Evidence Based Dentistry Guide by Indian Dental Academy

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Fasten your seat
belts for the
bumpy ride to
evidence based
practice.

Never discuss divergent
views concerning religion
and politics with friends,
you could lose a friend and
create an enemy.

EVIDENCE
Generally, an article published in a
scientific journal- reporting results
of a clinical trial- is considered as
evidence.

EVIDENCE BASED DENTISTRY






Webster’s dictionary: judicious as
exercising sound judgment.
Defined : “ a conscientious explicit ,
and judicious use of current best
evidence in conjunction with clinical
experience to make decisions regarding
patient care.”
In other words, it is using evidence to
base one’s therapeutic decision –
making, rather than whim, instinct , or
hearsay.



ADA: “ an approach to oral health care
that requires the judicious integration
of systematic assessments of clinically
relevant scientific evidence , relating to
patient’s oral and medical condition
and history, with the dentist’s clinical
expertise and patient’s treatment
needs and preferences.


Our literature is often
inconclusive, inconsistent or
even contradictory. This leaves
clinicians frustrated, confused
and skeptical of all research
 EBO is not a cook book approach
to orthodontics.



EVIDENCE BASED
DENTISTRY
An approach to oral health care that
requires the judicious integration of
systemic assessments of clinically
relevant scientific evidence, relating
to the patients oral and medical
condition and history, with the
dentist’s treatment needs and
preferences

PROCESS INTEGRATES
1.
2.
3.

Clinical expertise
Best research evidence
Patient treatment needs


HISTORY OF EBD
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Origin in the middle of 19 th century in Paris,
when young graduates started challenging
the validity of clinical decisions based solely
upon personal experience.
Mc Master University in Canada in 1985 ,
introduced some concepts in its curriculum.
American College of Physicians followed.
Establishment of Center for Evidence- based
Medicine in Oxford, UK in 1995.
The litigious nature of society further fueled
the need for practicing evidence based
health care

Faulty arguments against evidence
based decision making


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Dogmatic approach
Influence of drug companies
Academics Vs clinical research
“Galileo ploy”


UNTESTED
HYPOTHESESAND
THEORIES Vs
SCIENCE AND
EVIDENCE – BASED
CARE

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CONFOUNDING
EFFECTS

A goal of sound experimental research and
design is the control of confounding
factors.
When factors are not controlled, the
effects of treatment are clouded with the
outside influence of extrinsic factors and
the treatment effects cannot be isolated
and analyzed.
If the findings of confounded studies are
accepted ,there is a strong possibility that
this will negatively impact patient
care.i.e.beneficial treatment will be
ignored and useless treatment adopted.

CONTROLLING GROUP


Research does lend itself to the use of a control.
nonetheless ,when controls are required and
used, the liability and validity of a study are
improved. with observational research vis-à-vis
experimental research, the group not having
treatment is often called the comparison or
matched group rather than the control group.
Through the use of a control group in
experimentally designed studies, a researcher
can assert with confidence that the treatment or
condition introduced is directly responsible for the
findings obtained, instead of due to chance or
some other extraneous variable.


HAWTHORNE EFFECT




Despite the effectiveness of experiment
design, potential threats can directly
impact validity ,a time management study
in 1930 at western electrics Chicago based
Hawthorne plant desired to improve
employee morale and particularly
productivity.
Reverse Hawthorne effect- resentment or
apathy developing in control group which
does not receive treatment. This produces
poor behavior or improvement in control
groups.

TYPES OF STUDIES
STUDIES

EXPERIMENTAL

RCT

OBSERVATIONAL


CASE

CASE

CONTROL

COHORT

REPORT

LEVELS OF EVIDENCE
To judge the quality of studies a “hierarchy of
evidence” exists the relative strength of
various studies.
The evidence that is most likely to be useful for
making decisions regarding patient
management:

1. Systematic Review (Meta-analysis)
2. Randomized Controlled Trials (RCTs)
3. Cohort Studies
4. Case-control Studies
5. Cross-sectional Surveys
6. Case Series/ Report

NARRATIVE LITERATURE

SYSTEMATIC REVIEW

QUANTITATIVE

QUALITATIVE

(Meta analysis)


SYSTEMATIC REVIEWS
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Systematic reviews are a synopsis of the
existing evidence on a specific topic.
Provides means to keep up with numerous
articles published annually in every field.
Concentrates on a very specific and
narrow, clinically relevant question.
Team of experts
Inclusion and exclusion criteria is used
Bias unlikely to happen

STEPS IN PERFORMING
SYSTEMATIC REVIEW



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1.
2.
3.
4.

