Are the valid results of this harm

study important?
1. What is the magnitude of the association
between the exposure and outcome?
 former smokers had modestly increased
odds of having 6+ missing teeth
(adjusted OR =1.48), while current
smokers had a moderate-to-strong
adjusted OR (ORadj =4.17), in each
case relative to never smokers.
 When persons who drank alcoholic
beverages were compared with
abstainers, the mean number of missing
teeth was higher among the nondrinkers
(2.94 vs. 1.82), and the probability
distributions were significantly different
(PK-W = .002).
 Are the valid results of this harm
study important?
2. What is the precision of the estimate of the
association between the exposure and
outcome?
1 +sites with 5 +mm AL:
• Long-term smoker 7.13 (3.53, 14.38)
• Other age-32 smoker 5.68 (3.06, 10.54)
Incidence:
• Long-term smoker 5.16 (2.73, 9.76)
• Other age-32 smoker 3.20 (1.83, 5.58)
 Strength of the association
 Although the OR and RR tell us about the
strength of the association, we need to translate
this into some measure that is useful and
intelligible both to us and to our patient. This is
of particular importance when the discussion
concerns a medication or some other medical
intervention we and our patient are considering.
For this, we can turn to the NNH (number
needed to harm), which tells us the “number of
patients who need to be exposed to the putative
causal agent to produce one additional harmful
event”.
 Number Needed to Harm
 The NNH can be calculated directly from
trials and cohort studies in a fashion
analogous to the NNT, but this time as the
reciprocal of the difference in adverse
event rates:

NNH = 1/[a/(a+b)]-[c/(c+d)]
 Number Needed to Harm

 For an OR derived from a case–control study,

the calculation is more complex (remember, we
can’t determine “incidence” directly in a case–
control study).

NNH = 1+[PEER(OR-1)]/PEER(1-PEER)(OR-1)
Patient Expected Event Rate (PEER) = 7.5% (Incidence of
AL from ages 26 to 32) (See Table 1). With OR of 5.2, the
NNH estimated from table above was < (9-16).
 Can this valid and important
evidence about harm be applied to
our patient?
1. Is our patient so different from those
included in the study that its results
cannot apply?
 The issue is not whether our patient fulfills
all the inclusion criteria for the study we
found, but whether our patient is so different
from those in the study that its results are of
no help to us.
 Can this valid and important
evidence about harm be applied to
our patient?
2. What is our patient’s risk of benefit and
harm from the agent?
 To apply the results of a study to an
individual patient, we need to estimate our
patient’s risk of the adverse event if she
were not exposed to the putative cause.
 Can this valid and important
evidence about harm be applied to
our patient?
3. What are our patient’s preferences,
concerns, and expectations from this
treatment?
 It is vital that we incorporate our patient’s
unique concerns and preferences into any
shared decision-making process.
 Can this valid and important
evidence about harm be applied to
our patient?
4. What alternative treatments are
available?
 Finally, we and our patient could explore
alternative management options. Is there
another medication we could consider? Is
there any effective non-pharmacological
therapy available?
Steps in Practicing EBM

1. Convert the need for information into an

answerable question.
2. Track down the best evidence with which to
answer that question.
3. Critically appraise the evidence for its validity,
impact, and applicability.
4. Integrate the evidence with our clinical expertise
and our patient’s characteristics and values.
5. Evaluating our effectiveness and efficiency
in executing steps 1–4 and seeking ways to
improve them both for next time.
 Resolution to the clinical scenario
 Returning to our patient and having reviewed the
evidence about cigarette smoking and
periodontal disease, he is considered to be a
long-term smoker. The bottom line from the study
suggests that long-term cigarette smoking may
increase the risk of periodontal disease, and this
association appears strong.
 After discussion with our patient, he would like to
consider the following options further in an
attempt to reduce his symptoms:
 Smoking cessation program
 Cigarette substitute such as nicotine gum, patch or e-
cigarette
Steps in Practicing EBM
1. Convert the need for information into an
answerable question.
2. Track down the best evidence with which to
answer that question.
3. Critically appraise the evidence for its validity,
impact, and applicability.
4. Integrate the evidence with our clinical expertise
and our patient’s characteristics and values.
5. Evaluating our effectiveness and efficiency
in executing steps 1–4 and seeking ways to
improve them both for next time.