2. Evidence based medicine
Evidence based dentistry
Evidence based practice
Evidence based decision making
Evidence based Periodontology
Development of EBP
Stages in evidence based practice
Evidence based approach in periodontal therapy.
Conclusion
3. Evidenced based medicine is conscientious, explicit, and
judicious use of current best evidence in decisions about the
care of individual patients.
Sackett et al 1996, Philips 2010
4. •.
Definitions of EBD
Evidence-based dentistry is an approach to oral
health that requires the judicious integration
of Systematic assessments of clinically
relevant Scientific evidence, relating to the
patient’s oral and medical condition and history,
with the dentist’s clinical expertise and the
patient’s treatment needs and preferences.
ADA policy on evidence-based dentistry (KAO 2006)
5. “
EBD is a Systematic
practice of dentistry in
which the dentist
Finds, Assesses, and
Implements
methods of Diagnosis And
Treatment on the basis of
the best available Current
Research, their Clinical
Expertise, and the needs
and preferences of the
patient”.
Mosby’s Medical Dictionary .
Evidence-based dentistry
is the practice of dentistry
that integrates the best
available evidence with
clinical experience and
patient preference in
making clinical decisions.
Sutherland S., J Can Dent
Assoc 2001; 67:204-6
6. The EBD process is not a rigid methodological
evaluation
Scientific basis
Best possible decisions
Appropriate health care
•Unbiased reviews
•Scientific evidence-MEDLINE
web based software
• Clinical and patient factors
7. Formalized process and structure for learning skills like:
a) Efficient and effective online searching skill
b) Critical appraisal skills
So, that best scientific evidence is considered when making patient care decisions.
evaluation Sorting out validity and Non validity
8. Evidence alone never
sufficient clinical
decision.
Hierarchies of quality
and applicability of
evidence exist to guide
clinical decision
making.
10. To improve the quality of health care.
Because there is
a. Variations in practice pattern.
b. Difficulties in Assimilating scientific evidence
into practices.
Demonstrate best use of limited sources.
EBD is sometimes described as doing the right
thing, for the right patient, at the right time.
11. Variations
What is known and what is
practiced
Integrating new evidence
Lack/Weak scientific
evidence
Assimilating
evidence
Up to date thorough
reading
Attending courses
Internet and electronic
databases-
MEDLINE
PUBMED
COCHRANE LIBRARY
12. Evidence is based on the existence of at least one
well-conducted randomized control trial (RCT).
Triveni et al IOSR-JDMS) (July. 2015),
It is considered as the synthesis of all valid
research that answers a specific question, which
distinguish it from single research study.
13. Dave Sackett and colleagues
who generated "levels of
evidence" for ranking the
validity of evidence.
Sackett DL, Rosenberg WM,
Gray JA, Haynes RB,
Richardson WS. Evidence
based medicine: what it is
and what it isn't. British
Medical Journal.
1996;312:71–72.
14. Primary source
•original research publications
that have not been filtered or
synthesized.
•Available online :electronic
journals
Secondary source
•synthesized publications of the
primary literature.
•Includes:
Systematic reviews
Meta analyses
Evidence-based article reviews
clinical practice guidelines
protocols.
17. 1.Convert information, needs and problems into
clinical questions so that they can be answered.
2. Conduct a computerized search with maximum
efficiency for finding the best external evidence with
which to answer the question
3. Critically appraise the evidence for its validity and
usefulness (clinical applicability).
4. Apply the results of the appraisal, or evidence, in
clinical practice.
5. Evaluate the process and your performance.
19. Evidence-based Periodontology is the application
of evidence-based health care to periodontology.
Muir Gray proposed a definition : “An approach
to decision making in which the clinician uses
the best evidence available, in consultation with
the patient, to decide upon the option which
suits that patient best.”
Muir Gray JA. Evidence-based, locally owned, patient-
centred guideline development. Br J Surg; 1997;84(12):1636-7
20. Evidence :
1. Highest quality
2. Lower levels of evidence.
(more prone to bias less reliable data)
In addition, the data presentation supplies more
clinically relevant information, including the
probability of achieving a certain effect such as a
benefit, and considering possible adverse effects.
