SBP is expected to increase by .29 units, provided other variables remain unchanged. Regarding to BMI, every unit increase in BMI, SBP increased by 1.99 units and DBP increased by .86 units provided other variables remain unchanged. Conclusion: This study found that BMI is associated with SBP and DBP, which suggested that interventions for bodyweight management might be beneficial for the management of hypertension.

Nonunion of intertrochanteric fracture is uncommon because there are excellent blood supply and good cancellous bone in the intertrochanteric region of the femur. A diagnosis of primary intertrochanteric nonunion is made when at least 15 weeks after the fracture there is radiological evidence of a fracture line, with either no callus (atrophic) or with callus that does not bridge the fracture site (hypertrophic). The patient was subsequently treated successfully with an open reduction procedure. Open reduction and internal fixation with right DHS (Dynamic Hip Screw) with 8 screw holes plate inserted first and then 6 screws inserted under the guidance of Image Intensifier (C Arm). We would like to report a case of right intertrochanteric fracture with non-union. A 60 years old patient presented with the history of pain in the right hip, off and on for many years after the operation. The pain was associated with stiffness of the right hip joint. This case is selected for reporting because it’s a relatively rare incidence.

Introduction: Obesity, high body fat percentage and hypertension could increase the mortality and morbidity due to cardiovascular diseases. These risk factors develop during childhood and adolescent period. The present study aimed at determining the association between body fat composition and BP level among the Chinese community in Melaka, Malaysia. Methodology: This is a cross-section study with the secondary data analysis of the health records of the patients who had attended the medical camps conducted in Melaka, Malaysia. The body fat and visceral fat were measured by using (Handheld Body Fat Scale Analyzer). The blood pressure measurement was done according to the Clinical Practice Guidelines, Ministry of Health, Malaysia. The participants who had systolic blood pressure (SBP) of 140 mmHg and/ or diastolic blood pressure (DBP) of 90 mmHg were defined as hypertension. Results: The prevalence of hypertension among male participants was 42.5%, meanwhile, among female was 23.6%. The prevalence of overweight and obesity was higher among males (37%) compared to females (20.8%). Gender, body fat (%) and was found to be associated with systolic blood pressure. Visceral fat (%) was the only associated factor of diastolic blood pressure. Conclusion: This study found that body and visceral fat compositions are significantly correlated with systolic BP and visceral fat composition is significantly correlated with diastolic BP. High body and visceral fat composition should be used as a measure of increased risk for hypertension among old age peoples.

Introduction: Anger has been defined in many ways from “a negative, phenomenological (or internal) feeling state” to “a basic emotion in which the function is to provide the organism with motivated capacities to overcome obstacles”. Anger has been the subject of many discourses and its vehemence in many religions and cultures. The study aimed to determine the ability of anger management among different gender and factors associated with anger management. Methods: This is a cross-sectional prospective study. The validated ‘Quality of Life’ questionnaire from University of Washington, Seattle Washington, United Sates of America and Novaco Anger Scale from Mental Health America of Northern Kentucky & Southwest Ohio (WHOQOL-BREF) were used for students’ perception on anger management. Quantitative data were analyzed using Epi Info Version. 7 Software. Results: The total of 358 students participated in this study. There is a significant association between anger management among different ethnicity. Conclusion: Gender was not a significant factor in anger management, it was probably due to equal opportunity among male and female in acquiring education, application for scholarships and usage of education facilities. Gender equality had a big impact in enhancing the good anger management properties.

