SECTION I: EVIDENCE-BASED DECISION MAKING

CHAPTER 81
Introduction to Evidence-Based
Decision Making
Jane L. Forrest, Syrene A. Miller, and Michael G. Newman

CHAPTER OUTLINE
BACKGROUND AND DEFINITION
PRINCIPLES OF EVIDENCE-BASED DECISION MAKING
Evidence-Based Versus Traditional Decision Making
Evidence-Based Dentistry
NEED FOR EVIDENCE-BASED DECISION MAKING
Variations in Practice Patterns
Assimilating Evidence into Practice

ach day, dental care professionals make decisions about

clinical care. It is important that these decisions incorporate
the best available scientific evidence to maximize the
potential for successful patient care outcomes. It is also important
for readers of this book to have the background and skills necessary
to evaluate information they read and hear about. These evaluative
skills are as important as learning facts and clinical procedures. The
ability to find, discriminate, evaluate, and use information is
the most important skill that can be learned as a professional.
Becoming excellent at this skill will provide a rewarding and fulfilling professional career.

BACKGROUND AND DEFINITION

Using evidence from the medical literature to answer questions,
direct clinical action, and guide practice was pioneered at
McMaster University, Ontario, Canada, in the 1980s. As clinical
research and the publication of findings increased, so did the
need to use the medical literature to guide practice. The traditional
clinical problem-solving model based on individual experience or
the use of information gained by consulting authorities (colleagues
or textbooks) gave way to a new methodology for practice and
restructured the way in which more effective clinical problem
solving should be conducted. This new methodology was termed
evidence-based medicine (EBM).17 EBM is defined as the integration of the best research evidence with clinical expertise and patient
values.36
The use of evidence to help guide clinical decisions is not new.
However, the following aspects of EBM are new:

768.e6

EVIDENCE-BASED DECISION-MAKING PROCESS

AND SKILLS
Asking Good Questions: the PICO Process
Searching for and Acquiring the Evidence
Appraising the Evidence
Evaluating the Outcomes
CONCLUSION

The methods of generating high-quality evidence, such as

randomized controlled trials and other well-designed
methods.
The statistical tools for synthesizing and analyzing the evidence (systematic reviews and metaanalysis).
The ways for accessing the evidence (electronic databases)
and applying it (evidence-based decision making and practice guidelines).13,14
These changes have evolved along with the understanding of
what constitutes the evidence and how to minimize sources of bias,
quantify the magnitude of benefits and risks, and incorporate
patient values.18 In other words, evidence-based practice is not just
a new term for an old concept and as a result of advances, practitioners need (1) more efficient and effective online searching skills
to find relevant evidence and (2) critical appraisal skills to rapidly
evaluate and sort out what is valid and useful and what is not.33
Evidence-based decision making (EBDM) is the formalized
process and structure for learning these skills so that the best scientific evidence is considered when making patient care
decisions.

PRINCIPLES OF EVIDENCE-BASED
DECISION MAKING
Evidence-Based Versus Traditional
Decision Making
Initially, the focus of EBM emphasized using randomized clinical
trials and other quantifiable methods. as EBM has evolved, however,

CHAPTER 81 Introduction to Evidence-Based Decision Making

This definition is now incorporated in the ADA Accreditation

Standards for Dental Education Programs.2 Dental schools are
expected to develop specific core competencies that focus on the
need for graduates to become critical thinkers, problem solvers, and
consumers of current research findings to enable them to become
lifelong learners. These skills parallel those of evidence-based practice by teaching students to find, evaluate, and incorporate current
evidence into their decision making.2

Scientific
evidence

Experience
and
judgment

768.e7

Patient
preferences
or values

Clinical patient
circumstances

NEED FOR EVIDENCE-BASED

DECISION MAKING
An evidence-based approach has emerged in response to the need
to improve the quality of health care and to demonstrate the best
use of limited resources.16,25 Two forces driving the need to improve
the quality of care are (1) the variations in practice patterns and (2)
the difficulty that clinicians confront in assimilating scientific evidence into their practices.9,33,36

Variations in Practice Patterns

Figure 81-1 Evidence-based decision making.