FIRST STEP : framing an important and
well defined question that is relevant to
patient care.
Framing a question in a proper format
and identifies four crucial “ PICO”
elements. These elements are:
Population or patient type
Intervention
Comparison
Outcome

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SECOND STEP: determining inclusion and

exclusion to select the eligible studies.
Subcategory of outcome, exposure,
confounder, effect modifiers, intermediates,
type of control as well as type of study design
and other consideration.


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THIRD STEP: design a search
strategy.
Employed to search available studies
include both electronic databases
such as MEDLINE, EMBASE, Web of
science and Cochrane, databases
and manual searches.


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FOURTH STEP: involves application
of the selection criteria identified in
step Two to the potential studies
retrieved from both electronic and
manual search strategies determined
in step Three.
This action will result in selection of
the eligible studies for the review
and appraising these studies.



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1.
2.
3.
4.
5.
6.

FIFTH STEP: Performing a statistical
summary of the abstracted data, or
Meta- analysis.
Data from different study designs are
summarized with the purpose of the
following six tasks:
Deciding whether to combine the data or
defining what to combine
Evaluating the statistically heterogeneity
of the data
Estimating a common effect
Exploring and explained heterogeneity
Assessing the potential for bias
Presenting the results in the form of a
table



FINAL STEP: INTERPRET THE
EVIDENCE TO ANSWER THE
RESEARCH QUESTION


META ANALYSIS


It identifies the major varying factors
for their significance, and reports
that studies match their defined
standardization criteria


RANDOMISED CONTROL
TRIALS

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An experimental study on patients with a
particular disease or disease –free
subjects in which the individuals are
randomly assigned to either an
experimental intervention or a control
group to determine the ability of an agent
or a procedure to diminish symptoms, to
decrease risk of death from disease during
follow up period.
Provide strongest evidence causation of
evidence.

Drawbacks:
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Raise ethical concerns in control
groups
Costly and time consuming to
implement
Because of the strict eligibility
criteria and loss to follow-up, RCT
sample size requirements are difficult
to attain and maintain,
Result becomes in limited external
validity of results for the general
population

COHORT STUDIES

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An observational study that follows an
exposed cohort compared to an
unexposed cohort to determine the
incidence of given outcome.
Well designed cohort study provides
strong support for causation
Non concurrent cohort studies are
relatively weaker because they rely on
existing records.
Disadvantages : require large sample size
Length of the studies result in
misclassification in outcome status
Continuous assessment of the exposure
and outcome results.

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
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CASE CONTROL
STUDIES
These are observational studies where

in cases with a particular outcome and
controls that donot have the same
outcome are first selected and
exposure assessment is done
retrospectively.
Quick, relatively inexpensive
Appropriate in studying rare diseases
Assessment of multiple risk factors for
a particular disease within the same
study

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CASE REPORT AND
CASE SERIES

Document unusual occurrences of
outcomes
First clues of a new diseases or
adverse effects of exposure
Case series are an extension of case
reports


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HISTORY

Early part of 19 century ushered in
evidence based decision making for
health care.
1920 Geis report- Medical and Dental
schools to be scientific in their teaching.
Dentistry and Orthodontics have lagged
behind medicine in the quest to
incorporate science in to clinical practice.
Perhaps, the art in the practice of
dentistry has overshadowed the need for
science.

Making sense of Evidence
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

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The evidence gathered is checked for
its scientific validity, and applicability
in patients.
Why article not published in
prestigious journal ?
The RCT is considered to be ‘de
rigueur’ for arriving at a scientifically
valid conclusion.

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

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1.
2.
3.