Background: Medical doctors have to develop in professionalism in addition to become competent in clinical skills. Therefore, educators in Melaka Manipal Medical College have inculcated personal and professional development (PPD) projects into medical curriculums. The projects were in the form of Role Plays/Narratives/Creative writing and Mentored Student Project (MSP). Short terms outcomes of the projects were evaluated, and the research disclosed the positive effect of all PPDs on medical students. However, the long-term effect was yet to be evaluated. The findings of the previous study have not explained why those PPD projects are successful. While twenty fresh medical graduates were asked to reflect on one best learning experience as a qualitative evaluation of the programme, students’ appreciation of MSP disclosed. This study aimed to explore the students’ reflection to identify the reasons for their appreciation of MSP and the long-term effect of it. Study Design: Qualitative research. Methodology: Three reflective writings by fresh graduates were analyzed using the interpretive phenomenological analysis (IPA) approach. Students expressed their conscious perceptions about MSP in the form of words in their reflections. The researcher carefully read the reflections and interpret the words and phrases to catch the students’ perception of MSP. Results: The qualitative analysis revealed the reasons for participating in MSP and their appreciation about MSP. The main reason for students’ participation in MSP was to fulfill the requirement of the medical programme although one student mentioned that she was interested in MSP due to the nature of MSP. Four themes were formulated as reasons for their appreciation of MSP: (1) having an opportunity to choose their research topic, (2) the presence of a mentor to guide each student group, (3) opportunity for the poster presentation on results of MSP and (4) satisfaction with the overall outcome of the MSP. Conclusion: This study highlights the long-term impacts of MSP on students which matched with the expected learning outcomes set by Ministry of Education Malaysia. The analysis disclosed not only the outcome but also the process of MSP contribute for its success.

Background: Neonatal jaundice is a common condition that sometimes lead to devastating neurological consequence such as kernicterus. Aim: This study was aimed to find out the clinical features and etiology of neonatal jaundice in term newborn admitted to Ratchaburi Hospital. Study Design: Hospital-based retrospective study Methodology: The study was conducted by reviewing 117 medical records of neonatal jaundice who were admitted at Ratchaburi Regional Hospital, Bangkok, Thailand from 1st October 2007 to 30th September 2008. Both the patient’s and their mother’s profiles, etiology and clinical features of jaundice were extracted. Results: The results showed that the most common etiology was inconclusive jaundice (64.9%) followed by ABO incompatibility (17.9%) and breast feeding jaundice (10.2%). Other less common causes were G6PD deficiency, minor blood group incompatibility and cephalhematoma. The onset of the neonatal jaundice usually occurred on the 2nd to the 4th day of life and almost all newborns responded well to phototherapy. Most of interventions were started on the 2nd day of life. Moreover, exchange transfusion was needed in four cases. The maximum and minimum haematocrit was significantly lower while Nucleated Red Cell (NRC) count and percent of reticulocytes counts were significantly higher in haemolysis group than in non-haemolysis group,. Conclusion: From our study, the most common etiology was inconclusive jaundice which is followed by ABO incompatibility but non-immune hemolysis and polycythemia were not encountered. There was significant difference of hematocrit, NRC and reticulocytes between hemolytic and non-hemolytic groups. Detailed approach of history taking and physical examination, early investigations of jaundice work up and septic work up are recommended in eliciting various etiologies and preventing complications.

Behavioral addiction to smartphones is a common phenomenon in the present digital age, wherein indulgence in these devices is compulsive and impacts physical, social, and psychological health of the population. The smartphones effect on a dental student's life is detrimental to their academics, health, and efficiency in providing clinical patient care. To assess use and addiction of smartphones among dental students under six major domains and to compare this based on their gender, ethnicity, and year of study.A cross-sectional study using a validated questionnaire, Smartphone addiction scale was conducted among 349 undergraduate students (Overall results are presented as mean scores under six domains with total score as 142.40 (33.65). The total scores compared between two genders did not show statistical difference, however on comparing individual domains, females (25.25) had higher mean score for daily life disturbance (Our research presents the extent and pattern of smartphone of usage and addiction among the undergraduate students at a dental school in Malaysia. The indicators of addiction highlighted in the study are pivotal in spreading awareness regarding this overuse and addiction as well as planning further research in this area.

