Ebd/cosmetic dentistry courses

EVIDENCE BASED
DENTISTRY
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indianentalacademy.com

CONTENTS
• INTRODUCTION
• DEFINITION
• TRADITIONAL MODEL OF PRACTICE
• MODEL OF EVIDENCE BASED DENTISTRY
• STEPS IN EVIDENCE BASED DENTISTRY
• THE QUESTION
• SEARCH INTO EVIDENCE
• APPRAISAL OF THE EVIDENCE
• SYSTEMATIC REVIEW OF LITERATURE
• APPLYING EVIDENCE TO PATIENT
• EVALUATING ONES PERFORMANCE
• EVIDENCE BASED PERIODONTAL THERAPIES
• CONCLUSION
• REFERENCES

INTRODUCTION
• Everything old is new again.
• In early 1990’s at “Mac Master University” a concept developed.
• The use of scientific evidence to approach critical clinical problems.
• Dr.David Sackett laid the foundation stone of evidence based health
care. Though this concept was originally developed in medicine, soon
its principle spread to all health specialities.
• Dr.David Sackett was of strong opinion that scientific literature should
be used as evidence and based on this evidence health care should be
rendered.
• Dr.David Sackett defined evidenced based practice as ‘Integrating
individual clinical expertise with the best available external clinical
evidence from systematic research.

DEFINITION
• Evidence based medicine has been defined as “the
conscientious, explicit and judicious use of current best
evidence in making decision about the care of individual
patients”.
• ADA defined “Evidence based dentistry”. Evidence based
dentistry is an approach to oral health that requires the
judicious integration and systematic assessment of
clinically relevant scientific evidence, relating to the patients
oral and medical condition and history with the dentist’s
clinical expertise and the patients treatment needs and
preferences”.

DEFINITION
Scientific
Literature
Dentists Clinical
Expertise
Patients Preference
O
OO

TRADITIONAL MODEL OF PRACTICE
Complaint Training
Symptoms Know ledge
Signs Personal experience
Patient Doctor Consultation w ith colleagues
Advice Journal brow sing
Decision CE Courses
Burden
Of
I llness
Treatments Hypothesis, etc.

TRADITIONAL MODEL OF PRACTICE
• At present the treatment, a dental practitioner provide is based on his
basic education, his experience, his knowledge and also the influence
from his colleagues, CE courses and journal browsing. This is
“However” sufficient to encounter routine problems…!!!
• But in certain challenging situation, when patient is demanding or there
is introduction of new materials, etc. the clinical abilities of dentist
become limited…
• At present there are about 2,43,500 article in dental literature, and the
increment in number of articles per months is 5%. Hence, today’s busy
practitioner don’t have time to access and read all of them.
• Then how should he give quality treatment to his patient.
• PROBLEM ORIENTED EVIDENCE SEARCH IS A POSSIBLE
ANSWER!!!

MODEL OF EVIDENCE BASED
DENTISTRY

STEPS IN EVIDENCE BASED
DENTISTRYm
• STEP-1: Translation of Clinical Problem into
Answerable question.
• STEP-2: Track down the best evidences to answer
the question.
• STEP-3: Critical Appraisal of the evidence for its
validity and clinical applicability.
• Step-4: Application of the results of critical appraisal
in clinical practice.
• STEP-5: Evaluation of One’s Performances.

THE QUESTION IN EVIDENCE
BASED DENTISTRY
• How Question arise?
• Which question?
• Types of questions?
• Phrasing of Question?
• How a question stress a search?

HOW QUESTION ARISE?
• Everybody is ignorant, only on different subjects.
• Practice by pattern recognition - with experience
practitioner builds up a mental library based upon
this, he is able to encounter critical clinical
challenges.
• But because of infinite variety of circumstances the
clinician is venerable to confusion and then questions
starts emerging, especially in encountering rare
problems and latest treatment modalities.

WHICH QUESTION?
• “An idle brain is devil’s workshop”
• What should be given topmost priority and what should be
addressed at last?
• FIRST: Choose questions from the patients perspective.
• SECOND: Those questions that are most likely to yield definitive
answers.
• THIRD: These question that help doctor to stay current and in
preparing for next occasion.
• FINALLY: Those interesting question that spark the learning
process.
• The advantages of these criteria are it helps us to balance
between patients demands and clinician’s decision…!

