Evidence Based Dentistry 26.12.11

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EVIDENCE BASEDDENTISTRY

Presented byMd. Zavir khan

Under the Supervision of;Prof.S H Hashmi

Co-Supervised by;

Prof Geeta Rajpoot

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Introduction

Dentistry is both an art &science

It is a science because ourfundamental understandings orbuilding blocks of knowledge arefounded on the scientific

process of research.Thisincludes basic,applied & clinicalresearch.

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It is an art in that it draws on

experience & personalobservation,because science cantaccount for the complexity of all

variables in each situation.the synthesisof scientific understanding & clinicalobservation provides the basis formeaningful dental care.

Evidence based dentistry is an attemptto synthesize both these aspects ofdentistry.

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WHAT IS EVIDENCE-BASED

DENTISTRY? The foundation for Evidence

based practise was laid byDavidSackett

Who has defined it as integratingindividual clinical expertise with

the best available externalclinical evidence from systematicresearch.

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It allows dentists, as wellas academic researchers,

to keep abreast of newdevelopments and to makedecisions that should

improve their clinicalpractice.

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ADA DEFINATION OF EBD

An approach to oral health care thatrequires the judicious integration of:

systematic assessments of clinicallyrelevant scientific evidence, relatingto the patients oral and medicalcondition and history, together with

the dentists clinical expertise andthe patients treatment needs andpreferences.

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SOME IMPORTANT TERMS

Randomized controlled trial:

RCTs are quantitative, comparative,controlled experiments in whichinvestigators study two or moreinterventions in a series of individualswho receive them in random order.

The RCT is one of the simplest andmost powerful tools in clinical research

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The principal of evidencebased dentistry are finding thebest information quickly when

it is needed,assessing itsquality and deciding whether itis relevent

Will help practitioner to useresearch evidence in making

everyday clinical decisions.3/17/2012 8


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META ANALYSIS : In statistics, a meta-analysis

combines the results of severalstudies that address a set ofrelated research hypotheses.

Meta-analyses are often, but

not always, importantcomponents of a systematicreviewprocedure

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http://en.wikipedia.org/wiki/Statisticshttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Statistics


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Systematic review :

is a literature review focused on asingle question that tries toidentify, appraise, select andsynthesize all high quality researchevidence relevant to that question.

Systematic reviews of high-qualityrandomized controlled trials are

crucial to evidence-based medicine.3/17/2012 10
http://en.wikipedia.org/wiki/Literature_reviewhttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Literature_review


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Cochrane Library : is a collection of databases in medicine

and other healthcare specialties providedby the Cochrane Collaboration and otherorganisations.

At its core is the collection of CochraneReviews, a database of systematic reviewsand meta-analyses which summarize andinterpret the results of medical research.

The Cochrane Library aims to make theresults of well-conducted controlled trialsreadily available and is a key resource inevidence-based medicine

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http://en.wikipedia.org/wiki/Health_carehttp://en.wikipedia.org/wiki/Health_carehttp://en.wikipedia.org/wiki/Databasehttp://en.wikipedia.org/wiki/Medicinehttp://en.wikipedia.org/wiki/Cochrane_Collaborationhttp://en.wikipedia.org/wiki/Cochrane_Collaborationhttp://en.wikipedia.org/wiki/Cochrane_Collaborationhttp://en.wikipedia.org/wiki/Cochrane_Collaborationhttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Clinical_trialhttp://en.wikipedia.org/wiki/Clinical_trialhttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Clinical_trialhttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Cochrane_Collaborationhttp://en.wikipedia.org/wiki/Health_carehttp://en.wikipedia.org/wiki/Medicinehttp://en.wikipedia.org/wiki/Database


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CONTD..The Cochrane Library consists of the following

databases: The Cochrane Database of Systematic Reviews(Cochrane Reviews)

The Database of Abstracts of Reviews of Effects(DARE)

The Cochrane Central Register of Controlled Trials(CENTRAL)

The Cochrane Database of Methodology Reviews(Methodology Reviews)

The Cochrane Methodology Register (MethodologyRegister) Health Technology Assessment Database (HTA) NHS Economic Evaluation Database (NHS EED)

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WHY DO WE NEED EVIDENCE-BASED

DENTISTRY?

to improve the quality of health care

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CONTD

Demonstrate best use of limitedresources

Stay up to date

Medical information changesconstantly

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How to practice?

Identify the clinical problem

Formulate clear question

Clarify the relevant problem

Search for evidence

Ignore irrelevant information; interpret the

relevant evidence

Decide in appropriate action based on best evidenceavailable

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scenario Acute ulcerative gingivitis can be treated

with the antibiotic metronidazole. Why isit that not every patient givenmetronidazole recovers from the disease?Why do some untreated patients recover?

Given this, how can we say thatmetronidazole is an effective treatment?

the above example illustrates that people

are naturally variable in their responses toexposures or treatments. Different peoplerespond to the same exposure or sametreatment, in different ways.

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Clinical research allows us tomake decisions about causes of

and treatments for disease,while allowing for the naturaldifferences between people.

Evidence-based dentistry isfounded on clinical research.

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5 As

1. Asking answerable questions (Asking)

2.

Searching for the best evidence (Acquiring)

3. Critically appraising the evidence (Appraising)

4. Applying the evidence (Applying)

5. Evaluating the outcome (Assessing)

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Asking answerable questions

A prudent question is one half of

wisdom - Francis Bacon

Turning the clinical problems into

a well-built clinical question is a

key skill of evidence-based

practice.

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Pico analysis

P:Patient (or Problem)

I:Intervention (or Cause,

Prognosis) C:Comparison (or Control)

O: Outcome(s)

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scenario

for an arthritic patient does

using electric toothbrush

provide more effective oralhygiene maintenance than by

using manual toothbrush??

