() Effectiveness of Vitamin B12 on Recurrent Aphthous Stomatitis in

long term care: a Systematic Review

Centre conducting review
The Taiwan Joanna Briggs Institute Collaborating Centre : A Collaborating Centre of the
Joanna Briggs Institute, National Yang-Ming University, Taipei, Taiwan

Primary reviewer/contact
Hsin-Li Liu, RN, MSN. 1.2
Contact: sinliliu@gmail.com

Reviewer panel:
Ruo-ping Han, PhD. 1
Yueh-Juen Hwu, PhD. 1.2
Shu Chin Chiu, RN. 2.3
Kai-Yu Tseng, PhD. 1.2
Lee-Wen,Pai RN, MSN. 1.2

1. Central Taiwan University of Science and Technology.

2. A Collaborating Centre of the Joanna Briggs Institute, National Yang-Ming University,
Taipei, Taiwan
3. Feng-Yuan Hospital Department of Health

Background
Recurrent Aphthous Stomatitis (RAS) also known as canker sores, is one of the most
common oral mucosa inflammatory ulcerative diseases worldwide. RAS is also an idiopathic
1
condition in most patients. The Aphthous ulcer condition is characterized by localized,
shallow, rounded, painful, small, clean borders, a peripheral erythematous halo, and a yellow
or grayish, base. Aphthous ulcers usually occur in recurrent bouts at intervals of a few days to
a few months. 1.2.3
Aphthous ulcers are painful sores that can occur anywhere inside the mouth, include the
skin covering the inside of the lips and cheeks, the floor of the mouth, the tip or underside of
the tongue, the soft palate, and the tonsillar areas. 4 It is one of the most painful oral mucosal

398


inflammatory ulcerative conditions and frequently impacts on daily life 5 include activities
such as eating, swallowing and speaking. 4.6
An Aphthous ulcer usually heals within 7 to 14 days, however they often recur. If the
ulcer persists for more than 3 weeks or there is recurrent formation of new aphthous ulcers,
may other clinical abnormal, may arise in multisystemic disease.1 including Behcets
disease,7.8.9.10.11.12.13 Sweets syndrome, 14.15.16.17
cyclic neutropenia,1.18-20. benign familial
21.22. 23.24. 25
neutropenia, Magic syndrome, a periodic syndrome with fever and pharyngitis,
26.27.28
various nutritional deficiencies with or without underlying gastrointestinal disorders,
29.30.31.32
some other primary immunodeficiencies, and infection with human
33.34
immunodeficiency virus. Rarely, drugs such as nonsteroidal anti-inflammatory drugs
35 36
(NSAIDS) or nicorandil can give rise to oral ulcers, similar to RAS.
Epidemiological studies indicate that RAS is prevalent worldwide and may affect up between
2% and 50% in the general population; most estimates fall between 5% and 25% and the
three-month recurrence rates can be as high as 50%. 37.38.39

The Aphthous ulcers symptoms can present in three main forms minor, major or
herpetiform ulcers: Minor Aphthous ulcers is the most common, and appear as small (less
than 10 mm in diameter), round, clearly defined, painful ulcers. Healing occurs in 10 to 14
40
days without scarring. Major Aphthous ulcers lesions are larger (greater than 1 cm in
41
diameter). Healing may take 20 to 30 days or longer, and frequently results in scarring.
40
Healing usually takes place within 7 to 15 days which generally results in scarring. The
third and least common variety of RAS is herpetiform ulcers, presents with multiple small and
painful ulcers, clusters of pinpoint lesions which often occur in multiples from 1 to 100, each
being 23 mm although they tend to fuse, producing large irrgular ulcers. It might have
female predisposition and tends to have an onset older age than other types of RAS. 42.43.44

The cause of aphthous ulcers remains unknown, however factors may include systemic
diseases, nutritional deficiencies, food allergies, genetic predisposition, immune disorders,
1.2.
medications, and human immunodeficiency virus infection and environment. Nutritional
deficiencies or hemotologic diseases have been documented in 20% of patients with RAS.
45.46
When Studies have found that patients to physicians for treatment for deficiencies of iron,
folate, and vitamin B12, record a 71% improvement in aphthous ulcer following replacement
47.48
therapy. The lack of clarity regarding the aetiology of aphthous ulcers has resulted in
treatments that are largely empirical. A medline search, starting at the year 1951, found 578
399


articles related to the treatment of RAS, including 110 clinical trials. Medical preparations
49.50.51 52 53
from Licorice herbs Myrtus communis (myrtle) herbs and multivitamins, adhesive
54 55 56
pastes, local antiseptics, local and systemic antibiotics, topical non-steroidal
57 58
anti-inflammatory drugs, topical corticosteroids, and even topical and systemic
59.60.61
immunomodulators, immunosuppressants, and corticosteroids were among the
treatments given to patients with RAS.