so has the realization that the evidence from clinical research is

only one key component of the decision-making process and does
not tell a practitioner what to do.20 In other words, the use of current
best evidence does not replace clinical expertise or input from the patient
but rather provides another dimension to the decision-making
process,16,24,25 which is also placed in context with the patients clinical circumstances (Figure 81-1). It is this decision-making process
that we refer to as evidence-based decision making and that is
defined as the formalized process of using the skills for identifying,
searching for, and interpreting the results of the best scientific
evidence, which is considered in conjunction with the clinicians
experience and judgment, the patients preferences and values, and
the clinical/patient circumstances when making patient-care decisions. EBDM is not unique to medicine or any specific health
discipline; it represents a concise way of referring to the application
of evidence to clinical decision making.
EBDM focuses on solving clinical problems and involves two
fundamental principles, as follows18:
1. Evidence alone is never sufficient to make a clinical
decision.
2. Hierarchies of quality and applicability of evidence exist to
guide clinical decision making.
EBDM is a structured process that incorporates a formal set of
rules for interpreting the results of clinical research and places a
lower value on authority or custom. In contrast to EBDM, traditional decision making relies more on intuition, unsystematic clinical experience, and pathophysiologic rationale.18,31

Evidence-Based Dentistry
Since the 1990s, the evidence-based movement has continued to
advance and is widely accepted among the health care professions,
with some refining the definition to make it more specific to their
area of health care. The American Dental Association (ADA) has
defined evidence-based dentistry (EBD) as an approach to oral
health care that requires the judicious integration of systematic
assessments of clinically relevant scientific evidence, relating to the
patients oral and medical condition and history, with the dentists
clinical expertise and the patients treatment needs and
preferences.3

Studies of appropriateness in health care confirm that a wide range

of variability exists between what is known and what is practiced.7,8,15,22 Much too often, variations occur because of a gap
between the time that current research knowledge becomes available and its application to care. Consequently, there is a delay in
adopting useful procedures and in discontinuing ineffective or
harmful ones.5,12,19,23 This integration of new evidence has been slow
partly because of the traditional approach to learning and practice,
with its reliance on authority rather than on seeking out the most
current empirical evidence. Coupled with this reliance on authority,
clinicians tend to practice the same as they were taught in school.
Consequently, trends indicate the longer clinicians are out of
school, the greater the gap in their knowledge of up-to-date care.
Also contributing to variations in practice is the lack of, or weak
scientific evidence for, answering specific clinical questions,16
including those related to the most frequent treatments in dentistry
and dental hygiene.6,25 In these cases, an evidence-based approach
serves another purpose by helping to inform the profession and
investigators of needed research. The American Academy of Periodontology (AAP), the European Academy of Periodontology, the
Academy of Osseointegration, and other organizations have
responded to this need by using an evidence-based approach to
plan and implement consensus conferences on periodontal and
implant therapy. In a 2002 AAP consensus conference, 15 systematic reviews were prepared on topics relevant to contemporary
periodontal practice, which then served as the basis for developing
consensus reports, including implications for practice and additional research.30

Assimilating Evidence into Practice

Assimilating scientific evidence into practice requires keeping upto-date through reading extensively, attending courses, and using
the Internet and electronic databases, such as MEDLINE
(PubMed) and the Cochrane Library, to search for published scientific articles. However, with the proliferation of clinical studies
and journal publications, keeping current with relevant research is
nearly impossible given the increasing number of good clinical
articles located in over 700 dental journals worldwide.
Consequently, substantial advances made in the knowledge of
clinical dentistry and periodontics have not been translated into
practice or fully applied to allow patients to receive the total benefit.
Another explanation for the delay in integrating new evidence
is the need for translating it into information that is useful for each

768.e8

PART 9 Complementary Topics

BOX 81-1 Advantages of Evidence-Based Approach

Compared with Other Assessment Methods
Evidence-Based Approach
Is objective.
Is scientifically sound.
Is patient-focused.
Incorporates clinical experience.
Stresses good judgment.
Is thorough and comprehensive.
Uses transparent methodology.
Data from Newman M, Caton J, Gunsolly J: Ann Periodontol 8:1, 2003.

BOX 81-2 Skills and Abilities Needed to Apply

an Evidence-Based Decision-Making Process
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.
Data from Sackett DA, Strauss SE, Richardson WS, et al: Evidence-based medicine:
how to practice and teach EBM, London, 2000, Churchill Livingstone.

decision maker, including the patient. Using a standard, unbiased

method to evaluate information is considered better and necessary
because the number of new scientific insights that emerge each year
is overwhelming. Box 81-1 identifies why an evidence-based
approach is better than using other methods of assessment.30