TYPES OF QUESTIONS…….
• Based upon the information the researcher or clinician is trying
together.
• Sackett et al suggested two types of questions:
– Background questions?
– Foreground questions?
• Background questions?
– They are less specific.
– Often related to general understanding of a disease.
– They have three components. Generally starts with why,
who, what, when and a verb/adj that connects them to item
of interest.
– E.g., What is the wear rate of this post-composite.
– What is the nerve pathways responsible for unlocalized
pain. www.indianentalacademy.com

• Foreground Questions?
– They are most specific.
– Often related to management of the patient.
– It usually has four components
• A population
• An intervention
• A comparative intervention
• An outcome
– “PICO”
• E.g. In patients with unlocalized dental pain is a cold test more
sensitive than an electric pulp test in identifying pulpitis?
• In patients with asymptomatic impacted third molar is removing
the teeth cause greater loss of bone support at the distal of
second molar than not removing them?

• However, another classification has grouped all questions
based upon where they arise like…. Question of?
– Clinical evidence: How to gather clinical findings
properly and interpret them soundly.
– Diagnosis: Low to select and interpret diagnostic tests.
– Prognosis: How to anticipate the patients likely course.
– Therapy: How to select treatment that do more good
than harm.
– Prevention: How to screen and reduce the risk of
disease.
– Education: How to teach yourself the patient and the
family what is needed.www.indianentalacademy.com

• Examples:
– Would a specific appliance reduce chronic snoring in
a middle aged man - A QUESTION OF THERAPY?
– Would a selective group of probing depths
performed in all patients equal to the diagnosis of
periodontal disease as accurately as complete
mouth probing - A QUESTION OF DIAGNOSIS.
– Does a single episode of unilateral facial pain in 22
year old patient increase the likelihood of developing
future TMJ dysfunction? - A QUESTION OF
PROGNOSIS.

• Examples:
– Do over the counter whitening agents increase the
likelihood of tooth sensitivity in patients who use them
regularly? - A QUESTION OF HARM.
– In 65 years old edentulous patients would implant
supported denture be more beneficial then
conventional denture - A QUESTION OF THERAPY.
– And sooooooooo on……..!
– In certain situations the clinical problem could not be
described in a single question hence in such condition
first the question is split into background question and
then into foreground question.www.indianentalacademy.com

WHY TO SPLIT?
FOREGROUND
A B C
A - Learner
B - Increase knowledge + Experience
C - Extensive knowledge + Extensive experiencewww.indianentalacademy.com

PHRASING THE QUESTION…..!
• TIPS
– Don’t worry about the classification.
– Don’t worry about the type of question.
– Find what patient wants!
– Ask yourself what best you can offer.
– Frame in simple terms.
– Remember PICO.

HOW A QUESTION STEERS A
SEARCH
• The direction of search is enhanced
by the very question itself.
• If question is specific, search for its
answer becomes easy.
• Hence, foreground questions are easy
to search then background questions.

CONDUCTING A SEARCH OF
LITERATURE
• This is the second step in EBD.
• This is time consuming and tedious.
However, no search is complete until
it is comprehensive.
• The search can be grouped under
three headings.
– Traditional reference sources.
– Peer - Reviewed journal sources.
– Electronic data base.www.indianentalacademy.com

Traditional Reference Source:
• Textbooks
• Index Cards
• Index Medicus
• Index to Dental Literature
• Expert opinion.
• All have few advantages and lot of
disadvantages…….!

Peer Reviewed Journal
• They are one of the best source of information.
• Large number of journals in dental and medicine are membership
organization. One need to subscribe them.
• However, out of these very few are “Peer Reviewed Journal”.
• Previously these journals were in printed format until 1990s at
present they are compelled in CD ROM as per each year, all of
these CD-ROM has search engine.
• It has few limitations as journal displays topic of particular edition.
• Different organizations have only articles of there speciality
without provision of sharing the articles to other specialities…!
• Hence, one has to subscribe all articles from all organizations
which is not possible.
• Hence, search is limited.