Background: Periodontitis is a public health concern since it is a major factor in tooth loss worldwide and has association with many systemic diseases. Sleep is a complex and essentially biological process and a critical factor for maintaining mental and physical health. Since inflammation is characteristic of both chronic periodontitis and sleep deprivation, few studies in recent years present the contradictory results regarding this potential association. The objective of the present study was to investigate the association between quality of sleep and chronic periodontitis. Materials and Methods: A total of 200 individuals participated in this study. All participants underwent a comprehensive clinical periodontal examination. case–control were identified using the Centers for Disease Control and Prevention/American Academy of Periodontology case definitions for periodontal disease. The quality of sleep was assessed by Pittsburgh Sleep Quality Index. The univariate and multivariate logistic regression analysis was used to test the influence of variables (quality of sleep, age, sex, ethnicity, education, and socioeconomic status), in the occurrence of periodontitis. Odds ratio (OR) and respective confidence intervals (CIs) were calculated and reported. P ≤0.05 was considered statistically significant. Results: The prevalence of poor quality of sleep was 56.75% in cases (periodontitis group) and 43.24% in control group. There was positive association between quality of sleep and chronic periodontitis (OR = 3.04; 95% CI = 1.42–6.5; P = 0.004). In multivariate logistic regression analysis, only the age was significantly related to the periodontitis (OR = 1.11; 95% CI = 1.07–1.41; P < 0.001) , other variables failed to reach the significant level. Conclusion: Poor quality of sleep was significantly associated with chronic periodontitis. Only the age was significantly related to periodontitis among the other covariable measured. Key Words: Chronic periodontitis, periodontal medicine, quality of sleep, sleep deprivation

Interprofessional education (IPE) helps preparing the learners in all healthcare professions to work effectively in collaborative teams. This study was undertaken to assess the readiness and perception of IPE of preuniversity health professional students even before they enter their health professional courses.The preuniversity health professional students along with final-year medical and dental students were recruited for the study. The readiness for interprofessional learning scale was used to measure the student's readiness toward IPE before the interprofessional-related activity session. The preuniversity students also completed the IEPS scale after their interaction with final-year medical and dental students.Most of the aspiring health professional students during their foundation year expressed positive attitude toward readiness for IPE. Most preuniversity students realized that by learning with various professional students would make them effective member of healthcare team. The students had positive perception toward competence and autonomy, perceived need for cooperation, perception of actual cooperation, and understanding other's value, which were significantly higher from score 3 of somewhat disagree (Most of the aspiring health professional students in their preuniversity year expressed positive attitude toward readiness for IPE although were not prepared to take roles and responsibility within the interprofessional group. They could well perceive the need for cooperation, perception of actual cooperation, and understanding other's value while working in an IP team.

Introduction: Simulation is the imitation of the operation of a real-world process or system over time. Innovative simulation training solutions are now being used to train medical professionals in an attempt to reduce the number of safety concerns that have adverse effects on the patients. Objectives: (a) To determine its usefulness as a teaching or learning tool for management of surgical emergencies, both in the short term and medium term by students’ perception. (b) To plan future teaching methodology regarding hi-fidelity simulation based on the study outcomes and re-assessment of the current training modules. Methods: Quasi-experimental time series design with pretest-posttest interventional study. Quantitative data was analysed in terms of Mean, Standard Deviation and standard error of Mean. Statistical tests of significance like Repeated Measure of Analysis of Variance (ANOVA) were used for comparisons. P value < 0.001 was considered to be statistically significant. Results: The students opined that the simulated sessions on high fidelity simulators had encouraged their active participation which was appropriate to their current level of learning. It helped them to think fast and the training sessions resembled a real life situation. The study showed that learning had progressively improved with each session of simulation with corresponding decrease in stress. Conclusion: Implementation of high fidelity simulation based learning in our Institute had been perceived favourably by a large number of students in enhancing their knowledge over time in management of trauma and surgical emergencies.

