EVIDENCE BASED

DENTISTRY

SARAH ASIF JR1

DEPARTMENT OF ORTHODONTICS AND
DENTOFACIAL ORTHOPAEDICS

Supervisor- Co Supervisor
Dr.Mohd Tariq Dr.Afaf Zia
Dept of Orthodontics Dept of Periodontics
 Contents
• Introduction
• Principles of EBDM
• The Need for EBDM
• Levels of Evidence
• Evidence-Based Decision Making Skills and the 5-
Step Process
• Applying the PICO Process
• Structuring the PICO Question
• Benefits of EBDM
• Conclusion
 Introduction
 Usingevidence from the literature to answer
questions, direct clinical action and guide practice
was pioneered at McMaster University Ontario,
Canada in the 1980’s

 Theold clinical problem-solving model gave way to a

new methodology for practice and restructured the
way for more effective clinical problem-solving
method termed as

Evidence-Based Medicine
 Itis defined as- “The integration of the best
research evidence with our clinical expertise and
our patient’s unique values and circumstances.”

 Rather than refer to medicine, often this definition

has been broadened to mean ‘practice’ or healthcare’
and is the definition used for Evidence-Based
Practice (EBP).

 Several professions have adapted this definition to

make it specific to their discipline.
 ADA defines Evidence-
Based Dentistry as:
“An approach to oral
health care that requires
the judicious integration
of systematic Evidence
assessments of clinically
relevant scientific
Patients
evidence, relating to need and
Clinical
patient’s oral and medical expertise
prefrences
condition and history, with
the dentists’ clinical
expertise and the patient’s
treatment needs and
preferences.”
 Definition
also recognizes that research evidence is a
valued component of the clinical decision-making
process.

 Intentis that the use of current best evidence does not

replace clinical skills, judgment, or experience.

 Rather provide another dimension to the decision

making process that also considers the patient’s
preferences.

 It
is this decision-making process that we refer to as
Evidence-Based Decision Making (EBDM)
 Evidence-based Practice a New
or an Old Concept?

 The use of evidence in practice is not new.

 New is the nature of the clinical evidence in itself.

 Methods for gathering it,

 Statistical tools for synthesizing and analyzing it,
 Ways for accessing electronic databases and applying it
in evidence-based decision-making and practice
guidelines.
 Evidence-based practice is a new term for an old
concept and as a result of advances, practitioners need:

 More efficient and effective online searching skills to find

relevant evidence.

 Critical appraisal skills to rapidly evaluate and sort out

what is valid and useful, and what is not.
 What EBD is not…..
 Itdoes not take the clinical decisions out of clinicians
hands and put them into the hands of the literature.

 Gives guidelines for the clinician and relies first on

clinical expertise.

 It does not mean that third parties will control dental

practices;rather educated dentists, understanding the
literature, will be able to prevent the misrepresention of
data by commercial interests.
 Itdoes not mean the clinician need not study basic
and dental material sciences rather the need to
evaluate the research presented, with a solid
background to base their evaluations.

 Itdoes not mean clinicians abandon everything

they learned in dental school and to go backwards
to justify things the profession universally accepts.
Who Benefits from EBD?
 Patients will be more educated, more involved in
their treatment decisions, and more appreciative of
quality care.

 Dentists, who will have at their disposal more valid

research on which to predicate their clinical decisions.

 Researchers, who will benefit by being called upon

to do the necessary clinical testing.
 EVIDENCE BASED DECISION
MAKING

“ 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 clinician’s
experience and judgement,the patient’s
prefrences and values and the clinical/patient
circumstances when making patient care
decisions”

 Itis a concise way of referring to the application of

evidence to clinical decision making.
 Scientific
evidence

EBDM
Experience
Patient
and
judgement prefrences

Clinical
patient
circumstance
Evidence-Based
Traditional Practice
Practice

Systematic Limited
appraisal of Unknown
Uses best appraisal of
quality of basis of
evidence quality of
evidence evidence
evidence

Subjective,
Objective, Acceptance Black and
opaque,
transparent, of levels of white
potentially
less biased uncertainty conclusions
biased
 Need for EBDM…….
 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

 Driving forces

 Variations in clinical practice patterns.