21. Is not simply systematic reviews of randomized
controlled trials
Is an approach to patient-care and nothing more.
So,the expectations that are sometimes laid on it
can be inappropriate.
It cannot provide answers if research data do not
exist
It cannot substitute for highly developed clinical
skills.
Therefore, it can never be cookbook healthcare
or use statistics in isolation to drive clinical care.
What evidence-based periodontology is not
22.
23. EBP is built upon developments in clinical
research design throughout the18th, 19th and
20th centuries.
Evidence-based medicine has only been known
for just over a decade and the term was coined by
the Clinical epidemiology group at McMaster
University in Canada.
One of the earliest to take up the challenge in
periodontology (in fact in oral health research
overall) was Alexia Antczak Bouckoms in Boston,
USA.
24. 1994 : Alexia Antczak Bouckoms set up an Oral Health Group as part of the Cochrane
Collaboration.
1997 :The editorial base of the Oral Health group subsequently moved to Manchester University
with Bill Shaw and Helen Worthington as co-ordinating editors.
1996: World Workshop in Periodontology held by the American Academy of Periodontology which
included elements of evidence-based healthcare, supported by Michael Newman at UCLA.
2001 :The first Cochrane systematic review in periodontology was published and
researched the effect of guided tissue regeneration for infrabony defects
2002: European workshop on periodontology. The workshop was organized by the
European Academy of Periodontology for the European Federation of Periodontology
25. 2003 : Contemporary Science Workshop by the
American Academy of Periodontology
Many other groups are now using similar methods in
healthcare and research. Most recently
2003 : International Center for Evidence-Based
Oral Health was launched
(http://www.eastman.ucl.ac.uk/ iceboh)
to produce high quality evidence-based research
with an emphasis on, but not limited
to,periodontology and implants and to provide
generic training in systematic reviews and research
methods.
26. One of the barrier in application of research
findings in clinical practice
the way that results are often presented.
A mean value will be published, based on a
statistical analysis comparing experimental
groups.
Such an outcome could include achieving a health
benefit or preventing further disease.
Clinical Relevance
27. The NNT(number needed to treat) is the average
number of patients who need to be treated to
prevent one additional bad outcome.
NNT
achieve avoid
NNTb NNTh
•It is defined as the inverse of the Absolute risk
reduction.(ARR)
•It was described in 1988.
28. For detailed guidance regarding the use and calculation of
the NNT the reader is recommended to the electronic
journal Bandolier: http://www.jr2.ox.ac.uk/
bandolier/booth/painpag/NNTstuff/numeric.htm.
29.
30.
31.
32.
33. Framing the question:
Forces clinician to focus on what he and patient believes
Identify key terms for computerized
search.
Easy identification of:
a) Problems, results ,outcome.
b) Types of evidence and information
required.
Determine effectiveness of
intervention and application
Increase chances of finding the answer.
34. In patients with periodontal disease, will
short-term systemic antibiotics, when
compared to surgery, reduce pocket depth?
Outcome
Population Intervention Comparison
Population
intervention
comparison
outcome
35. Özkan Y, Orbak R (2016) The Evidence-Based Periodontology. JSM Dent 4(5):
1075.
37. A review of a clearly
formulated question
that attempts to
minimize bias using
systematic and explicit
methods to identify,
select, critically
appraise and
summarize relevant
research.
38. 1.Find and summarize all available studies.
2. Provide an objective assessment of the quality or research and in
particular the degree of protection from bias within the original
studies.
3. Estimate research effects across multiple studies with meta-analysis.
a. Meta-analysis is valid only if studies are similar in their research
question and design.
b. Meta-analysis can estimate uncertainty and precision of the effect.
c. Meta-analysis may generate hypotheses for differential effects
across subgroups of the population tested.