Necessary to know the type of
randomization done, by going
through the methodology of study.
Element of blinding too should be
apparent in the study.
Even though the study is determined
to be valid , still may not be
applicable to one’s patient.
Different characteristics of patient
Results may be weak
Statistical analysis may not be
adequate

Face mask protraction therapy in early
skeletal Class III
AJO DO 2005 128; 299-309

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Does RME enhance the efficiency of
maxillary protraction with face mask in
developing Class III malocclusion?
Results: Face mask therapy effective in
early Class III MO
The need for palatal expansion in the
absence of a transverse discrepancy or a
skeletal/ dental cross bite is not supported.
Correction due to combined skeletal and
dental change.

Critical appraisal
EBD 2006:7,16-17.
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First prospective RCT of the subject
Inclusion of control group to quantify
growth before recruiting participants.
Results are conclusive.
The skeletal change following
protraction is significant, but has no
correlation with expansion.

Skeletal and dental changes with fixed slow
maxillary expansion treatment. Systematic
review.
JADA Feb 2005
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Eight studies were selected, each
lacked a control group, and four also
did not have a measurement error
treatment.
A control group is necessary to factor
out normal growth changes in the
dental arch and cranio facial structure.
No strong conclusion could be made on
dental and skeletal changes after SME.

Meta analysis of immediate changes
with RME treatment
JADA Jan 2006

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Results: Of the 31 selected abstracts, 12
were rejected b coz they failed to report
immediate changes after the activation
phase of RME and instead reported
changes only after the retention phase.
The greatest changes were in the
maxillary transverse plane in which the
width gained was caused more by dental
expansion than true skeletal expansion.
Few vertical and anteroposterior changes
were statistically significant, and none was
clinically significant.

A systematic review concerning early
orthodontic treatment of unilateral
posterior cross bite
Angle Orthod 2003;73:588-596

The aim of this study was to assess the
orthodontic treatment effects on unilateral
posterior cross bite in primary and early
mixed dentition by systematically reviewing
the literature. Two RCT’s of early treatment of
cross bite have been found and these two
studies support grinding as treatment in the
primary dentition. There is no scientific
evidence to show which of the treatment
modalities, grinding, quad helix, expansion
plates or RME is most effective

Orthodontics and Temporo-mandibular
Disorders – A meta-analysis
AJO DO 2002;121:438-446

Orthodontists are blamed for causing TMD.
Epedemiologic studies show that TMD
symptoms are most prevalent among
patients between 15-25 years of age.
Orthodontists may encounter patients who
complain about TMD during or after
treatment.
Does traditional orthodontic treatment
change the prevalence of TMD?
No study indicated that traditional appliance
increased the prevalence of TMD, except
for mild or transient signs

The effect of topical fluorides on
decalcification in patients with fixed
orthodontic appliances: A systematic review
AJO DO 2005; 128: 601-606

Decalcification is a significant problem during
fixed orthodontic treatment. Topical fluorides
can reduce or eliminate the problem, but the
relative effectiveness of different or
combinations of topical fluoride preparations is
unknown.
Results: The use of topical fluorides in addition to
fluoride toothpaste reduced the incidence of
decalcification in populations with both
fluoridated and non fluoridated water supplies.
Different preparations and formats appear to
decrease decalcification but there was no
evidence that any one method was superior.

Incremental versus maximum bite
advancement during Twin block therapy:
A randomized controlled clinical trial.
AJO-DO 2004;126:583-8

•Experimental patients had 2mm initial bite advancement and
subsequent 2mm advancements at 6 weekly intervals with a Twin
block appliance incorporating advancement screws.
•The aim of this study was to evaluate the effectiveness of
incremental and maximum bite advancement during treatment of
class II div 1 malocclusion with the Twin-block appliance in the
permanent dentition.
•The use of incremental advancement of the twin block did not
confer any advantage in terms of process and outcome of the
treatment.