EVIDENCE-BASED DECISION-MAKING
PROCESS AND SKILLS
The growth of evidence-based practice has been made possible
through the development of online scientific databases such as
MEDLINE (PubMed) and web-based software, along with the
use of computers and mobile phones that enable users to quickly
access relevant clinical evidence from almost anywhere. This combination of technology and good evidence allows health care professionals to apply the benefits from clinical research to patient care.35
EBDM recognizes that clinicians can never be completely current
with all conditions, medications, materials, or available products,
and it provides a mechanism for assimilating current research findings into everyday practice to answer questions and to stay current
with innovations in dentistry. Translating the EBDM process into
action is based on the abilities and skills identified in Box 81-2.36

Asking Good Questions: The PICO Process

Converting information needs and problems into clinical questions
is a difficult skill to learn, but it is fundamental to evidence-based
practice. The EBDM process almost always begins with a patient
question or problem. New searching tools have reduced the need
for a formal written question, however, it is still important to expedite the process. A well-built question should include four parts

that identify the patient problem or population (P), intervention

(I), comparison (C), and outcome(s) (O), referred to as PICO.36
Once these four components are clearly and succinctly identified,
the following format can be used to structure the question:
For a patient with _____ (P), will _____ (I) as compared to _____
(C) increase/decrease/provide better/ in doing _____ (O)?

The formality of using PICO to frame the question serves three

key purposes, as follows:
1. PICO forces the clinician to focus on what he or she and
the patient believe to be the most important single issue and
outcome.
2. PICO facilitates the next step in the process, the computerized search, by identifying key terms that will be used in the
search.36
PICO directs the clinician to clearly identify the problem, the
results, and the outcomes related to the specific care provided to
that patient. This in turn allows identification of the type of evidence and information required to solve the problem, as well as
considerations for measuring the effectiveness of the intervention
and the application of the EBDM process. Thus EBDM supports
continuous quality improvements through measuring outcomes
of care and self-reflection. Box 81-3 provides a case example
showing the PICO process, beginning with the patient problem or
population (P), the intervention (I), the comparison (C), and the
outcome (O).

Searching for and Acquiring the Evidence

Evidence typically comes from studies related to questions about
treatment/prevention, diagnosis, etiology/ harm, and prognosis of
disease, as well as from questions about the quality and economics
of care. Evidence is considered the synthesis of all valid research
that answers a specific question, which distinguishes it from a
single research study.21 Once synthesized, evidence can help inform
decisions about whether a method of diagnosis or a treatment is
effective relative to other methods of diagnoses or to other treatments and under what circumstances. The challenge in using
EBDM arises when there is only one research study available on a
particular topic. In these cases, individuals should be cautious in
relying on the study because it can be contradicted by another study
and it may only test efficacy and not effectiveness. This underscores
the importance of staying current with the scientific literature, since
the body of evidence evolves over time as more research is conducted. Another challenge in using EBDM occurs when the
limited research available is weak in quality or poorly conducted.
In these cases, one may rely more heavily on clinical experience
and patient preferences/values than the scientific evidence (see
Figure 81-1).

Levels of Evidence. The highest level of evidence, or the

gold standard, is the systematic review (SR) and meta-analysis
using two or more randomized controlled trials (RCTs) of human
subjects. SRs and metaanalyses are considered the gold standard
for evidence because of their strict protocols to reduce bias and the
synthesis of research from more than one study. These reviews
provide a summary of multiple research studies that have investigated the same specific question. SRs use explicit criteria for
retrieval, assessment, and synthesis of evidence from individual
RCTs and other well-controlled methods. Systematic reviews facilitate decision making by providing a clear summary of the current
state of the existing evidence on a specific topic. SRs provide a way
of managing large quantities of information,28 making it easier to