 Slow translation and assimilation of the scientific evidence
into practice.
 Managing the information overload.
 Changing educational competencies that require students
to have the skills for lifelong learning.
Principles of EBDM…..
Two fundamental principles:

 Evidence alone is never sufficient to make a

clinical decision.

 A hierarchy of evidence exists to guide clinical

decision-making.
Its a structured process which incorporates a
formal set of rules for interpreting the results of
clinical research and places a lower value on
custom.
Advantages of EBDM
IS OBJECTIVE

SCIENTIFICALLY SOUND

PATIENT FOCUSED

INCORPORATES CLINICAL EXPERIENCE

STRESSES GOOD JUDGEMENT

THOROUGH AND COMPREHENSIVE

TRANSPARENT METHODOLOGY
 EBDM Process and Skills…..

Convert Conduct a
informatio- computeriz- Critically
n needs ed search appraise
and with the Apply the
Evaluate
problems maximum evidence results of
process and
into clinical efficiency for its appraisal in
your
questions with the validity clinical
so that best and practice. performance.
they can evidence to usefulnes-
be answer the s.
answered. question.
 PICO PROCESS:Asking Good
Question
 Converting information needs and problems into
clinical questions

 A well built question should include four parts

 The patient problem or population -P
 Intervention -I
 Comparison -C
 outcomes –O

“ For a patient with___(P),will___(I) as

compared to____(C) increase/decrease/provide
better/in doing ____(O)? ”
Purpose of PICO…..
 Forcesthe clinician to focus on what the patient
believes to be the most important single issue and
outcome.

 Allows the identification of the type of evidence

required to solve the problem and for measuring the
effectiveness,intervention and application of EBDM.

 One of the greatest difficulties in developing each

aspect of the PICO question is providing an
adequate amount of information without being too
detailed.
 Case Example
 Your new patient, Mr. Jim Logan, is a 48-year old
marketing executive. His chief complaint is the
discoloration of his front teeth, which he feels is
getting worse as he gets older. He would like them to
be as white as they were when he was 25 and even
brought in a picture to show you.He would like them
whitened within 1 week
 When reviewing his health history and behaviors, you
learn that Mr. Logan is a coffee drinker and recently
stopped smoking
 Upon examination, you determine his only treatment
needs are preventive care and suggest you re-
evaluate the discoloration after that appointment since
the stain could be removed during his prophylaxis.
 If additional treatment is needed, you can make him
custom trays for use with an at-home whitening/
bleaching system, which is safe and will meet his
time requirement.
 You present the bleaching procedure options and
related fees to him.
 He questions you about the differences between
laser bleaching and Whitestrip that do not require a
tray and can be purchased at the local grocery store.
He would like to know if the whitening strips are just
as effective especially since is cost considerably less.
 To find the answer,you must define Jim’s question so
it facilitates an efficient search of the literature.
 STEP 1 Identify the Patient Problem or
Population [P] by describing the patient’s chief
complaint or by generalizing the condition to a larger
population.

 Problem is further shaped by the important

characteristics that influence the results such as:

 Level of disease or health status

 Age, race, gender, previous conditions, past and
current medications.
 In this case, the chief complaint is discoloration of
his front teeth and that coffee and tobacco are
contributing factors.

 So, in addition to the chief complaint, age, and

current habits, previous behaviors may influence the
treatment making decision.
 STEP 2 Identifying the Intervention [I] is
the second step in the PICO process.

 This includes the use of a specific diagnostic

test,treatment, adjunctive therapy, medication, or the
recommendation to the patient to use a product or
procedure.