Several Vitamin B12 (cobalamin) treatment for RAS have addressed this, the goals
being to decrease pain, healing time, number and size of the ulcer, and to increase disease-free
periods, vitamin B12may play an important role for Aphthous ulcers. A study by Brachmann
(1954) first suggested Vitamin B12 deficiency could be associated with Aphthous ulcers.
62
The most common etiology of Vitamin B12 deficiency is food-cobalamin malabsorption
63
resulting from gastric dysfunction. Studies which examined the impact of age suggest a
64
high prevalence of subnormal cobalamin concentrations, and in some reports, an inverse
relationship between age and serum cobalamin concentrations. 65.66 Burgan and colleagues, in
their study of 143 patients experiencing recurrent aphthous stomatitis, found that 26.6% of
67
aphthous subjects demonstrated B12 deficiency in contrast to 12.6% of the controls. Piskin
et al. found 35 patients with RAS who have vitamin B12 levels were found to be significantly
lower than 26 healthy controls, while significant differences were not found for the other
48
assessed hematological factors. Volkov et al. was used a randomized, double-blind,
placebo-controlled trial to confirmed the vitmin B12 in the RAS of treatment. Study suggests
that daily 1000mcg vitamin B12 under the tongue may be preventive for Aphthous ulcers after
68
5 and 6 months of use, it was found that high levels of vitmin B12 seemed to reduce the
incidence of ulcers. 69
Burgress and Haley suggest that 500mcg Vitamin B12 30 discs with instructions to use
two initially and then one each succeeding day, placing into saliva via adherent discs adhered
to the buccal side of a tooth and disc dissolved over 20 to 40 minutes, it near an ulcer when
present. All were instructed to make careful observations of their ulcers and report their
observations at least once each week over a 30-day period. can result in the seven subjects
who received the active discs, all seven (100%) reported a benefit. Six out of seven reported
reduced duration of each ulcer, four out of seven reported less peak pain from each ulcer, and
four out of seven reported lower frequencies of ulcers. This initial data suggested that the
discs might reduce frequency of minor RAU and reduce duration and peak pain levels of

400


ulcers. 67
Treatment with vitamin B12 by oral supplementation is safe, inexpensive and effective
36.37.38
for RAS. Nonetheless, despite the results of the above studies, the potential effect of
Vitamin B12 on Aphthous ulcers is not well established. The purpose of this review was to
study whether the daily used Vitamin B12 via oral supplements may be an effective strategy
for reducing the number, duration, and pain of Aphthous ulcers.

The Cochrane Library, Joanna Briggs Institute (JBI) database and CINAHL databases have
been searched and no previous systematic reviews on this specifc topic were identified as
being published or underway.

REVIEW QUESTION(S)/OBJECTIVES
The review objective is to synthesize the best available evidence on the effectiveness of
daily orally taken vitamin B12 on the incidence, duration or severity of Recurrent Aphthous
Stomatitis RAS.

Inclusion criteria

Types of Studies
The review will consider any randomized controlled trials undertaken in in-patient and
out-patient settings. In the absence of RCTs, other research study designs, such as
non-randomized or quasi-randomized controlled trials and before-and-after studies, will be
considered for inclusion.

Types of Participants
Adults 18 + years old With Recurrent Aphthous Stomatitis RAS of either gender will be
considered eligible.

Types of Interventions
daily orally taken vitamin B12

Types of Outcome measures

The outcome measures will include:
401


(1) Incidence of RAS expressed as the proportion of participants experiencing one or more
Aphthous ulcers or expressed as number and size of the ulcer during the study period
(2) Duration of RAS episodes expressed as the average number of days of RAS episodes.
(3) Severity of these RAS episodes

Search strategy
The search strategy is designed to identify all published and unpublished papers in
English language from 1970 to present. The search will proceed in three stages, as follows;
An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis
of the text words contained in the title and abstract, and of the index terms used to describe
article. A second search using all identified keywords and index terms will then be undertaken
across all included databases.