CHAPTER 81 Introduction to Evidence-Based Decision Making

keep current with new research. SRs should not be confused with
traditional literature reviews; Table 81-1 compares these two types
of reviews.
Metaanalysis is a statistical process often used with SRs. It
involves combining the statistical analyses of several individual
BOX 81-3 Case Scenario Using PICO Process
in Evidence-Based Decision Making
Julie is a healthy patient who has an optimal site for dental implant
placement. She is concerned about taking prescription medications
and inquires about the need to take antibiotics for implant placement.
Based on this information, how should the question be structured
so that the answer can be found quickly? Applying the PICO process,
each key component is first identified as follows:
P (problem) = Patient getting a dental implant placed
I (intervention) = antibiotic prophylaxis
C (comparison) = no antibiotics
O (outcome) = minimize complications and increase the success
rate of the dental implant.
Next, the question is structured using the components:
For a patient getting a dental implant placed, will antibiotic
prophylaxis as compared to no antibiotics minimize complications and
increase the success rate of the dental implant?
From this question, key terms can be identified to use in conducting
the search: dental implant and antibiotic prophylaxis.
Using the PubMed Clinical Queries feature (Figure 81-2, A), the
search entered into the search box was dental implants AND
antibiotic prophylaxis. By connecting them with the Boolean operator
AND, PubMed combines the two terms to find research that studies
dental implants and antibiotic prophylaxis. The search resulted in
67 individual clinical studies and 15 systematic reviews citations,
including a systematic review by the Cochrane Collaboration. (Figure
81-2, B) Since systematic reviews provide a higher level of evidence,
the most current one directly addressing the question should be
reviewed first (Figure 81-2, C). The conclusions drawn by the author
of this systematic review state that there is some evidence that 2g
of amoxicillin given orally 1 hour preoperatively significantly reduce
failures of dental implants placed in ordinary conditions and that it
might be recommendable to suggest the use of one dose of prophylactic
antibiotics prior to dental implant placement. However, it is unclear
whether postoperative antibiotics are beneficial and which is the most
effective antibiotic.
In the event that there are no Systematic Reviews answering the
question, the individual studies under the Clinical Study Category
should be reviewed. Using this feature it is necessary to select the
appropriate type of question that is being asked. For example, clinical
query for a therapy question filters the citations for Randomized
Control Trials and, in this case, 67 citations were identified (see Figure
81-2, A).

768.e9

studies into one analysis. When data from these studies are pooled,
the sample size and power usually increase. As a result, the combined effect can increase the precision of estimates of treatment
effects and exposure risks.28
SRs and metaanalyses are followed respectively by individual
RCT studies, cohort studies, case-control studies, and then studies
not involving human subjects.32 In the absence of scientific evidence, the consensus opinion of experts in appropriate fields of
research and clinical practice is used (Figure 81-3). This hierarchy
of evidence is based on the concept of causation and the need to
control bias.26,27 Although each level may contribute to the total
body of knowledge, not all levels are equally useful for making
patient care decisions.27 In progressing up the pyramid, the number
of studies and correspondingly the amount of available literature
decrease, while at the same time their relevance to answering clinical questions increases.
Evidence is judged on its rigor of methodology, and the level of
evidence is directly related to the type of question asked, such as
those derived from issues of therapy or prevention, diagnosis, etiology, and prognosis (Table 81-2). For example, the highest level of
evidence associated with questions about therapy or prevention will
be from SRs of RCT studies. However, the highest level of evidence associated with questions about prognosis will be from SRs
of inception cohort studies.34 Knowing which type of study will
provide the best evidence for clinical decision making and how to
retrieve this information quickly from the scientific literature is
important to evidence-based practice.

Sources of Evidence. The two types of evidence-based

sources are primary and secondary, as follows:

Primary sources are original research publications that have
not been filtered or synthesized.
Secondary sources are synthesized publications of the primary
literature. These include SRs and metaanalyses, evidencebased article reviews, and clinical practice guidelines and
protocols. This terminology is often confusing to individuals
new to the EBDM approach because, although SRs are
secondary sources of evidence, they are considered a higher
level of evidence than a primary source such as an RCT.
Both primary and secondary sources can be found by conducting a search using such biomedical databases as MEDLINE
(PubMed), EMBASE, HealthSTAR, and CINALH (Cumulative
Index to Nursing and Allied Health). In addition, the Cochrane
Collaboration Library provides access to systematic reviews. Many
other secondary sources, such as evidence-based journals, are available to quickly inform the busy practitioner on important issues.
However, it is also necessary to review the primary literature when
secondary sources are not available.

SCIENCE TRANSFER
By using rigorous selection criteria and combined analysis of
multiple papers focused on clinical procedures, it is possible to
use an evidence-based approach to determine the scientific merit
of periodontal therapy. This approach can provide another avenue
of clinical decision making that can supplement the clinical experience and detailed evaluation of individual patients that have
previously been the basis for treatment selection.

Periodontics has led dentistry in using this scientific methodology; however, at present, there are insufficient clinical trials that
truly meet all the necessary criteria to be considered fool-proof
evidence when combined together. Clinicians should be cognizant of evidence-based reviews but should also carefully evaluate
each paper so that they can use their expertise and experience to
come up with the best therapy for each individual patient.

Figure 81-2 Case scenario PubMed Clinical Queries search. A, Systematic Review search. B, Search results for Systematic Reviews. C, Cochrane Database of Systematic
Reviews abstract. (Courtesy the U.S. National Library of Medicine, Bethesda, MD.)