Electronic Database or
Bibliographic Database
• Pubmed
• Medline
• Internet Grateful Med.
• PUB-MED:
– Developed by National Library of Medicine, USA.
– Excellent tool for accessing dental, medical and biomedical journals.
– It is regularly updated and has wide array of networking.
– Full text with figures and photographs.
• MEDLINE:
– It is Pub-Meds premier bibliographic database exclusively for
medicine, dentistry, nursing.
– 11,000,000 articles as old as 1960s 4000 medical journals across 72
countries.
– Dentistry alone consists of 2,43,500 articles.
– All articles are listed as per keywords given by authors.www.indianentalacademy.com

• Internet Grateful Med.
– It provides free access to MEDLINE, AIDSLINE, AIDS DRUGS, BIO-
ETHICS LINE, DIR LINE, HISTLINE, POPLINE.
• Digital Library:
– Converting entire information of library into digital format.
• The Search Proper
– Clinical situation
– Question: In edentulous patients with fixed implant supported prosthesis is
the risk of implant failure greater when it is supported by only four implants.
Then when it is supported by more implants?”
• Search is done on Medline
– Keyword: The first term entered is “edentulous”. The software maps “Jaw”
“edentulous” “edentulous mouth”.
– Population: Specific population implies to those “implant supported
prosthesis” Software maps dental prosthesis implant supported and dental
implants.

• The next word would be “4 implants” versus more but
“4” is not selected.
• The next word “implant failure” software maps
prosthesis failure and finally gets 5 articles.
• Hence, the search question has resulted in 5 articles.
• 4 were not useful.
• 1 was by “Brane mark et al” that “compare the use of four
implants against six implants in edentulous patients”.
• It is a cross-sectional study carried out for a period of 11 years.
• It concluded that the result obtained with 4 implants and 6
implants were equal.
• Hence the problem was solved.

10 STEPS FOR EFFECTIVE
SEARCHING
• STEP-1: Never rely on single term. Use synonyms…
• STEP-2: Begin with a MeSH terms.
• STEP-3: Consider alternate terms e.g., use $ or * - injur$ will
search injury, injuries or injured.
– Use wild card ? E.g. h?emorrhage will retrieve both haemorrhage
and hemorrhage.
• STEP-4: Combine search results e.g., ALL (or) AND to include
both terms or ANY to include either terms or NOT to exclude.
• STEP-5: If you retrieve too many references.
– FILTER by using more specific terms.
– Restricted text word.
– MeSH text. More specific, more relevant MeSH terms.

10 STEPS FOR EFFECTIVE
SEARCHING
• STEP-6: If you retrieve to few references.
– Broaden your search.
– Use synonyms and broader terms. Combine MeSH terms with text
word.
– Use Sub-headings.
• STEP-7: Limited search results at the end of our search by:
– Language of articles.
– Check tags such as age groups, human, female, etc.
– Publication types such as reviews meta analyses, RCTs.
• STEP-8: Browse through retrieved references and select relevant
references for printing and downloading to disc.
• STEP-9: Be flexible.
• STEP-10: Ask you library staff for help.www.indianentalacademy.com

CRITICAL APPRAISAL OF THE
EVIDENCE FOR ITS VALIDITY AND
APPLICABILITY
• It helps in making the sense of the evidence.
• Need of making sense.
– To make judicious use.
– To check for its scientific validity.
– To check for clinical applicability to one’s patient.
– To statistical analysis of the results may further quantify the strength
of evidence.
• How to make Sense:
– Critical appraisal of a topic “CAT”.
• Advantages of Critical Appraisal:
– Defines the current acceptable standard of health care.
– Concise and portable.
– Immediate applicability. No need to repeat experiment.
– Improves one’s skills.
– Educational values.
– Points out areas for further research.www.indianentalacademy.com

CRITICAL APPRAISAL OF THE
EVIDENCE FOR ITS VALIDITY AND
APPLICABILITY
• Limitations of Critical Appraisal:
– CATs done by individuals can be wrong.
– CATs are based on a single
– Scope of a CAT is often too narrow.
– CATs may have a short shelf-life. Need to be updated.
• CRITICAL APPRAISAL OF TOPIC
– The CATs basically revolve around three broad issues.
• What are the results?
• Are the result of the trial valid?
• Will the result help me in caring for my patients?