The databases to be search include:

Cochrane Central Register Controlled Trials (CENTRAL),
Joanna Briggs Institute Library of Systematic Reviews
Database of Abstracts of Reviews of Effectiveness.
CINAHL
PubMed
ScienceDirect
MEDNAR
Dissertation International
Conference Proceedings

The specific disease descriptor to be added to the search strategy for each database is
1.Recurrent Aphthous Stomatitis
2.Canker sore
3.Oral ulcer
4.Mouth sore
5.cobalamin

Search term and keywords included

1.Vitamin B12
2.Recurrent Aphthous Stomatitis
402


3.Mouth sore
4.Aphthae
5.Canker sore
6. cobalamin
7. Vitamin B12 RCT
8. cobalamin RCT
9. Combine 1 or 2
10. Combine 3 or 4
11. Combine 5 or 6
12. Combine 2 or 7
13. Combine 2 or 8
14. Combine 7 and 8
15. Combine 2 or 3 or 7
16. Combine 2 or 3 or 8

Assessment of Methodological Quality

Papers selected for retrieval will be assessed by two independent reviewers for
methodological validity prior to inclusion in the review using two standardized critical
appraisal instruments from the JBI-MAStARI (Joanna Briggs Institute-Meta-Analysis of
Statistics Assessment and Review Instrument) (Appendix I) will be used. Any disagreements
that arise between the reviewers will be resolved through discussion, or with a third reviewer.

Data Collection/Extraction
Data will be extracted from papers included in the review using standardized data
extraction tools from the JBI-MAStARI. (Appendix II) Data extracted from
experimental/observational studies will include specific details about the interventions,
populations, study methods and outcomes of significance to the review question and specific
objectives.

Data Synthesis
Quantitative papers will, where possible, be pooled using the JBIMAStARI. All results
will be subject to double data entry. Odds ratio (for categorical data) and weighted mean
differences (for continuous data) and their 95% confidence intervals will be calculated for
analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical
403


pooling is not possible the findings will be presented in narrative form.

Potential Conflict(s) of Interest

No conflict of interest.

404


References
1. Porter SR, Hegarty A, Kaliakatsou F, Hodgson TA, Scully C.Recurrent aphthous
stomatitis. Clin Dermatol 2000;18:569-78
2. Porter SR, Scully C, Pedersen A. Recurrent aphthous stomatitis. Crit Rev Oral Biol Med
1998;9:306321.
3. Ship JA, Chavez EM, Doerr PA, Henson BS, Sarmadi M.Recurrent aphthous stomatitis.
Quintessence Int 2000;31:95-112.
4. Field EA, Longman LP. Tyldesleys Oral Medicine, 5th edn. Oxford: Oxford University
Press, 2003.
5. Tabolli S, Bergamo F, Alessandroni L, Di Pietro C, Sampogna F, Abeni D. Quality of life
and psychological problems of patients with oral mucosal disease in dermatological
practice. Dermatology (Basel, Switzerland). 2009;218(4):314-320.
6. Miller MF, Ship II. A retrospective study of the prevalence and incidence of recurrent
aphthous ulcers in a professional population,1958-1971. Oral Surg Oral Med Oral Pathol
1977;43(4):532-7.
7. Yurdakul S, Yazici H. Behet's syndrome. Bailliere's Best Practice & Research in
Clinical Rheumatology . October 2008;22(5):793-809.
8. zen S. Pediatric onset Behet disease. Current Opinion in Rheumatology. September
2010;22(5):585-589.
9. International Study Group for Behcets Disease. Criteria for diagnosis of Behcets
disease. Lancet 1990;335:1078 80.
10. Krause I, Rosen Y, Kaplan I, et al. Recurrent aphthous stomatitis in Behcets disease:
Clinical features and correlation with systemic disease expression and severity. J Oral
Pathol Med 1999;28:1936.
11. Rogers R. Recurrent aphthous stomatitis in the diagnosis of Behcets disease. Yonsei
Med J 1997;38:370 9.
12. Lee S. Diagnostic criteria of Behcets disease: Problems and suggestions. Yonsei Med J
1997;38:3659.
13. Krause I, Uziel Y, Guedj D, et al. Mode of presentation and multisystem involvement in
Behcets disease: The influence of sex and age of disease onset. J Rheumatol
1998;25:1566 9.
14. El Maghraoui A, Abouzahir A, Tabache F, et al. [Systemic manifestations of Sweet's
syndrome: a case report]. Annales De Mdecine Interne. September