768.e10
PART 9 Complementary Topics

Continued

768.e11

Figure 81-2, contd

CHAPTER 81 Introduction to Evidence-Based Decision Making

PART 9 Complementary Topics

Figure 81-2, contd

768.e12

CHAPTER 81 Introduction to Evidence-Based Decision Making

768.e13

TABLE 81-1 Comparison of Characteristics of Systematic Reviews and Literature Reviews

Characteristic

Systematic Review

A Literature Review

Focus of review

Specific problem; narrow focus.

Example: Effectiveness of Periostat as an adjunct to
scaling and root planing for the treatment of adult
periodontitis.
Multidisciplinary team
Preestablished criteria based on validity of study design
and specific problem.
All studies that meet criteria are included.
Bias minimized based on criteria.

Range of issues on a topic; broad focus.

Example: Effectiveness of adjunctive antimicrobial agents for
treating periodontitis.

Who conducts
Selection of studies
to include

Reported findings

Synthesis of
selected studies
Main results
Conclusions or
comments

Based on
ability to
control for
bias and to
demonstrate
cause and
effect

Search strategy and databases searched.

Number of studies that met and did not meet criteria;
why studies were excluded.
Description of study design, subjects, length of trial,
state of health/disease, outcome measures.
Critical analysis of included studies.
Determination if results could be statistically combined,
and if so, how metaanalysis was conducted.
Summary of trials; total number of subjects.
Definitive statements about findings in relation to
objectives and outcome measures.
Discussion of key findings with interpretation of the
results, including potential biases and
recommendations for future trials.

Meta-analysis
systematic reviews

Randomized
controlled trials
Cohort studies

Case control studies

Case reports

Ideas, editorials, opinions

Animal research
In vitro (test tube) research
Figure 81-3 Levels of clinical evidence.

PubMed is designed to provide access to both primary and

secondary research from the biomedical literature. PubMed provides access to MEDLINE, the National Library of Medicines
premier bibliographic database covering the fields of medicine,
nursing, dentistry, veterinary medicine, the health care system, and
the preclinical sciences. MEDLINE contains bibliographic cita-

Individual
Criteria not preestablished or reported in methods; search on
range of issues.
May include or exclude studies based on personal bias or
support for the hypothesis, if one is stated.
Inherent bias with lack of criteria.
Literature presentation format is crafted by individual author.
Search strategy, databases, and total number of studies (pro
and con) are rarely identified.
Descriptive in nature, reporting the outcomes of studies rather
than their study designs.
Reporting of studies that support a procedure or position and
those that do not, rather than combining data or conducting
a statistical analysis.
Summary of the findings by author in relation to purpose of
literature review and specific objectives.
Discussion of key findings with interpretation of the results,
including limitations and recommendations for future trials.

tions and author abstracts from more than 5200 biomedical journals published in the United States and 80 other countries. The
database contains over 18 million citations dating back to 1966,
and it adds more than 520,000 new citations each year.29
Using PubMeds Clinical Queries feature, one can quickly pinpoint a set of citations that will potentially provide an answer to
the question being posed. Although online databases provide
quicker access to the literature, knowing how databases filter information and having an understanding of how to use search terms
and database features allows a more efficient search to be
conducted.
These concepts are applied to the case scenario in the PubMed
search illustrated in the History (see Figure 81-2, A). By using the
key terms identified in the PICO question and combining them
using the Boolean operators OR and AND, the number of
relevant articles have been narrowed to a manageable 39.
Knowing what constitutes the highest levels of evidence and
knowing how to apply evidence-based limits and filters are necessary skills when searching the literature with maximum efficiency.27
One can further refine the search using the Limits feature, allowing the user to search for publication types such as metaanalyses,
RCTs, clinical trials, and practice guidelines. In the case shown
here, the search results indicate there are no metaanalyses; two
RCTs, one of which compares the effectiveness of clindamycin and
cephalexin; and five citations related to the practice guidelines that
outline the American Heart Associations recommendations for
antibiotic prophylaxis for patients with infective (bacterial) endocarditis (see Figure 81-2, B and C). Of the 39 citations, there are
also two clinical trials, which happen to be the same as the RCTs.
Many journals now offer access through the Internet as electronic companions of print journals or stand-alone journals. When
these are available, PubMed provides links from their website
directly to the article, sometimes for a fee.

