evidence based dentistry: the new outlook in practice of dentistry

1. Evidence-based dentistry: An overview
Vineet Dhar
2016 Jul-Sep
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2. CONTENTS
• INTRODUCTION
• NEED
• HISTORY
• DEFINITION
• STEPSOF EBD (5AS)
• BEST SCIENTIFIC EVIDENCE
• QUALITY OF EVIDENCE
• CHALLENGES OR BARRIERS
• EVIDENCE BASEDVSTRADITIONAL PEDODONTICS
• SUMMARY
• CONCLUSION
• REFERENCES
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3. INTRODUCTION
• In the current era, clinicians are expected to keep up with the advancements in
dental therapies, materials, research, and clinical recommendations.
• There is abundance of research-based and even anecdotal evidence supporting
various aspects of dentistry.
• It is therefore common for doctors and patients to use online resources for a
quick search and to prepare for the upcoming medical/dental visit.
• Although online information is a great resource, it is often difficult for the
clinicians and more so for the patients to evaluate the extensive literature
available in terms of validity, quality of data, and reliability of information.
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4. WHAT ISTHE NEED OFTHE HOUR?
• to bridge the gap between research and clinical dental practice
• to optimize the information available to clinicians and patients
• formulating evidence-based clinical guidelines for best practices that the
dentists can refer to
• right kind of online resources should be made available to the patients.
• these resources must be derived from high-quality evidence-based research,
which can be used to establish the best standards for clinical care.
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5. HISTORY
The concept was introduced in the 19th century
“the conscientious, explicit and judicious use of current best evidence in
making decisions about the care of individual patients. The practice of
evidence-based medicine means integrating individual clinical expertise with
the best available external clinical evidence from systematic research”
- (Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. 1996.
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6. DEFINITION
• The ADA defines the term
“as an approach to oral health care that requires the judicious integration of
systematic assessments of clinically relevant scientific evidence, relating 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. [Last retrieved on 2016 Jun 23]
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7. subjective and can vary among various
providers and population,
ADA identifies 3 main areas
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8. FIVE STEPS OF EBD
ASK
ACQUIRE
APPRAISEAPPLY
ASSESS
5As
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9. 1. ASK
• Asking a clear and focussed questions
• Use PICO to create a search question
POPULATION INTERVENTION
OUTCOME COMPARISON
Converting information needs/
problems into clinical questions so
they can be answered
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10. • What is the PICO format?
• It’s a way of breaking down your clinical question into researchable parts.
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11. P=PATIENT/POPULATION
• Consider how you would describe a group of patients similar to your own?
• What is the condition or disease you’re interested in?
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12. I=INTERVENTION
• This is what you want to do to this patient.
• Are you treating, diagnosing, or observing?
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13. C = Comparison.
• It is usually the main alternative or what is traditionally done compared with
the intervention.
• It is very important to note that your question does not always need a direct
comparison. Sometimes you may be comparing to a placebo or doing
something to doing nothing, in which case it may be left blank.
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14. O = Outcome
• This should be patient oriented.
• What are you hoping to improve, accomplish, measure, or affect?
• How would you explain this to your patient?
• Let’s try applying this asking the question process to a sample patient.
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15. EXAMPLE QUESTION
• Patient/population= children
• Intervention =Topical fluoride
• Comparison = no topical fluoride
• Outcome = incidence of caries
Are topical fluoride treatments effective in reducing
caries in children?
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16. EXAMPLE QUESTION NO. 2
Patient/population/problem = children with dental caries
Intervention = xylitol gum
Comparison = no xylitol
Outcome = decrease in incidence of caries
In children with dental caries will xylitol gum chewing, as compared to no
xylitol gum, result in a decreased incidence of caries?:
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17. 2. ACQUIRE
• FINDINGTHE EVIDENCE
Conducting a computerised
search with maximum
efficiency for finding the best
external evidence with which
to answer the question 17

18. ONLINE DATABASES
• MEDLINE via PUBMED
• https://pubmed.ncbi.nlm.nih.gov/
• The Cochrane library: https://www.cochranelibrary.com/
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20. Best Scientific Evidence
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24. POSSIBLE OUTCOMES
• 1. The evidence supports a particular treatment as being effective.
• 2. The evidence does not support a particular treatment as being effective.
• 3. The evidence appears to support, but is not completely definitive for a
particular treatment.
• 4. There is inadequate evidence to support or refute a particular treatment at
this time.