405


2000;151(5):413-416.
15. von den Driesch P. Sweets syndrome (acute febrile neutrophilic dermatosis). J Am Acad
Dermatol 1994;31:53559.
16. von den Driesch P, Schlegel GR, Kiesewetter F, et al. Sweets syndrome: Clinical
spectrum and associated conditions. Cutis 1989;44:193200.
17. Driban NE, Alvarez MA. Oral manifestations of Sweets syndrome. Dermatologica
1984;169:1023.
18. Lange RD, Jones JB. Cyclic neutropenia: A review of clinical manifestations and
management. Ann J Pediat Haematol Oncol 1981;3:3637.
19. Scully C, MacFadyen EE, Campbell A. Orofacial manifestations in cyclic neutropenia.
Br J Oral Surg 1982;20:96101.
20. Sucker C, Djawari D. Rezidivierede Gingivostomatitis ulcerosa bei zyklischer
Neutropenie. Hautarzt 1999;50:5036.
21. Porter SR, Scully C, Standen GR. Oral ulceration as a manifestation of autoimmune
neutropenia. Oral Surg Oral Med Oral Pathol 1994;78:17980.
22. Hasturk H, Tezcan I, Yel L, et al. A case of chronic severe neutropenia: Oral findings and
consequences of shortterm granulocyte colony-stimulating factor treatment. Aust Dent J
1998;43:913.
23. Orme RL, Nordlund JJ, Barich L, et al. The MAGIC syndrome (mouth and genital ulcers
with inflammed cartilage). Arch Dermatol 1990;126:9404.
24. Le Thi Huong D, Wechsler B, Piette JC, et al. Aortic insufficiency and recurrent valve
prosthesis dehiscence in MAGIC syndrome. J Rheumatol 1993;20:397 8.
25. Marshall GS, Edwards KM, Butler J, et al. Syndrome of periodic fever, pharyngitis and
aphthous stomatitis. J Pediatr 1987;110:43 6.
26. Grattan CEH, Scully C. Oral ulceration: A diagnostic problem. Br Med J
1986;292:1093 4.
27. Eversole LR. Immunopathology of oral mucosal ulcerative desquamative, and bullous
diseases. Oral Surg Oral Med Oral Pathol 1994;77:55571.
28. Weusten BLAM, van de Wiel A. Aphthous ulcers and vitamin B12 deficiency. Neth J
Med 1998;53:1725.
29. Porter SR, Scully C. Orofacial manifestations in primary immunodeficiencies involving
IgA deficiency. J Oral Pathol Med 1993;22:1179.
30. Scully C, Porter SR. Orofacial manifestations in primary immunodeficiencies: common
variable immunodeficiency. J Oral Pathol Med 1993;22:157 8.
406


31. Scully C, Porter SR. Orofacial manifestations in primary immunodeficiencies:

Polymorphonuclear leukocyte defects. J Oral Pathol Med 1993;22:310 1.
32. Porter SR, Scully C. Orofacial manifestations in primary immunodeficiencies:
T-lymphocyte defects. J Oral Pathol Med 1993;22:308 9.
33. Zakrzewska JM, Robinson P, Williams IG. Severe oral ulceration in patients with HIV
infection: A case series. Oral Dis 1997;3(Suppl 1):S1946.
34. MacPhail LA, Greenspan JS. Oral ulceration in HIV infection: Investigation and
pathogenesis. Oral Dis 1997; 3(Suppl 1):S1904.
35. Healy CM, Thornhill MH. An association between recurrent oro-genital ulceration and
nonsteroidal anti-inflammatory drugs. J Oral Pathol Med 1995;24:468.
36. Scully C, Porter SR. Nicorandil-induced oral ulceration. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod (in press).
37. Scully C, Porter S. Oral mucosal mucosal disease: recurrent aphthous stomatitis. Br J
Oral Maxillofac Surg. 2008 Apr;46(3):198-206. Epub 2007 Sep 11.
38. Rees and Binnie, 1996 Rees T, Binnie W. Recurrent aphthous stomatitis. Dermatologic
Clinics 1996;14(2):243-256.
39. Ship II. Epidemiologic aspects of recurrent aphthous ulcerations. Oral Surg Oral Med
Oral Pathol 1972;33:4006.
40. Field EA, Brookes V, Tyldesley WR. Recurrent aphthous ulceration in children-a review.
Int I Paed Dent 1992;2:1-10.
41. Wray D, Ferguson MM, Mason DK, Hutcheon AW, Dagg JH. Recurrent aphthae:
treatment with vitamin B12, folic acid, and iron. BMJ 1975;2:4903.
42. Lehner T. Progress report: oral ulceration and Behgets Syndrome. Gut 1977;18:491-511.
43. Scully C, Porter S. Recurrent aphthous stomatitis: urrent concepts of aetiology,
pathogenesis and management. I Oral Pathol Med 1989;18:21-27.
44. Porter SR, Scully C. Aphthous stomatitis-an overview of aetiopathogenesis and
management. Clin Exp Dermatol 1992;16:235-243.
45. Casiglia JM, Morwski GW, Nebesio CL. Aphthous Stomatitis. Emedicine Dermatology.
http://emedicine.medscape.com/article/1075570-overview Accessed February 3, 2010.
46. Nolan A, McIntosh WB, Allam BF, et al. Recurrent aphthous ulceration: Vitamin B1, B2
and B6 status and response to replacement therapy. J Oral Path Med 1991;20:38991.
47. Olsen A, Feinberg I, Silverman S, Abrams D, Greenspan JS. Serum vitamin B12' folate,
and iron levels in recurrent oral ulceration. Oral Surg Oral Med Oral Pathol
1982;54:517-520.
407