768.e14

PART 9 Complementary Topics

TABLE 81-2 Type of Question Related to Type of Methodology

and Levels of Evidence
Type of Question

Methodology of
Choice32

Therapy, prevention

Systematic review
(SR) of randomized
controlled trials
(RCTs)
SR of cohort studies

Diagnosis

SR of controlled trials
(Prospective cohort
study)
Controlled trial
(Prospective: compare
tests with a
reference or gold
standard test.)

Etiology, causation,
harm

SR of cohort studies
Cohort study
(Prospective data
collection with
formal control
group.)

Prognosis

SR of inception cohort
studies
Inception cohort study
(All have disease but
free of the outcome
of interest.)
Retrospective cohort

Question Focus27
Study effect of therapy
or test on real
patients; allows
for comparison
between
intervention and
control groups;
largest volume of
evidence-based
literature.
Measures reliability
of a particular
diagnostic measure
for a disease
against the gold
standard
diagnostic measure
for the same
disease.
Compares a group
exposed to a
particular agent
with an unexposed
group; important for
understanding
prevention and
control of disease.
Follows progression
of a group with a
particular disease
and compares with
a group without the
disease.

Evidence-Based Resources. Recognizing that finding relevant studies is difficult, evidence-based groups are developing many
resources for easy access by busy practitioners. These resources
include summaries of SRs and individual research articles, as well
as clinical practice guidelines and protocols.
Evidence-based journals are an emerging resource designed
specifically to assist clinicians. They publish summaries of SRs and
relevant research articles in succinct formats. Two journals related
to dental practice are published: the Journal of Evidence-Based
Dental Practice (http://www.us.elsevierhealth.com/JEBDP/) and
Evidence-Based Dentistry (http://www.naturesj.com/ebd). Depending on the journal, they provide concise and easy-to-read summaries of original research articles and of systematic reviews
selected from the biomedical literature. A one- to two-page structured abstract, with an expert commentary highlighting the most
relevant and practical information, is generally provided. In addition to summaries with commentary of SRs, selected abstracts of
new SRs from the Cochrane Collaboration Library are provided.
The Cochrane Collaboration is an international, volunteer, nonprofit organization. There are approximately 50 specialist review

groups in 13 countries, including an oral health group and a tobacco

addiction group. All Cochrane groups provide peer-reviewed SRs
that meet international standards10 and have an obligation to
update their reviews every 2 to 4 years to account for new evidence.
The results of their work are stored in the Cochrane Library databases, one of which is the Cochrane Database of Systematic
Reviews (COCH), a rapidly growing collection of SRs of the
medical literature. There is no cost to access abstracts of the full
SRs, which provide a concise summary of the background, objectives, search strategy, selection criteria, data collection and analysis,
main results, and reviewers conclusions.
The ADA Center for Evidence-Based Dentistry website,
ebd.ada.org, launched in 2009, provides links to systematic
reviews pertinent to dentistry. This is a great resource for dentists
new to the EBD approach. The systematic reviews are updated
quarterly and are indexed by topic at http://ebd.ada.org/
SystematicReviews.aspx.

Clinical Practice Guidelines and Protocols. Growing

sources of synthesized information on a specific topic include practice guidelines and protocols. As defined by the Institute of Medicine, guidelines are systematically developed statements to assist
practitioner and patient decisions about appropriate health care for
specific clinical circumstances.11 The inclusion of scientific evidence in clinical practice guidelines has now become the standard,
since guidelines should incorporate the best available scientific
evidence. SRs support this process by putting together all that is
known about a topic in an objective manner.
Although not identified as guidelines, AAP Position Papers,
Statements, and Parameters of Care have been developed and updated
on multiple aspects of periodontal practice. The AAP regularly
monitors treatments, products, and concepts to ensure that even
though these have been evaluated once, they are still the best available or as useful as originally envisioned.1 Changing patterns of
disease and improvements in treatments may render a previously
accepted approach as inappropriate, whereas a test, device, drug,
procedure, or intervention for which there is new or mounting
evidence may prove to be important only after thorough evaluation,
continued development, and use in the field.30 AAP Position Papers,
Statements, and Parameters of Care are posted on their website,
http://www.perio.org/resources-products/posppr2.html.
The ADA posts information on a broader range of dental
topics on their website, http://www.ada.org. The ADA Guidelines,
Positions and Statements can be accessed under the section Professional Issues and Research.3 Practice guidelines related to treatment
of specific medical conditions are found on other websites such as
the American Heart Association.4 When these papers, reports,
guidelines, or protocols are published in a journal indexed by
MEDLINE, they will be identified as a citation during the search.
If difficulty identifying a guideline or protocol is encountered
or when it has not been formally published as an article in a
journal, one can search the related website rather than assume that
none exists.