 In this case, the intervention being considered is the

Whitestrips since he has specifically asked about
them.

 This also keeps the process patient-centered.

 STEP 3 Is the Comparison [C], which is
the main alternative(intervention) you are considering.

 It should be specific and limited to one alternative

choice, usually the gold standard, to facilitate an
effective computerized search.

 Comparison is the only optional component since

there may not be an alternative, however when there
is one, it should be used.

 In this case, custom trays for at-home bleaching is

the alternative.
 STEP 4 Is the Outcome [O]
 It specifies the result(s) of what you plan to
accomplish, improve, or affect, and it should be
measurable.

 Eg: Relieving or eliminating specific

symptoms,improving or maintaining function, and
enhancing esthetics.

 In this case, we are seeking evidence to

demonstrate the effectiveness of the
whitening/bleaching treatment under a given set of
conditions, i.e. within 1 week so they appear as
white as they were when he was 25 years old.
 Outcomes yield better search results when defining
them in specific terms and they should solve the
specific problem.

 “More effective or just as effective” are not

acceptable outcomes unless they describe how the
intervention is more effective or just as effective.

 Inthis case, just as effective in whitening teeth within

one week is the desired outcome.
 Structuring the PICO Question…

 Mr.Logan’s case, P = Patient Problem or

Population

 The first part of the question begins with the following

phrase: For a patient with...

 Inserting
the patient’s chief complaint or condition
completes this phrase.

“For a patient with tooth discoloration due to coffee

and tobacco”.
I = Intervention ,The main intervention being
considered is Whitestrip, so the question now reads:

“For a patient with tooth discoloration due to coffee

and tobacco, will Whitestrips”.

 C = Comparison, is stated “as compared to” which

in this case is custom trays. The question now
reads:

“For a patient with tooth discoloration due to coffee

and tobacco, will Whitestrips, as compared to
custom trays for use with an at-home whitening
bleaching system”.
O = Outcome(s) is then phrased as, be as effective
in whitening his teeth within 1 week.
Then complete PICO question can be stated as:

“For a patient with tooth discoloration due to coffee

and tobacco, will Whitestrips, as compared to
custom trays for use with an at-home whitening
bleaching system, be as effective in whitening his
teeth within 1 week?”
 Following the PICO Worksheet , you would then
identify the type of question and study and then list
any additional terms or phrases.

 Generating these,words and alternative key terms

are identified that facilitate finding evidence to
answer your question.

 Conducting a computerized search with maximum

efficacy.

 Foreg; key terms that could be used in the search

are ‘tooth bleaching’ or ‘tooth whitening’ or ‘
Whitestrips’ or ‘whitening strips’or ‘hydrogen
peroxide’ or ‘carbamide peroxide.’
Searching and Acquiring Evidence….

“Evidence is considered the synthesis of all valid

research that answers a specific question which
distinguishes it from a single research study.”

 Sources of evidence
 PRIMARY -original research publications that have
not been filtered or synthesized.
 SECONDARY-synthesized publications of the primary
literature
 PubMed www.pubmed.com
 Embase www.embase.com
 MEDLINE www.medscape.com
 Cochrane Collaboration www.cochrane.org
 Google Scholar www.scholar.google.com
 Peer-reviewed journals
 Professional associations that publish Guidelines
when not all of the highest levels of research are
available.
 By far the most relevant and readily available of
these is MEDLINE.

 Created and maintained by the United States

National Library of Medicine (NLM) of the National
Institutes of Health, is an index to the biomedical
literature from 1966 onward.

 Of the over 700 dental journals currently available

worldwide, about 320 are indexed in MEDLINE.
 The full MEDLINE database is available publicly to
anyone, free of charge, via the Internet.