QUESTIONS TO HELP YOU MAKE
SENSE OF A TRIAL:
• SCREENING QUESTION:
– Did the trial address a clearly focused issue?
– Was the assignment of patients to treatment
randomized?
– Were all the patients who entered the trial properly
accounted for at its conclusion.
• Detailed Questions:
– Were patients, health workers and study personnal ‘blind’
to treatment?
– Were the groups similar at the start of the trial?
– Aside from the experimental intervention, were the
groups treated equally?www.indianentalacademy.com

QUESTIONS TO HELP YOU MAKE
SENSE OF A TRIAL:
– How large was the treatment effect?
– How precise was the estimate of the treatment effect?
– Can the result apply to local population.
– Were all clinically important outcomes considered?
– Are the benefits worth the harms and the costs?

GRADING OF EVIDENCE:
• Grade-I: Evidence from systemic review (SRs) of
randomized control trials (RCTs). Large well
conducted RCTs with narrow confidence intervals.
• Grade-II: SRs of Cohort studies, individual cohort and
case-control studies. Low quality RCTs.
• Grade-III: Evidence from case series and poor quality
cohort and case control studies.
• Grade-IV: Expert opinion.

HIERARCHY OF
EVIDENCE
• Comparative studies.
• Descriptive studies.
• COMPARATIVE STUDIES (ANALYTICAL STUDIES)
Prospective studies
RCTs, assignment to therapy is
under the control of the
investigator
Cohort study
Retrospective
studies – case
control study

HIERARCHY OF
EVIDENCE
• DESCRIPTIVE STUDIES
– Case series
– Case reports
• Descriptive studies:
– Describe the general characteristics of a disease.
– Commonly seen are “case reports and case series”.
– Cross-sectional surveys: Report the status of an individual
w.r.t. both exposure and diseases assessed at one point in
time.
– It is also impossible to conclude what caused the disease or
casualty in disease.

HIERARCHY OF
EVIDENCE
• ANALYTICAL STUDIES
• Testing of Hypothesis:
– Two broad sub-categories I.e., intervention and observational
studies.
– Intervention Studies: Gold standard for clinical research
because it is possible to blind and assign subjects randomly
into treatment groups.
• Double blinded, RCT offer a strongest evidence for validity of
results.
– Observational Studies: Investigator observe the natural
course of events, noting which subjects are exposed or not
exposed, which have had a particular treatment and which
have not and which have or have not developed the outcome.
• Two sub-categories i.e., Cohort and Case Control studies.

SYSTEMIC REVIEWS OF
LITERATURE
• The overview and meta-analysis:
• Anatomy of Systemic Review:
– Preparation of a detailed research protocol that outlines the
clinical question of interest.
– Selection of criteria for inclusion of articles in the reviews.
– Systematic search of relevant published and unpublished
research.
– Determination of articles that meet pre-defined inclusion
criteria.
– Critical appraisal of the quality of selected articles.
– Extraction of outcomes data from the selected article.
– Data combination. www.indianentalacademy.com

SYSTEMIC REVIEWS OF
LITERATURE
• What to look for in a Useful Systematic Review
– Was a clinical question clearly stated and addressed?
– Were the search methods comprehensive enough to find all
relevant articles?
– Were explicit methods used to evaluate which articles to
include in the review.
– Was validity of the article assessed and was this assessment
reliable and free from bias?
– Were inconsistencies in the findings of the included studies
analyzed.
– Were the findings of the primary studies combined
appropriately.
– Were the reviewer’s conclusions supported by the data?

EVIDENCE BASED PERIODONTAL
THERAPY
• Introduction:
– Dr.P.Ramjford is considered the father of Evidence based
Periodontal therapy.
– Evidence based periodontal therapy was incorporated in
periodontics in AAP workshop, 1996.
– Great technological advances in the area of data access,
retrieval and management have made data search easy.
– The www has exploded greater possibilities for gathering data
from many source.
– Evaluation meta-analysis and modeling have like-wise
improved.
– Hence E.B.P. is incorporated in periodontics.