Appraising the Evidence

After identifying the evidence gathered to answer a question, it is
important to have the skills to understand the evidence found. In
all cases, it is necessary to review the evidence, whether it is an SR
or an original study, to determine if the methods were conducted
rigorously and appropriately. International evidence-based groups
have made this easier by developing appraisal forms and checklists
that guide the user through a structured series of YES/NO questions to determine the validity of the individual study or systematic

CHAPTER 81 Introduction to Evidence-Based Decision Making

TABLE 81-3 Examples of Critical Analysis Guides

Guide

Purpose

CONSORT (Consolidated Standards

of Reporting Trials) statement2
PRISMA (Preferred Reporting Items
for Systematic Reviews and
Metaanalyses)
CASP (Critical Appraisal Skills
Program)13

To improve the reporting and

review of RCTs.
To improve the reporting and
review of SRs.
To review RCTs, SRs, and
several other types of studies.

RCTs, Randomized controlled trials; SRs, systematic reviews.

review. Table 81-3 provides examples of guides that can be used

for critical analysis.

Common Ways Used to Report Results. Once the

results are determined to be valid, the next step is to determine if

the results; potential benefits (or harms) are important. Sackett and
colleagues36 identify the clinically useful measures for each type of
study. For example, in determining the magnitude of therapy
results, we would expect articles to report the control event rate
(CER), the experimental event rate (EER), the absolute and relative risk reduction (ARR or RRR), and numbers needed to treat
(NNT). NNT provides the number of patients (e.g., surfaces, periodontal pockets) that would need to be treated with the experimental treatment or intervention to achieve one additional patient
(surfaces, periodontal pockets) who has a favorable response. These
concepts are explained more fully in Chapter 82.

Evaluating the Outcomes

The final steps in the EBDM process are to evaluate the effectiveness of the intervention and clinical outcomes and to determine
how effectively the EBDM process was applied. For example, one
question to ask in evaluating the effectiveness of the intervention
is, Did the selected intervention or treatment achieve the desired
result?
In the Julie case scenario (see Box 1-3), the question is, Did
the antibiotic minimize complications and increase the success rate
of the dental implant?
Using an EBDM approach requires understanding new concepts and developing new skills. Questions that parallel each step
in the EBDM process can be asked in evaluating self-performance.
For example, How well was the search conducted to find appropriate and relevant evidence to answer the question? As with most
learning, time and practice are essential to mastering new
techniques.

CONCLUSION
An EBDM approach closes the gap between clinical research and
the realities of practice by providing dental practitioners with the
skills to find, efficiently filter, interpret, and apply research findings
so that what is known is reflected in the care provided. This
approach assists clinicians in keeping current with conditions that
a patient may have by providing a mechanism for addressing gaps
in knowledge to provide the best care possible.
As EBDM becomes standard practice, individuals must be
knowledgeable about what constitutes the evidence and how it is
reported. Understanding evidence-based methodology and distinctions between different types of articles, such as systematic reviews
and literature reviews, allows the clinician to judge better the validity and relevance of reported findings. To assist practitioners with

768.e15

this endeavor, systematic reviews are being conducted to answer

specific clinical questions, and journals devoted to evidence-based
practice are being published to alert readers about important
advances in a concise and user-friendly manner. By integrating
good science with clinical judgment and patient preferences, clinicians enhance their decision-making ability and maximize the
potential for successful patient care outcomes.