 The NLM offers free Internet access through 3

Websites—
 PubMed,
 Internet Grateful Med
 Recently launched NLM Gateway.
 In addition to MEDLINE and PubMed, Gateway
also accesses-

 OLDMEDLINE (pre-1966 journal citations),

 LOCATORplus (books, serial titles and audiovisual
resources),
 DIRLINE (a directory of health
organizations,research resources and projects).
 Cochrane Collaboration is an international
nonprofit organization whose overall aim is to build
and maintain a database of up-to-date systematic
reviews of RCTs and to make them readily
accessible electronically.

 BritishNational Health Service created the

Cochrane Centre, at Oxford, UK, named in honor of
Archie Cochrane, to facilitate the preparation and
maintenance of systematic reviews.
 Tremendous international interest followed and by
1993, centers had been established in Denmark,
Canada, the United States and Australia.

 There are now fifteen Cochrane Centers worldwide.

 The Cochrane Oral Health Group is based at the

University of Manchester, UK.
(http://hiru.mcmaster.ca/cochrane/default/htm)
 Bestsites are those produced by academic centers,
including university and hospital sites, government-
sponsored and professional organization sites.

 Centre for Evidence-Based Dentistry

(www.ihs.ox.ac.uk/cebd/) are located at the Institute
of Health Sciences, Oxford University ,United
Kingdom.
 The Health Information Research Unit at
McMaster University
(http://hiru.hirunet.mcmaster.ca) in
Hamilton,Ontario has become internationally
famous.

 Thelibrary of Ottawa General Hospital (

www.ottawahospital.on/professionals/library)
provides a large collection of links to resources for
evidence-based health care.
 The National Institutes of Health (NIH) National
Library of Medicine databases, particularly
MEDLINE via PubMed(http://www.ncbi.nlm.nih.gov/
) and NLM Gateway http://gateway.nlm.nih.gov/ are
the best government-sponsored Professional sites.

 National Guideline Clearinghouse (NGC) has

one of the most extensive collections of guidelines.

 Itcan be accessed through the website of the

Agency for Healthcare Research and Quality
(www.ahcpr.gov/clinic/cpgsix.htm) of the U.S.
Department of Health and Human Services.
 The Canadian Medical Association clinical
practice guidelines site (www.cma.ca/cpgs/)
provides methodological guidance for the
development of guidelines, as well as a handbook
on the implementation of guidelines.

 The German Guidelines Information Service

(www.leitlinien.de/gergis.htm) has evaluation
criteria, as well as an appraisal instrument to
evaluate the methodological quality of published
guidelines.
Search Techniques…..
 MeSH (Medical Subject Headings) is a special
vocabulary developed by the NLM to index each
reference.

 Currently,MEDLINE has an entry vocabulary of

over 300,000 terms linked to its more than 19,000
MeSH terms.

 The choice of entry terms is important; we should try

to focus the term as much as possible.
 Besides searching by subject, searching can be
done by “text words,” which are words or phrases in
the title or abstract of the article.

 A useful feature when searching by subject is

called “EXPLODING”.

 For eg, if the subject term “ceramic restoration”

were entered in a database than all articles dealing
with restorations in general would be retrieved.
 Another
useful operation, called TRUNCATION, can
be employed when doing text word searches.

 Forexample, “dent*” will find all terms that begin with

the letters d-e-n-t, including “dental,” “dentistry,”
“dentist” and so on.

 BOOLEAN OPERATOR used for combining terms

or phrases by AND,OR ,NOT
Levels of Evidence….
 The highest level of evidence or the gold standard is
the systematic reviews and meta-analysis using two
or more RCTs of human subjects.

 Hierarchyof evidence is based on the concept of

causation and the need to control bias.

 Thelevel of evidence is directly related to the type of

question asked.
 What is the “Best Evidence”

 RCT- strongest design for a clinical study because it

minimizes bias by ensuring that the patients in each
group are as similar as possible in all respects.