4. If the effect is consistent across multiple studies (with small
differences in design), then it may more readily possible to
generalise the results to clinical practice than the results from a
single study.
5.Overcome limitations of underpowered studies in detecting a true
difference if such a true difference really exists.
What A High Quality Systematic Review Can
Do?
39. It cannot be used in isolation to dictate clinical
practice.
It is a synthesis of available research and must be used
in context with clinical judgement and patient
preference.
Produce strong conclusions if the research base is
weak in quality.
Overcome limitations of narrowly designed clinical
research.
Exclude relevant studies.
Be a miracle research design
What A High Quality Systematic Review
Can’t Do?
41. These components help in the design of the
search strategy that aims to be comprehensive.
Multiple electronic databases:
•MEDLINE
•EMBASE
•CENTRAL :
(Cochrane
Collaboration
Register of Trials
and Records).
Other Supplementary
approaches:
•bibliographies of retrieved
studies and review articles,
•hand-searching of journals for
missed reports
• contacting researchers,
industry and journals for
unpublished data.
42. Search strategy aims for high sensitivity.
Downside of this approach is low precision
The systematic review
screens the search findings against prestated criteria.
to exclude studies irrelevant to answering the question.
Increase the quality of relevant studies(critically
appraised)using objective criteria that
influence the study outcome.
Aim
43. Experimental studies:
Randomized-controlled trial: parallel group design
– a group of participants (or other unit of analysis,
e.g. teeth) is randomized into different treatment
groups. These groups are followed up for the
outcomes of interest.
Randomized-controlled trial: split-mouth design
– each patient is his/her own control. A pair of similar
teeth, or groups of teeth (quadrants), may be selected
and randomly allocated to different treatment groups.
Non-randomized controlled trial – allocation of
participants under the control of the investigator, but the
method falls short of genuine randomization.
Different study designs
44. Cohort: a longitudinal study, identifying groups of
participants according to their exposure/intervention
status. Groups are followed forward in time to measure
the development of different outcomes.
Case-Control: a study that identifies groups of
participants according to their disease/outcome status.
Groups are investigated/ questioned to determine their
exposure status.
Cross-sectional: a study (survey) undertaken on a defined
population at a single point in time (snap-shot). Subjects
are observed on just one occasion and are not followed
up.
46. Not all evidence is created equal (Richards 2003)
Quality of evidence vary according to study design
hierarchy of evidence.
The publication of research in a high-ranking journal
may not be an absolute guarantee of quality.
As quality is not merely a hypothetical concept but also
affects study outcomes.
concept
47.
48.
49. Guidelines are there to help:
Publication of clinical research
Authors
Editors
Reviewers
50. Guidelines are available to help the publication of clinical
research:
. 1. CONSORT (Consolidated Standards of Reporting Trials) for reporting
randomized controlled trials
2. STARD (Standards for Reporting of Diagnostic Accuracy) for reporting studies
on diagnostic tests (http://consortstatement.org/).
Guidelines for reporting systematic reviews are available:
1.QUOROM (Quality of Reporting of Meta-analyses) (http:// consort-
statement.org/)
2.MOOSE (Meta-analysis Of Observational Studies in Epidemiology)
3.QUADAS (Quality Assessment of studies of Diagnostic Accuracy included in
Systematic reviews).
51. some evidence is better than other evidence,
greater emphasis on good than on poor quality evidence
when making clinical decisions.
How exactly we decide what constitutes
good quality evidence. This process is
critical appraisal.
53. The validity of published evidence is potentially
affected by the quality of every stage of the
experimental process from:
aims and objectives,
design,
execution,
analysis,
interpretation,
and finally publication
55. For systematic reviews , independent reviewers
usually undertake quality appraisal in
These checklists are based on a combination of
factors that have been shown empirically to affect
quality (such as allocation concealment) and also
topic specific factors deemed important by the
reviewers.
Two such checklists are there:
duplicate checklists
56.
57.
58.