REFERENCES
1. American Academy of Periodontology (AAP): Index of AAP
guidelines, position papers, statements and parameters of care,
2004, http://www.perio.org/resources-products/posppr2.html.
2. American Dental Association (ADA) Commission on Dental
Accreditation: Accreditation standards for dental education programs, Chicago, 2002, ADA.
3. American Dental Association (ADA): ADA policy on
evidence-based dentistry. professional issues and research,
ADA guidelines, positions and statements, 2002, http://
www.ada.org.
4. American Heart Association (AHA): Bacterial endocarditis
guidelines, 2004, http://circ.ahajournals.org/cgi/content/full/
96/1/358; see also Dajani AS, Taubert KA, Wilson W, et al:
Prevention of bacterial endocarditis, Circulation 96:358,
1997.
5. Anderson G, Allison D: Intrapartum electronic fetal heart rate
monitoring: a review of current status for the Task Force on
the Periodic Health Examination. In Preventing disease: beyond
the rhetoric, New York, 1990, Springer-Verlag, pp 19.
6. Bader J, Ismail A: Survey of systematic reviews in dentistry,
J Am Dent Assoc 135:464, 2004.
7. Bader JD, Shugars DA: Variation in dentists clinical decisions,
J Public Health Dent 55:181, 1995.
8. Bader J, Shugars D: Variation, treatment outcomes, and practice guidelines in dental practice, J Dent Educ 59:61, 1995.
9. Browman G, Levine M, Mohide E, et al: The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation, J Clin Oncol 13:502,
1995.
10. Cochrane Collaboration: What is the Cochrane Collaboration? 2004, http://www.cochrane.org/.
11. Committee on Quality of Health Care in America IOM:
Crossing the quality chasm: a new health system for the 21st century,
Washington, DC, 2000, National Academy of Sciences, pp
151.
12. Crowley P, Chalmers I, Keirse M: The effects of corticosteroid
administration before preterm delivery: an overview of the
evidence from controlled trials, Br J Obstet Gynecol 97:11, 1990.
13. Davidoff F: In the teeth of the evidence: the curious case of
evidence-based medicine, Mt Sinai J Med 66:75, 1999.
14. Davidoff F, Case K, Fried P, Cerra F: Evidence-based medicine: why all the fuss? Ann Intern Med 122:727, 1995.
15. Ecenbarger W: How honest are dentists? Readers Digest, Feb.
1997, p 50.
16. Eisenberg J: Statement of health care quality before the House
Subcommittee on Health and the Environment, Washington, DC,
1997, Agency for Health Care Policy and Research Archive.
17. Evidence-based Medicine Working Group: Evidence-based
medicine: a new approach to teaching the practice of medicine,
JAMA 268:2420, 1992.
18. Evidence-based Medicine Working Group: Users guides to the
medical literature: a manual for EB clinical practice, Chicago,
2002, American Medical Association.

768.e16

PART 9 Complementary Topics

19. Frazier P, Horowitz A: Prevention: a public health perspective.

In Oral health promotion and disease prevention, Copenhagen,
1995, Munksgaard.
20. Greco P, Eisenberg J: Changing physicians practices, N Engl
J Med 329:1271, 1993.
21. Greenhalgh T: Is my practice evidence-based? Should be
answered in qualitative, as well as quantitative terms, BMJ
313:957, 1996.
22. Grembowski D, Milgrom P, Fiset L: Dental decision-making
and variation in dentist service rates, Soc Sci Med 32:287, 1991.
23. Grimes DA: Graduate education, Evid Base Med 86:451, 1995.
24. Haynes R: Some problems in applying evidence in clinical
practice, Ann NY Acad Sci 703:210, 1999.
25. Institute of Medicine: Dental education at the crossroads: challenges and change, Washington, DC, 1995, National Academy
Press.
26. Long A, Harrison S: The balance of evidence: evidence-based
decision making, Health Serv J 6(suppl):1, 1995.
27. McKibbon A, Eady A, Marks S: PDQ: evidence-based principles
and practice, Hamilton, Ontario, 1999, BC Decker.
28. Mulrow C: Rationale for systematic reviews, BMJ 309:597,
1994.

29. National Library of Medicine: Fact Sheet, Whats the Difference Between MEDLINE and PubMed? Accessed 6-9-09.
http://www.nlm.nih.gov/pubs/factsheets/dif_med_pub.html
30. Newman M, Caton J, Gunsolly J: The use of the evidencebased approach in a periodontal therapy contemporary science
workshop, Ann Periodontol 8:1, 2003.
31. NHS Centre for Reviews and Dissemination, University of
York: Undertaking systematic reviews of research on effectiveness, 1997, http://www.york.ac.uk/inst/crd/report4.htm.
32. Oxford Centre for Evidence-Based Medicine: Levels of evidence and grades of recommendations, 1998, http://
www.cebm.net/levels_of_evidence.asp.
33. Palmer J, Lusher A, Snowball R: Searching for the evidence,
Genitourinary Med 73:70, 1997.
34. Phillips B, Ball C, Sackett DL, et al: Levels of evidence and
grades of recommendations, Centre for Evidence-Based Medicine, 2001, http://www.cebm.net/levels_of_evidence.asp.
35. Rosenberg W, Donald A: Evidence based medicine: an
approach to clinical problem-solving, BMJ 310:1122, 1995.
36. Sackett DA, Strauss SE, Richardson WS, et al: Evidence-based
medicine: how to practice and teach EBM, London, 2000,
Churchill Livingstone.