 SYSTEMATIC REVIEWS AND META

ANALYSIS-“secondary” publications or integrative
research” summarize, analyze and report the
combined results of a number of RCTs.
 The “unit of analysis” is the individual study rather
than the individual patient.
 Appraising the Evidence
 Itsimportant to have the skills to understand the
evidence found,review it thoroughly and determine if
the methods were conducted rigorously.

 International
evidence-based groups have developed
appraisal forms and checklists.

 These guide the user through a structured series

of”YES/NO” questions to determine the validity of the
study.
 Examples of Critical Analysis
Guides….

 CONSORT (Consolidated Standards of Reporting

Trials)- to improve the reporting and review of
RCTs.
 QUOROM(Quality of Reporting of Meta-Analysis)-
to improve the reporting and review of SRs.
 CASP(Critical Appraisal Skills Program)-to review
RCTs,SRs and other types of studies
CONSORT checklist of items for reporting
 SYSTEMATIC REVIEWS AND
META ANALYSIS
Widelyaccepted standards have been developed for the
conduct of SRs for issues related to therapeutic question.

Agreed-upon standards and critical appraisal techniques

for reviews which synthesize the results of observational
studies.

Was a clearly stated question asked?

The question being addressed by the review should be
focused in terms of the population being studied.
If key elements are not present in the title/abstract go on
to the next title.
 Were the inclusion criteria appropriate?
 Specific inclusion and exclusion criteria related to the
population, intervention, outcome and acceptable
study design must be well defined and clearly stated.
Was a comprehensive literature search
done?
 All pertinent studies should be included and
important ones must not be missed.
 A number of high-quality, methodologically sound
studies remain unpublished (“publication bias”).
 Authors of the overview should clearly state their
search strategy, including key words and databases
used including other sources, such as multiple
databases, reference lists from relevant papers,
conference proceedings and personal contacts with
experts.
 Was the validity (quality) of the primary
studies assessed?
 The methodological quality of the studies must be
searched by the reader.

Was the assessment of the studies

reproducible and free of bias?
 Decisions regarding which studies met the inclusion
criteria, the validity of the study and meaning of the
data within each study must be judged by the
reviewer.
 Two or more authors of the review should perform
each of these steps independently, blind to each
other’s decisions, and come to agreement by
consensus.
 Were the results similar from study to
study?
 Even with strict inclusion criteria, there is bound to
be some variation in the results of the studies.
 The authors should present the salient features of
each.
 Study in terms of the included patients,severity of
their disease, the intervention and the way in which
the outcome was measured, and hence explain the
variability of the results.
 Were the findings of the studies combined
appropriately?
 If studies seem too dissimilar, they should not be
combined mathematically.
 If test indicates that the study results are similar to
combine mathematically, a meta-analysis is done.
 Major advantages of meta-analysis is that the
results of a number of small but similar studies can
be combined to achieve a large enough sample to
detect an effect.
 Were the authors’ conclusions supported by
the data?
 The results of each study must be reported in detail
to allow the reader to judge the grounds for the
reviewers’ conclusions i.e. Do the results and
conclusion answer the original question asked

Will the results help in caring for patients?

 With all research, one needs to decide if the
patients and the practice setting are similar to the
studies included in the review.
 Whether they can be implemented in the
intervention in your practice and are the potential
benefits worth any potential harm or cost.
 RCTS
Was the allocation of patients to study
groups random?
 Consider whether or not the treatment allocation
was truly randomized and whether the assignment
of each patient to either the treatment group or the
control group was decided completely by chance or
by some other similar method.

 Look for words like random allocation, randomly

assigned or randomized trial in the title or abstract.
 Look for the way randomization was done; coded
and sealed envelopes, random number tables or a
computer generated sequence.

 Any method of allocation where the sequence

could be guessed by anyone is inappropriate.

 Unfortunately, usually randomization methods are

not often described.
 Were all the patients who entered the trial
accounted for and analyzed at the end of the
study?