59. EBA and mechanical nonsurgical pocket therapy
Effect of smoking on NST
EBA in periodontal regeneration
EBP and open flap debridement
EBA and mucogingival surgery
EBA and dental implants
60. A total of 9 reviews were searched for the best evidence.
Nonsurgical pocket therapy (NST) was found to have a
positive effect with the exception of pockets <3 mm.
Patient, environmental, and operator factors affect
therapy delivery.
No difference was found between the effect of hand and
machine-driven instruments.
Machine-driven instruments were faster than hand-driven
instruments.
61. The various antiplaque and/or antigingivitis agents don’t
offer substantial benefit for treatment of periodontitis.
They may however contribute to the control of gingival
inflammation that exists with periodontitis.
Supragingival irrigation may be used as an adjunct to
tooth brushing and aid in the reduction of gingival
inflammation.
Even when subgingival irrigation is used, the evidence
shows that there are no clear substantial long-term
benefits for the treatment of periodontitis.
62. Antibiotic therapy and periodontics:
The risk-benefit ratio indicates that systemic antibiotics
should not be used for the treatment of gingivitis and
common forms of adult periodontitis.
But evidence suggests that systemic antibiotics may be
useful in aggressive forms of periodontitis.
Local delivery of antimicrobial agents:
There was modest gain in clinical attachment level and
decrease in probing depth and gingival bleeding.
A few side effects were demonstrated namely, transient
discomfort, erythema, recession, allergy, and rarely,
candida infection.
Conclusion: adjunctive therapies continued to be
explored, mechanical debridement is still the single best
option available. It remains the foundation treatment for
many adjunctive antimicrobial treatment investigations.
63. Systematic review :conducted by Labriola et al(2000).
Search strategy included Medline, Embase and Central.
Study design : controlled clinical trial.
The outcomes were:
There was reduced pocket depth reduction in smokers, compared with
nonsmokers.
no significant difference in the change of Clinical Attachment Level (CAL)
between smokers and nonsmokers.
The reason could be that the increased vasoconstriction in peripheral blood
vessels of smokers leads to decrease in bleeding and edema. Also, smokers
would have less potential for resolution of inflammation and edema within
the marginal tissues and therefore less potential for gingival recession.
64. Guided tissue regeneration:
Study population included chronic periodontitis patients in
subjects 21 yrs or older.
The meta-analysis done by Needleman et al (2001) and
Murphy et al (2003).
The outcomes assessed were:
o Short-term clinical outcomes: It included soft tissue
changes such as increased CAL and decreased PPD.
o Long-term clinical outcomes: It included disease
recurrence and tooth loss.
65. Patient-centered outcomes:
a) When compared with OFD, GTR showed increase in
CAL, decrease in PPD, and defect fill.
b) When GTR with bone substitutes was compared
with GTR alone, the results were similar.
c) No evidence was found for difference in use of
ePTFE versus bioabsorbable membranes.
d) Long-term clinical outcomes/patient-centered
outcomes could not be determined due to lack of
available data. Heterogeneity was large and bias
could not be eliminated
66. Meta-analysis was done by Reynolds et al (2003) and Trombelli et al
(2002).
Short-term changes(12 months after intervention)
Autogenous bone: Trombelli et al : greater CAL gain but not
statistically significant.
Reynolds et al :statistically signifcant gain in CAL
Bone allograft: gain in CAL, and increased defect fill,PPD reduction
Dentin allograft: a gain in CAL
Coralline calcium carbonate: a gain in CAL and bone fill but no
improvement in pocket depth reduction.
Bioactive glass: improvement of bony lesion when compared with
open flap debridement [OFD]
Porous/nonporous hydroxyapatite:(PMMA)and (PHEMA)
Polylactic acid granules:gain in CAL and decrease in probing pocket
depth.
67. Long-term outcomes:
Two-thirds of the patients showed gain in CAL in the grafted group
and one third of open flap debridement showed a decrease in CAL.
Fleming et al(1998), Galgut et al(1992), Yukna et al(1989).
Patient-centered outcome: No systemic or local adverse
effects.