THERAPY
• The Design Model: It is basically the same
– 5 stepped procedure.
– Step-1: Create answerable question.
– Step-2: Conduct an efficient search of literature
– Step-3: Critical appraisal of the evidence for its
validity.
– Step-4: Applying same to the patient.
– Step-5: Evaluation of once performance.

THERAPY
• Can subjects with gingivitis learn how to perform
adequate oral hygiene and achieve better
outcome of gingival health.
– After viewing an oral hygiene video OR
– After receiving personal hygiene instructions only.
• Do subjects with poor oral hygiene have more
bleeding on probing of their gingival collar than
subjects with good oral hygiene?

THERAPY
• Do root coverage procedure offer better result in
those cases where root is conditioned prior to
procedure than those cases where root
conditioning is not done?
• Do root coverage by free gingival graft superior
than lateral pedicle graft?
• Do prognosis of implants in non-smokers has
better prognosis than in smokers?

THERAPY
• AAP has stressed on systemic review of
literature for efficient Evidence Based
Periodontal Approaches. E.g., “Critical review of
literature of root coverage procedures.
• All articles from 1970 to 2000 were gathered.
• In all 290 article were found.
• Each article was “critically appraised”.
• Only 90 out of 290 articles met inclusion criteria.

THERAPY
• RESULTS:
– The overall clinical outcome of different technique
appear to be satisfactory.
– No procedure was superior to another however all
procedure had its own limitations.
– The published evidence is of little help in deciding
which procedure is best suited for each clinical
situation.

THERAPY
• SUGGESTIONS
– More homogenous way of collecting and reporting clinical data
and especially outcome measures will allow for an effective re-
analysis.
– Studies should be carried out keeping in mind that the
published results of sound clinical studies will sooner or later
be reviewed and compared with other studies.
• CONCLUSIONS: A standard format with minimum
requirements for data collection and presentation
should be established and imposed by International
Journals in order to provide reader and researcher
useful information.

THERAPY
• UNIQUE CONSTRAINTS IN PERIODONTICS
FOR EVIDENCE BASED PRACTICE:
– Improper terminology.
– Classification confusion.
– Diagnosis confusion.
– Etiopathogenesis is not well understood.
– Genetic and periodontitis - casual or linked.
• CONCLUSION: In near feature such constraints may
become less and Evidence Based Periodontics will
grow by leaps and bounds.

LIMITATIONS OF
EVIDENCE BASED DENTISTRY
• Authoritarian clinicians & teachers perceive it as
a threat!!
• Access to information is limited. Suitable
evidence (studies) may not be available.
• Some of the tools of EBHC are time consuming
and difficult to master.
• Evidence-based practice may increase rather
than decrease the cost of health care.

CONCLUSION
• It would be unwise to conclude without
clearing the misconceptions about Evidence
Based Dentistry.
– Evidence Based Dentistry is not a veil to mask the same old
inadequate research.
– Evidence Based Dentistry does not take the clinical decisions
out of clinician hands and put them into the hands of literature.
In fact the opposite is true. Evidence Based Dentistry gives
guidelines for the clinician and relics first on clinical expertise.
– Evidence Based Dentistry does not mean the clinician need
not study basis. In fact the opposite is true. To evaluate
research presented clinician need sound basics.

CONCLUSION
– Evidence Based Dentistry does not mean clinicians abandon
everything they learned in dental school. It does not force
clinicians to go backwards to justify things to profession
universally accepted.
• Hence, at present the current concept of Evidence
Based Dentistry is applicable to all specialities of
dentistry not only to justify the treatment rendered but
also to offer better service to the patient.

REFERENCES
• Evidence Based Dentistry - G.R.Golostein
• User’s Guide to Evidence Based Dentistry - JPD 2000,
Jan. Vol. 83.
• Evidence Based Dentistry - JPD 2000, April. Vol. 83.

THANK ‘U’
•“A man of words and not of deeds
is like a garden full of weeds”

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