Outcomes in a 2-phase RCT of early
class II treatment
AJO DO 2004;125:657-667
This study was a randomized control trial designed to examine the
2 major strategies used to treat class II malocclusion:early
treatment in mixed dentition before adolescence,followed by a
second phase of comprehensive treatment in permanent
dentition;and 1-phase treatment during the adolescent growth
spurt and early permanent dentition.
Results: there was no differences in the findings between the
‘intent to treat’(ITT) sample,who had completed phase 1,and an
‘efficacy analyzable’(EA)sample(n=137),which comprised only
patients who completed phase 2.During phase 2 of the trial,the
advantage created during phase 1 treatment in the 2 early
treatment group was lost,and by the end of fixed appliance
treatment,there was no significant difference between any of the 3
groups for all anteroposterior and vertical skeletal and dental
measures.

CONCLUSION


Currently, researchers and facilitating
organizations disseminate best evidence in
the forms perceived logical for clinical
practice .These forms are standard to
research reporting. Once reported,
evidence must be read,analyzed,and
accepted for its statistical
significance.Then,findings need to be
integrated with other types of evidence to
provide statistically component
comparisons and measures of decision
making.

REFRENCES
1. Incremental versus maximum bite advancement during twin
block therapy : A randomized controlled clinical trail- Phil

Banks, Jean Wright & Kevin O’Brein (AJODO 2004; 126: 583-8)

2. Outcomes in a 2-phase randomized clinical trail of early Class
II treatment- J.F.Camilla Tulloch, William R. Proffit & Ceib
Phillips (AJODO 2004; 125: 657-67)

3. Essential elements of evidenced- based endodontics: Steps
involved in conducting clinical research- Mahmoud Torabinejad
& Khaled Babjri (JOE 2005; 35: 563-8)

4. The effect of topical fluorides on decalcification in patients with
fixed orthodontic appliances: A systematic review- Barbara L
Chadwick, Jayne Roy, Jeremy Knox & Elizabeth T Treasure
(AJODO 2005; 128: 601-6)

5. Orthodontics & temporomandibular disorder: A meta- analysisMyung- Rip Kim, Thomas M Graber & Marlos A Viana (AJODO
2002; 121: 438-46)

6. Making the case for evidence- based orthodontics- Greg J
Huang
(AJODO 2004; 125: 405-6)
7. Putting the evidence first- David L Turpin (AJODO 2005; 128:
415)
8. Effect of Herbst treatment on temporomandibular joint
morphology: A systematic literature review- Kurt Popowich,
Brain Nebbe & Paul w Major (AJODO 2003;123: 388-94)
9. Evidence - based versus experience- based views on occlusion
& TMD- Donald J Rinchuse, Daniel J Rinchuse & Sanjivan
Kandasamy(AJODO February 2005,Volume 127,Number 2)
10. Fasten your seat belts for the bumpy ride to evidence-based
practice.Greg J.Huang(AJODO,Volume 127,Number 1)
11. Understanding science and evidence-based decision making
in orthodontics-Donald J Rinchuse,Emily M.Sweitzer,Daniel
J.Rinchuse,Dara L.Rinchuse,AJODO,Volume 127,Number 5)
12. Model of Evidence-Based Dental Decision Making,Janet
Baeuer,Sue Spackman,Francesco Chiappelli,Paolo Prolo(Journal
of Evidence-Based Dental Practice 2005;5:189-97)

13.Evidence-Based therapy:An Orthodontic dilemmaAnthony Gianelly(AJODO,Volume 129,Number 5)
14.A Systematic Review Concerning Early Orthodontic Treatment
Of Unilateral Posterior Crossbite-Sofia Petren,Lars
Bondemark,Bjorn Soderfeldt,Med Sc(Angle Orthodontist,Volume
73, Number 5,2003)
15. Face mask protraction therapy in early skeletal class III
malocclusion-Anmol S Kalha(EBD 2006:7.1)

16.Skeletal and dental changes with fixed slow maxillary
expansion treatment-Manuel Lagravere,Paul Major,Carlos Floresmir(JADA,Volume-136,February 2005)

17. Meta-analysis of immediate changes with rapid maxillary
expansion treatment-Manuel Lagravere,Giseon Heo,Paul Major,Carlos
Flores Mir(JADA,Vol.137,January 2006)


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Evidence Based Dentistry Guide by Indian Dental Academy

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