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P:(problem)

arthritic patient

I:(intervention)

electric toothbrush

C:(comparison)manual toothbrush

O:(outcome)

oral hygieneCommonly referred to as PICO.

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Finding evidence

Traditional sources ofinformation

Modern sources- electronicdatabases. The most widely

available database is Medlinewhich can be accessed via thePub Med interface.

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All clinical research studies areencompassed under the broadheading of epidemiologic

studies. These studies can be further

subdevided Descriptive ,

Analytical & interventionalstudies

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A new type of studies hasemerged after the advent ofEB research I.E. integrative

studies Integrative studies include

Systematic reviews & Metaanalysis.

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The quality of various research designs

can be placed in a research designhierarchy. Position of each research design within

the hierarchy is a function of thestrengths & weakness of featureswithin each design.

The higher the study design ranks in

the research hierarchy,the better thestudy design minimizes bias &distributes random variation equallybetween the study groups.

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Sources of evidence

Sources of evidence

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Levels of evidence

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Drilling for the Best

InformationCochrane Library

Usefu

lness

Clinical Evidence

Clinical Inquiries

Specialty-specific

journals

ACP Journal Club

Textbooks, Up-to-

Date, 5-MinuteClinical Consult

Journals/

Medline

PubMed

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Sources of Systematic Reviews

Cochrane Collaboration (www.cochrane.org)

International Organization that develops and maintainssystematic reviews

Created in 1992 by the British National Health Service

Cochrane Library (electronic database of trials andsystematic reviews)

Cochrane Oral Health Group, University of Manchester

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http://www.cochrane.org/http://www.cochrane.org/


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Supplement of the British Dental Journal

Central Resource for EBD relevant issues andarticles

Aimed at general dental practitioners

http://www.nature.com/ebd/index.html

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Sources of Systematic Reviews

The Journal of Evidence-BasedDental Practice

original articles reviews of articles on the results

and outcomes of clinical procedures and treatment http://www.elsevier.com

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http://www.elsevier.com/http://www.elsevier.com/


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Other Sources of Information

National Guideline Clearinghouse: www.guideline.gov

Comprehensive source for guidelines and materials Summary of guidelines, side by side comparisons Standard set of guideline attributes Type of evidence supporting the recommendations

U. S. Preventive Services Task Force www.preventiveservices.ahrq.gov

Recommendations based on reviews of the evidenceof effectiveness of clinical preventive services

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http://www.guideline.gov/http://www.preventiveservices.ahrq.gov/http://www.preventiveservices.ahrq.gov/http://www.guideline.gov/


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Appraising the evidence

The important thing is not to stop

questioning. Curiosity has its own

reason for existing AlbertEinstein

Once the evidence is collected itmust be screened for

validity(closeness to the truth)

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Contd.

Impact (size of the effect) andapplicability (usefulness in clinical

practice). The users guide are designed to test

an article on these 3 parameters.

These guides are basically a set ofquestions whose answers should beprovided to the reader by the articlein order to obtain best clinicalevidence for the ues in focus.3/17/2012 36


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Acting on the evidence

"Remember, people will judge you by your

actions, not your intentions. You may have a

heart of gold -- but so does a hard-boiled

egg." - Anon.

There are a number of well documenteddelays between clinical practice and the

available research evidence.

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Integrate the criticalappraisal with clinicalexpertise and with the

patients unique biology,values& circumstances.

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Evaluating your performance

"I hear and I forget. I see and Iremember. I do and I

understand." Confucius Finally,evaluate performance in

terms of effectiveness & efficiencyby questioning the ability to completesteps 1-4 successfully & seek ways toimprove performance in future.

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Advantage of evidence based approach

compared with other assessmentmethod

Is objective Is scientifically sound Is patient focused

Incorporates clinical experienceStresses good judgment Is thorough and comprehensiveUses transparent methodology

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Dentistry based on evidence and

evidence based dentistry .Are they same??????????Dentistry based on evidence

Tends to include selected evidence ofvariable quality

Evidence-based dentistry

Relies on identifying all the available evidenceand assessing its quality

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Barriers to implementing EBD

Lack of time

Lack of appropriate skills for

formulating clearquestions,executing efficientelectronic searches & evaluating

the literature.Keeping up to date

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Perhaps the greatestimpediments to the EBD are thefear & mistrust on the part of

practitioners that the evidencewill be misused by decisionmakers,particularly 3rd party

funders & regulatory bodies &that the individual anatomy ofdentists ,in caring for their

patients ,will be threatened.3/17/2012 43


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Problems of introducing EBD

Amount of evidence

Quality of evidence

Dissemination of evidence Practice based on authority

rather than evidence

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Advantages

Improved patient,staff & dentistsatisfaction

Greater pride among patients,staff &

dentist in high quality care Improved clinical decision making

capability

Greater confidence in T/t planing More opportunity to provide T/t

choices selected for minimizing risk ofharm & maximizing T/t safety.

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Greater satisfaction

Reduced overhead & improvedproduction by saving time & money.

Higher T/t acceptance

Enhanced patient trust & rapport

Improved practice buildingopportunities as patients share withothers their trust,confidence & pride intheir EBD practicing dentist.

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Conclusion

Evidence based care is a globalmovement in all the health sciencedisciplines

It represents a philosophical shift inthe approach to practice-a shift thatemphasizes evidence over opinion &at that same time judgement overblind adherence to rules

This approach provides a bridgebetween research & everyday patientcare. 3/17/2012 47


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In near term future for EBpractice is likely to becharacterised by continuation ofcurrent trends in dissemination ofEB info to clinicians.

The primary means for

dissemination will consists ofevidence summaries & EB T/trecommendations & guidelines.

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THANK YOU

Documents

Evidence Based Dentistry 26.12.11