◦ 1. Pebbled surface texture of grafted site
◦ 2. Transient slight gingival inflammation
◦ 3. Delayed soft tissue healing
◦ 4. Exfoliation/shedding of graft material
68. SRs :Heitz Mayfield et al(2002) and Antczak et al
(1993).
Pocket depth
reduction
•Surgical treatment
Clinical
attachment
level gain
•Moderate pockets
•Nonsurgical therapy
Furcation
involvement
•Unclear Predictability
69. Carlo Clauser in his meta-analysis found that:
a) All the surgical procedures allow complete root
coverage.
b) Connective tissue grafting achieves complete root
coverage more frequently than does GTR.
c) The probability of complete root coverage is high if the
initial recession is shallow, irrespective of the surgical
procedure employed.
d) The probability of achieving complete root coverage
decreases dramatically as the initial recession depth
increases.
70. Critical review by Pagliaro on surgical root
coverage led to the following conclusions:
a) The overall clinical outcome of different techniques
appears to be satisfactory, but the great variability
among different studies creates difficulties in deciding
which procedure is best suited for each clinical
situation.
b) The data are quite heterogeneous.
c) The data are seldom eligible for further comparative
analysis even after some missing data are computed.
d) The editors of periodontal journals could promote
decisive measures for establishing clear mandatory
standards for presenting data in research articles.
71. Taylor et al 2005
Most evidence is available for titanium implants, but some
evidence exist to support the use of hydroxyapatite and
titanium-plasma sprayed implant surfaces
There is also evidence to support the use of Two-stage
systems which require a second surgery to expose the
implant and also one-stage implant systems.
Clinicians should exercise caution when treating patients.
◦ Who smoke
◦ With untreated periodontal diseases
◦ Poor oral hygiene
◦ Uncontrolled systemic disease and
◦ History of radiation therapy in the region or active skeletal
growth.
72. The principles of evidence-based healthcare provide
structure and guidance to facilitate the highest levels
of patient care.
There are numerous components to evidence-based
periodontology including the production of best
available evidence, the critical appraisal and
interpretation of the evidence, the communication and
discussion of the evidence to individuals seeking care
and the integration of the evidence with clinical skills
and patient values.
Evidence-based healthcare is not an easier approach to
patient management, but should provide both
clinicians and patients with greater confidence and
trust in their mutual relationship
73. Carranza’s Clinical Peroidontology 10th ed,11th edition.
NeedlemanI, Moles DR ,Worthington H. Evidence-based
periodontology, systematic reviews and research quality.
Periodontology 2000 2005; 37:12-28.
Richards D. Not all evidence is created equal – so what is good
evidence? Evid Based Dent 2003: 4: 17–18.
Evidence-based approach. Dent Clin North Am 2002;46:54-62.
Muir Gray JA. Evidence-based, locally owned, patient centred
guideline development Br J Surg. 1997 Dec;84(12):1636-7.
Vishal Anand et al .Evidence - Based Periodontology - A
Review.Indian Journal of Dental Sciences.March 2013 Issue:1, Vol.:5
Özkan Y, Orbak R (2016) The Evidence-Based Periodontology. JSM
Dent 4(5): 1075.
Notas del editor
Initially..
Classic example:william focal infection theory….
Consensus based conference….
Sr uses explicit crteria…
So,it’s the integration of evidence + clinical practice to make proper decision
Example in miiler’s class 1 an 2 recession both gtr + connective tissue graft both can be used and data sugeested ctg is better than gtr in reducing recession.so does this mean that only ctg can be used
Patient view is required.
In which they used systematic review to inform consensus under the chairmanship of klaus lang.
Mean value + c.i
Example: meta analysis :compare gtr and flap surgery.not always necessary gtr will give addition gain in CAL.
Which gingivitis Indices is valid or not
Cohort-incidence ,cause and prognosis;
Case control –risk factors
Cross sectional-prevalance in defined population at a specific time.
Reporting clinical research is crucial and quality issues ll be there.
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