Introduction Tooth size, occlusal traits, and ethnicity are closely interrelated, and their impact on desirable orthodontic treatment outcome cannot be underestimated. This study was undertaken to assess the occlusal characteristics and ethnic variations in occlusion of Malaysian orthodontic patients and evaluate their correlation with Bolton’s tooth size discrepancy. Materials and Methods On 112 pretreatment study models of orthodontic patients, molar relationship, overjet, overbite, spacing, crowding, midline shift, and Bolton’s ratios were assessed. ANOVA, one-sample t-test, Chi-squared test, and Spearman’s rho correlation coefficient were used for statistical analysis. Results Significant difference between anterior ratio of our study and Bolton’s ideal values was found, for the entire study sample and Chinese ethnic group. Differences between races and malocclusion groups were not statistically significant (P > 0.05). Significant correlations were found as follows – in Angle’s Class I malocclusion between 1) anterior ratio and overbite, 2) overall ratio and maxillary crowding and spacing; in Angle’s Class II malocclusion between 1) anterior ratio and overjet and midline shift, 2) overall ratio and mandibular crowding; in Angle’s Class III malocclusion between 1) anterior ratio and mandibular crowding and both maxillary and mandibular spacing 2) overall ratio and mandibular crowding. Conclusions Significant differences in anterior ratio and Bolton’s ideal values for the Malaysian population were found, indicating variations in anterior tooth size as compared to Caucasians. Statistically significant correlations existed between Bolton’s ratios and occlusal traits. These findings can be applied clinically in diagnosis and treatment planning by keeping in mind the specific discrepancies that can occur in certain malocclusions and addressing them accordingly.

BACKGROUND: The gag reflex is an involuntary defence mechanism to protect the pharynx and throat from foreign objects. Gagging is a common problem encountered during dental treatment, making therapeutic procedures distressing and often difficult or even impossible to perform. Various interventions can be used to control the gag reflex: anti‐nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behavioural therapies, acupressure, acupuncture, laser, and prosthetic devices. This is an update of the Cochrane Review first published in 2015. OBJECTIVES: To assess the effects of pharmacological and non‐pharmacological interventions for the management of gagging in people undergoing dental treatment. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health's Trials Register (to 18 March 2019), the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2) in the Cochrane Library (searched 18 March 2019), MEDLINE Ovid (1946 to 18 March 2019), Embase Ovid (1980 to 18 March 2019), CINAHL EBSCO (1937 to 18 March 2019), AMED Ovid (1985 to 18 March 2019), and the proceedings of the International Association for Dental Research (IADR) online (2001 to 18 March 2019). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. We also conducted forwards citation searching on the included studies via Google Scholar. No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: We included randomised controlled trials (RCTs), involving people who were given a pharmacological or non‐pharmacological intervention to manage gagging that interfered with dental treatment. We excluded quasi‐RCTs. We excluded trials with participants who had central or peripheral nervous system disorders, who had oral lesions or were on systemic medications that might affect the gag sensation, or had undergone surgery which might alter anatomy permanently. DATA COLLECTION AND ANALYSIS: We independently selected trials, extracted data, and assessed risk of bias. We followed Cochrane's statistical guidelines. We assessed the overall certainty of the evidence using GRADE. MAIN RESULTS: We included four trials at unclear risk of bias with 328 participants (263 adults and 65 children who were four years