 Patients drop out because of side effects or

because they benefited from the intervention and
chose not to return for follow-up.
 Even when loss to follow-up is accounted for and
explained in the paper, follow-up of less than 80%
is considered unacceptable.
 Itis also important that patients be analyzed in the
group to which they were originally randomly
allocated, even if they switched groups or were
noncompliant with the experimental or control
treatment.

Were patients, clinicians and study

personnel “blinded”?
 The greater the extent of blinding of all study
personnel, the more rigorous the trial.
 Were the groups similar at the outset and
treated equally throughout the study?

 The study should present baseline data on all

patients in each group and if there are any
significant differences.
 Co-interventions if given differentially either to the
treatment and the control group can be problematic
but are much less of a problem in double-blind
studies.
 Allowed co-interventions should be described and
the extent of use of non-permissible co-interventions
should be documented too.
 Were clinically important outcomes assessed?
 A carious tooth that requires treatment is important
to a patient; a cariogenic bacterial count generally is
not.
 Effectiveness of an intervention with a clinically
relevant outcome must be looked for.

Can the results of the study be applied to my

patient(s)?
 Study’s inclusion and exclusion criteria,suggest as
to whether or not the results of the study are useful
in the management of the patient problem at hand.
 If the results can be generalized to your patients,
consider benefit greater than any potential harm or
added cost.
 Implementing Evidence-based
decisions in Clinical practice
 Evidencebased practice has been defined as
improving treatment outcomes by using research
evidence ,with clinical experience and patient
values and prefrences.

 Contemporary dental practice calls for decisions to

be made efficiently while facing clinical uncertainity
and not by just relying on the past experiences and
input from colleagues and experts.
 Science Transfer is a process where the practitioner
incorporates the evidence from the published
research advances into his clinical practice.

 Limitations-
 Difficulty in accessing and evaluating evidence
 Lack of awareness
 Resistance to changing behavior
 High frequency of clinical success
 For eg; Partial edentulism is not a pathologic
entity,and current evidence suggests that failure to
replace missing teeth does not result in loss of
adjacent teeth or severe arch collapse.

 Literaturealso suggests better long term outcomes

with implant versus conventional fixed prosthesis.

 Using this evidence the patient must be informed

that replacement of teeth is elective,and that
implants may offer better long term success than
fixed bridges.
 Consideration of the evidence alone and ignoring
the patient prefrences and values is meaningless.

 Clinical decision making depends much on the

patient’s perspective on the issue and how severly
it would affect the health of the patient
.
 It must be kept in mind that each clinical situation is
unique and hence calls for a specific treatment
course.
Evaluating the process and your
performance…..

 Includes a range of activities such as examining

outcomes related to the health/function of the patient
and patient satisfaction.

 Self-evaluation of developing skills is a most critical

aspect in mastery of EBDM which develops with time
and experience.

 With an understanding of how to effectively use

EBDM, one can conveniently stay current with
scientific findings on topics that are important to you
and your patients.
Initiatives….
EBD WEBSITE
 Critical summaries of systematic reviews.
 Database of systemic reviews.

EDUCATION-
 EBD workshop
 EBD conferences

CLINICAL RECOMMENDATIONS
 Sealants,topical fluorides,oral cancer
screening.
 Benefits of EBDM….
 Provides a strategy for improving the efficiency of
integrating new evidence into patient care.

 Assists you in developing treatment plans that are

scientifically defensible.

 It helps insure that your practice is continually

informed and strengthened by current research
findings, helping to close the gap.

 Itis about knowing how to structure good questions

to be able to find relevant information to better
inform your decision making.
 It is a logical system to assist us in identifying
current truth for implementation into practice.

 However, the research needs your personal

evaluation and comparison with your own clinical
observations to determine the usefulness.

 Whatever is considered truth today will probably be

questioned or disproven tomorrow.

 Evidence-based dentistry concepts are only a

guide to determine truth from hype on any clinical
question and such decisions come with careful
analysis and time.
THANK YOU