48. Piskin S, Sayan C, Durukan N, Senol M. Serum iron, ferritin, folic acid, and vitamin B12
levels in recurrent aphthous stomatitis. J Eur Acad Dermatol Venereol 2002;16:66-7.
49. Moghadamnia AA, Motallebnejad M, Khanian M. The efficacy of the bioadhesive
patches containing licorice extract in the management of recurrent aphthous stomatitis.
Phytother Res 2009;23:246250.
50. Das SK, Das V, Gulati AK, et al. Deglycyrrhizinated liquorice in aphthous ulcers. J
Assoc Physicians India 1989;37:647.
51. Brogden RN, Speight TM, Avery GS. Deglycyrrhizinised liquorice: A report of its
pharmacological properties and therapeutic efficacy in peptic ulcer. Drugs
1974;8:330339.
52. Babaee N, Mansourian A, Momen-Heravi F, et al. The efficacy of a paste containing
Myrtus communis (myrtle) in the management of recurrent aphthous stomatitis: A
randomized controlled trial. Clin Oral Invest 2010;6570.
53. Pedersen A, Hougen HP, Klausen B, Winther K. LongoVital in the prevention of
recurrent aphthous ulceration. J Oral Pathol Med 1990;19:371-5.
54. Reznik D, O'Daniels CM. Clinical treatment evaluations of a new topical oral medication.
Compend Contin Educ Dent Suppl 2001;32:17-21.
55. Meiller TF, Kutcher MJ, Overholser CD, Niehaus C, DePaola LG, Siegel MA. Effect of
an antimicrobial mouthrinse on recurrent aphthous ulcerations. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1991;72:425-9.
56. Kerr AR, Drexel CA, Spielman AI. The efficacy and safety of 50 mg penicillin G
potassium troches for recurrent aphthous ulcers. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2003;96:685-94.
57. Murray B, McGuinness N, Biagioni P, Hyland P, Lamey PJ. A comparative study of the
efficacy of Aphtheal in the management of recurrent minor aphthous ulceration. J Oral
Pathol Med 2005;34:413-9.
58. Gonzalez-Moles MA, Morales P, Rodriguez-Archilla A, Isabel IR, Gonzalez-Moles S.
Treatment of severe chronic oral erosive lesions with clobetasol propionate in aqueous
solution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:264-70.
59. Hutchinson VA, Angenend JL, Mok WL, Cummins JM, Richards AB. Chronic recurrent
aphthous stomatitis: oral treatment with low-dose interferon alpha. Mol Biother
1990;2:160-4.
60. Katz J, Langevitz P, Shemer J, Barak S, Livneh A. Prevention of recurrent aphthous
stomatitis with colchicine: an open trial. J Am Acad Dermatol 1994; 31(3 Pt 1):459-61.
408