or older), in which one trial compared acupuncture and acupressure (with thumb, device and sea band) at P6 (point located three‐finger breadths below the wrist on the inner forearm in between the two tendons) to sham acupuncture and acupressure with and without sedation. One trial compared acupuncture at P6 point to sham acupuncture. These trials reported both completion of dental procedure and reduction in gagging (assessor and patient reported) as their outcomes. One cross‐over and one split‐mouth trial studied the effect of laser at P6 point compared to control. One trial reported reduction in gagging and another reported presence or absence of gagging during dental procedure. Acupuncture at P6 showed uncertain evidence regarding the successful completion of dental procedure (RR 1.78, 95% CI 1.05 to 3.01; two trials, 59 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 2.57, 95% CI 1.12 to 5.89; one trial, 26 participants; very low‐certainty evidence) in comparison to sham acupuncture. Acupuncture at P6 with sedation did not show any difference when compared to sham acupuncture with sedation (RR 1.08, 95% CI 0.91 to 1.28; one trial, 34 participants; very low‐certainty evidence). Acupressure using thumb pressure with or without sedation showed no clear difference in completing dental procedure (RR 0.96, 95% CI 0.84 to 1.10; one trial, 39 participants; very low‐certainty evidence; and RR 0.85, 95% CI 0.50 to 1.46; one trial, 30 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 1.06, 95% CI 0.92 to 1.23; one trial, 39 participants; very low‐certainty evidence; and RR 0.92, 95% CI 0.60 to 1.41; one trial, 30 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Acupressure at P6 with device showed uncertain evidence regarding the successful completion of dental procedure (RR 2.63, 95% CI 1.33 to 5.18; one trial, 34 participants; very low‐certainty evidence) and uncertain evidence regarding the reduction in gagging (RR 3.94, 95% CI 1.63 to 9.53; one trial, 34 participants; very low‐certainty evidence) when compared to sham acupressure. However, device combined with sedation showed no difference for either outcome (RR 1.16, 95% CI 0.90 to 1.48; one trial, 27 participants; very low‐certainty evidence; and RR 1.26, 95% CI 0.93 to 1.69; one trial, 27 participants; very low‐certainty evidence; respectively). Acupressure using a sea band with or without sedation showed no clear difference in completing dental procedure (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 1.80, 95% CI 0.63 to 5.16; one trial, 19 participants; very low‐certainty evidence; respectively), or reduction in gagging (RR 0.88, 95% CI 0.67 to 1.17; one trial, 21 participants; very low‐certainty evidence; and RR 2.70, 95% CI 0.72 to 10.14; one trial, 19 participants; very low‐certainty evidence; respectively) when compared to sham acupressure with or without sedation. Laser at P6 showed a difference in absence of gagging (odds ratio (OR) 86.33, 95% CI 29.41 to 253.45; one trial, 40 participants; very low‐certainty evidence) and reduction in gagging (MD 1.80, 95% CI 1.53 to 2.07; one trial, 25 participants; very low‐certainty evidence) during dental procedure when compared to dummy laser application. No noteworthy adverse effects were reported. For acupuncture at P6, the trial authors were unsure whether the reported adverse effects were due to participant anxiety or due to the intervention. None of the trials on acupressure or laser reported on this outcome. We did not find trials evaluating any other interventions used to manage gagging in people undergoing dental treatment. AUTHORS' CONCLUSIONS: We found very low‐certainty evidence from four trials that was insufficient to conclude if there is any benefit of acupuncture, acupressure or laser at P6 point in reducing gagging and allowing successful completion of dental procedures. We did not find any evidence on any other interventions for managing the gag reflex during dental treatment. More well‐designed and well‐reported trials evaluating different interventions are needed.