Unfortunately, most dental systematic reviews result in either 3 or 4
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25. 3. APPRAISE
• Critically Appraising the Evidence
• Critical appraisal is the process of carefully and systematically
examining research to judge its trustworthiness, and its value and
relevance in a particular context.
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26. AIM: To assess whether a
reported piece of research is
good enough to be used in
decision making
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27. TRUSTWORTHINESS
RELEVANCE
RESULTS
VALIDITY
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28. • Validity : Validity defines the strength of the final results and whether
they can be regarded as accurately describing the real world.
INTERNAL EXTERNAL
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29. • A study which is sufficiently free from bias is said to have internal
validity
• External validity (Outcome) Asks the question of generalizability:
To what populations, settings, treatment variables and measurement
variables can this effect be generalized?”
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30. Clinical Relevance
• Outcome (External validity)
• Applicability... Increase with inc. ext. validity
• Cost… Inc. cost  dec. ext. validity
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31. QUALITY OF EVIDENCE
• One can consider an intervention to have a strong supporting evidence if it is
backed up by at least one systematic review of multiple well-designed RCTs
(GRADE) system is often used to rate the quality of evidence
and grading strength of recommendations in systematic
reviews and clinical practice guidelines.
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32. GRADE SYSTEM
• The Grading of Recommendations
Assessment, Development and Evaluation
• The GRADE process evaluates
• a summary of tables is created
• and strong, moderate, or weak quality
recommendations are assessed to balance
the desirable and undesirable consequences
of the various management options.
The
Study
Design
Risk Of
Bias
Imprecisi
on
Inconsiste
ncy
Indirectne
ss
Magnitud
e Of
Effect.
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33. 4. Apply
• Use the best identified valid and relevant evidence in patient care
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34. Translating Evidence into Clinical Practice
• PROBLEM: it is often tedious for the practitioners to read through the
elaborate reviews and extract relevant information out of them.
• SOLUTION: to create clinical recommendations/guidelines and critical
summaries that can be useful to all.
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35. The information overflow
from so many websites and
journals can often overwhelm
a clinician.
Sometimes, due to the lack of
data, the systematic reviews
may be insufficient to produce
relevant clinical guidelines
patient needs and preferences,
which may cause everything
else to take a backseat.
clinician's experience and lack
of motivation to change what
may have worked well for the
practice for years
RELATED
BARRIERS
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36. 5. Assess
• Assess how well the previous steps worked
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37. EVIDENCE BASEDVSTRADITIONAL
PEDODONTICS
SIMILARITIES:
• High value of clinical skills and experience.
• Fundamental importance of integrating evidence with patient values
DIFFERENCES
•EVIDENCE BASED
1.Uses the best evidence
2.Systematic appraisal of quality of
evidence.
3.More objective,more transparent and
less biased process.
4.Greater acceptance of levels of
uncertainty.
TRADITIONAL PEDODONTICS
Unclear basis of evidence.
Unclear or absent appraisal of quality
of evidence.
More subjective,more opaque and
biased process.
Greater tendency to make black and
white conclusions.
Evidence-Based Dentistry for Effective Practice
by Jan Clarkson (Editor), Jayne E Harrison (Editor), Amid I Ismail (Editor), Ian
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38. Step 1 : Clearly define
child’s problem and
specify it as a question
Step 2 identify needed
information to answer
the problem
Step 3 effeciently
search the literature
and select relevant
studies
Step 4 : apply rules of
evidence to assess
validity of the studies
step 5 : present
efficiently the content,
strengths and
weakness of the
articles to colleagues
Step 6 : extract clinical
message and apply it to
solve the patients’
problem
SUMMARY
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39. CONCLUSION
• Even though the EBD has been the “buzz word” for quite some time now, the
acceptance into dental practices has been a relatively slow process.
• However, to offer the acceptable clinical care and meet the increasing
awareness of the patient population, it is in the best interest of the
practitioners to adopt EBD sooner rather than later.
• The importance of providing a balanced mix of science, clinical expertise, and
patient needs to optimize patient care in a practice cannot be underestimated.
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40. References
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from: http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/policy-on-evidence-based-
dentistry .
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41. THANKYOU
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42. A Systematic Map of Systematic Reviews in Pediatric Dentistry—
What Do We Really Know?
• Ingegerd A. Mejàre, Gunilla Klingberg, Frida K. Mowafi, Christina
Stecksén-Blicks, Svante H. A. Twetman, and Sofia H. Tranæus
•
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