61. Femiano F, Gombos F, Scully C. Recurrent aphthous stomatitis unresponsive to topical

corticosteroids: a study of the comparative therapeutic effects of systemic prednisone and
systemic sulodexide. Int J Dermatol 2003;42:394-7.
62. Brachmann F. treatment of chronically recurrent aphthae with vitamin B12. Zohnarztl
welt 1954;9:58-59.
63. Dholakia KR, Dharmarajan TS, Yadav D, Oiseth S, Norkus EP, Pitchumoni CS. Vitamin
B12 deficiency and gastric histopathology in older patients. World J Gastroenterol.
2005;11:7078-83.
64. Dali-Youcef N, Andrs E. An update on cobalamin deficiency in adults. QJM: Monthly
Journal Of The Association Of Physicians . January 2009;102(1):17-28.
65. Davis R, Lawton A, Prouty R, Chow B. The Absorption Of Oral Vitamin B-12 In An
Aged Population. Journal Of Gerontology. 1965;20:169-172.
66. Allen LH. How common is vitamin B-12 deficiency? AM J Nutr 2009;89(2):693S-6S.
67. Burgess J A, Haley J T. Effect of Bioactive B12 in Adhering Discs on Aphthous Ulcers.
Inside Dentistry with commentary by Howard E.Strassler 2008;4(11):9.
68. Volkov I, Rudoy I, Freud T, Sardal G, Naimer S, Peleg R, Press Y. Effectiveness of
vitmin B12 in treating recurrent aphthous stomatitis: a randomized, double-blind,
placebo-controlled trial. J Am Board Fam Med. 2009;22(1):9-16.
69. Volkov I, Rudoy I, Abu-Rabia U, et al. Case report: Recurrent aphthous stomatitis
responds to vitamin B12 treatment. Can Fam Physician. 2005;51: 844-845.

409


Appendix I
Critical Appraisal Checklist for Experimental Studies
Reviewer __________________________________ Date _____________
Author ____________________________________ Year _____________
Record Number ____________________

1. Was the assignment to treatment groups random? Yes No Unclear N/A

2. Were participants blinded to treatment allocation?
3. Was allocation to treatment groups concealed from the
allocator?
4. Were the outcomes of people who withdrew described
and included in the analysis?
5. Were those assessing the outcomes blind to the
treatment allocation?
6. Were the treatment and control group comparable at
entry?
7. Were the outcomes measured in the same way for all
groups?
8. Were outcomes measured in a reliable way?
9. Was there adequate follow-up (>80%)?
10. Was appropriate statistical analysis used?

Overall Appraisal: Include Exclude Seek further info.

Reviewers Comments (Including reasons for exclusion):
___________________________________________________________________
___________________________________________________________________

410


Appendix II
Data Extraction Form for Experimental/Observational Studies
Reviewer __________________________________ Date _____________
Author _____________________________________Year _____________
Record Number ___________________
Study Method: RCT Quasi-RCT Longitudinal Retrospective Observational
Other
Participants:
Setting: ______________________________________________________________
Population: ______________________________________________________________
Sample size: ______________________________________________________________
Intervention:
Intervention 1: ______________________________________________________________
Intervention 2: ______________________________________________________________
Intervention 3: ______________________________________________________________

Clinical Outcome Measures:

Outcome Description Scale/Measure

411


Study Results:
Dichotomous Data
Outcome Intervention ( ) Intervention ( )
Number/Total Number Number/Total Number

Continuous Data
Outcome Intervention ( ) Intervention ( )
Mean and SD (Number) Mean and SD (Number)

Authors Conclusions:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Reviewers Comments:
___________________________________________________________________
___________________________________________________________________

412


Appendix III
Critical Appraisal Checklist for Narrative, Expert opinion & text
Reviewer _________________________________Date _____________
Author ___________________________________ Year _____________
Record Number ____________________________

Yes No Unclear
1. Is the source of the opinion clearly identified?
2. Does the source of the opinion have standing in the field of
expertise?
3. Are the interests of patients/clients the central focus of the
opinion?
4. Is the opinions basis in logic/experience clearly argued?
5. Is the argument developed analytical?
6. 6. Is there reference to the extant literature/evidence and any
incongruence with it logically defended?
7. Is the opinion supported by peers?

Overall Appraisal: Include Exclude Seek further info.

Reviewers Comments (Including reasons for exclusion):
______________________________________________________________
______________________________________________________________
______________________________________________________________

413


Appendix IV
Data Extraction Form for Narrative, Expert opinion & text
Reviewer _________________________________ Date ______________
Author ___________________________________ Year ________________
Journal _____________________ Record Number ________________

Study Description:
Type of Text: ______________________________________________________________
Those Represented: _____________________________________________

Stated: _______________________________________________________
_____________________________________________________________
Allegiance/Position:
_____________________________________________________________
______________________________________________________________
Setting: ______________________________________________________________
Geographical: ______________________________________________________________
Cultural: _______________________________________________________
Logic of Argument:
_____________________________________________________________
______________________________________________________________
Data Analysis:_______________________________________________________
Authors Conclusions:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

414


Conclusions Illustration from

Publication Evidence
(page number) Unequivocal Credible Unsupported

Extraction of findings complete: Yes

Reviewers Comments:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

415