Background: Sickle cell disease (SCD) is a group of disorders that affects haemoglobin, which causes distorted sickle‐ or crescent‐shaped red blood cells. It is characterized by anaemia, increased susceptibility to infections and episodes of pain. The disease is acquired by inheriting abnormal genes from both parents, the combination giving rise to different forms of the disease. Due to increased erythropoiesis in people with SCD, it is hypothesized that they are at an increased risk for folate deficiency. For this reason, children and adults with SCD, particularly those with sickle cell anaemia, commonly take 1 mg of folic acid orally every day on the premise that this will replace depleted folate stores and reduce the symptoms of anaemia. It is thus important to evaluate the role of folate supplementation in treating SCD. Objectives: To analyse the efficacy and possible adverse effects of folate supplementation (folate occurring naturally in foods, provided as fortified foods or additional supplements such as tablets) in people with SCD. Search methods: We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register comprising references identified from comprehensive electronic database searches and handsearches of relevant journals and abstract books of conference proceedings. We also conducted additional searches in both electronic databases and clinical trial registries. Date of last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register: 17 November 2017. Selection criteria: Randomised, placebo‐controlled trials of folate supplementation for SCD. Data collection and analysis: Four review authors assessed We used the standard Cochrane‐defined methodological procedures. Four review authors independently assessed the eligibility and risk of bias of the included trials and extracted and analysed the data included in the review. The quality of the evidence was assessed using GRADE. Main results: One trial, undertaken in 1983, was eligible for inclusion in the review. This was a double‐blind placebo‐controlled quasi‐randomised triaI of supplementation of folic acid in people with SCD. A total of 117 children with homozygous sickle cell (SS) disease aged six months to four years of age participated over a one‐year period (analysis was restricted to 115 children). Serum folate measures, obtained after trial entry at six and 12 months, were available in 80 of 115 (70%) participants. There were significant differences between the folic acid and placebo groups with regards to serum folate values above 18 μg/L and values below 5 μg/L (low‐quality evidence). In the folic acid group, values above 18 μg/L were observed in 33 of 41 (81%) compared to six of 39 (15%) participants in the placebo (calcium lactate) group. Additionally, there were no participants in the folic acid group with serum folate levels below 5 μg/L, whereas in the placebo group, 15 of 39 (39%) participants had levels below this threshold. Haematological indices were measured in 100 of 115 (87%) participants at baseline and at one year. After adjusting for sex and age group, the investigators reported no significant differences between the trial groups with regards to total haemoglobin concentrations, either at baseline or at one year (low‐quality evidence). It is important to note that none of the raw data for the outcomes listed above were available for analysis. The proportions of participants who experienced certain clinical events were analysed in all 115 participants, for which raw data were available. There were no statistically significant differences noted; however, the trial was not powered to investigate differences between the folic acid and placebo groups with regards to: minor infections, risk ratio (RR) 0.99 (95% confidence interval (CI) 0.85 to 1.15) (low‐quality evidence); major infections, RR 0.89 (95% CI 0.47 to 1.66) (low‐quality evidence); dactylitis, RR 0.67 (95% CI 0.35 to 1.27) (low‐quality evidence); acute splenic sequestration, RR 1.07 (95% CI 0.44 to 2.57) (low‐quality evidence); or episodes of pain, RR 1.16 (95% CI 0.70 to 1.92) (low‐quality evidence). However, the investigators reported a higher proportion of repeat dactylitis episodes in the placebo group, with two or more attacks occurring in 10 of 56 participants compared to two of 59 in the folic acid group (P < 0.05). Growth, determined by height‐for‐age and weight‐for‐age, as well as height and growth velocity, was measured in 103 of the 115 participants (90%), for which raw data were not available. The investigators reported no significant differences in growth between the two groups. The trial had a high risk of bias with regards to random sequence generation and incomplete outcome data. There was an unclear risk of bias in relation to allocation concealment, outcome assessment, and selective reporting. Finally, There was a low risk of bias with regards to blinding of participants and personnel. Overall the quality of the evidence in the review was low. There were no trials identified for other eligible comparisons, namely: folate supplementation (fortified foods and physical supplementation with tablets) versus placebo; folate supplementation (naturally occurring in diet) versus placebo; folate supplementation (fortified foods and physical supplementation with tablets) versus folate supplementation (naturally occurring in diet). Authors' conclusions: One doubIe‐blind, placebo‐controlled triaI on folic acid supplementation in children with SCD was included in the review. Overall, the trial presented mixed evidence on the review's outcomes. No trials in adults were identified. With the limited evidence provided, we conclude that, while it is possible that folic acid supplementation may increase serum folate levels, the effect of supplementation on anaemia and any symptoms of anaemia remains unclear. If further trials were conducted, these may add evidence regarding the efficacy of folate supplementation. Future trials should assess clinical outcomes such as folate concentration, haemoglobin concentration, adverse effects and benefits of the intervention, especially with regards to SCD‐related morbidity. Such trials should include people with SCD of all ages and both sexes, in any setting. To investigate the effects of folate supplementation, trials should recruit more participants and be of longer duration, with long‐term follow‐up, than the trial currently included in this review. However, we do not envisage further trials of this intervention will be conducted, and hence the review will no longer be regularly updated. Funding: This project was supported by the National Institute for Health Research, via Cochrane Infrastructure funding to the Cochrane Cystic Fibrosis and Genetic Disorders Group. Declaration of Interest: Ruchita Dixit: none known. Sowmya Nettem: none known. Simerjit S Madan: none known. Htoo Htoo Kyaw Soe: none known Adinegara BL Abas: none known Leah Vance: has undertaken a research year that allowed for her participation in this review was supported by Grant 2014086 from the Doris Duke Charitable Foundation. She has no other conflicts to disclose. Patrick Stover: none known.