Evidence based dentistry

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Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised January 9, 2012

The primary learning objectives for this course are to: 1) increase your knowledge of evidence-based concepts, principles and skills, and 2) specifically how to formulate a good clinical question in order to find relevant evidence to answer that question.

Conflict of Interest Disclosure Statement• Jane Forrest has done consulting work for P&G.

ADA CERPThe Procter & Gamble Company is an ADA CERP Recognized Provider.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at:http://www.ada.org/prof/ed/ce/cerp/index.asp

OverviewThe Evidence-based Decision Making (EBDM) process provides a mechanism for staying current in practice by addressing gaps in knowledge so that the clinician can provide the best care possible. To accomplish this EBDM requires understanding new concepts and skills, the first and often the most difficult is how to ask

Jane L. Forrest, EdD, BSDH Continuing Education Units: 2 hours

Evidence-Based Decision Making: Introduction and Formulating Good Clinical Questions

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an answerable question. This question provides the basis for identifying the key terms for conducting an efficient search, the second step of the EBDM process. These two steps provide the basis for the three that follow: critically appraising the evidence, applying the results in clinical practice, and evaluating the outcome. The EBDM approach recognizes that clinicians can never be completely current with all conditions, medications, materials, or available products.

Learning ObjectivesUpon the completion of this course, the dental professional will be able to: • Define Evidence-Based Medicine/Practice.• Define Evidence-based Decision Making and its purpose.• Explain why evidence-based practice is not just a new term for an old concept.• Identify two principles of EBDM.• Discuss the need for EBDM.• Identify the levels of evidence and premise upon which they are based.• Describe the 5 steps and skills necessary for EBDM.• Formulate a good question using the PICO process.• Discuss the benefits of EBDM.

Course Contents• Introduction - What is Evidence-Based

Decision Making?• Is Evidence-based practice a new term for an

old concept?• Principles of EBDM• The Need for EBDM• Levels of Evidence• Evidence-Based Decision Making Skills and

the 5-Step Process• Evidence-Based Decision-Making in Action• Applying the PICO Process• Structuring the PICO Question• Benefits of EBDM• Conclusion• Course Test• References• About the Author

Introduction - What is Evidence-Based Decision Making? Evidence has always contributed to clinical decision-making; however, with the proliferation of clinical studies and journal publications, keeping current with relevant research is nearly impossible. Because we rely on well-designed research studies to demonstrate the efficacy and effectiveness of diagnostic tests, treatment strategies, new materials, and products, knowing how to find the scientific evidence is an essential component for clinical practice.

Using evidence from the medical literature to answer questions, direct clinical action and guide practice was pioneered at McMaster University, Ontario, Canada in the 1980’s. As clinical research and the publication of findings increased, so did the need to use the medical literature to guide practice. The old clinical problem-solving model based on individual experience or the use of information gained by consulting authorities (colleagues or text books) 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)1 and is defined as:

The integration of the best research evidence with clinical expertise and patient values.2

Rather than refer to medicine, often this definition has been broadened to mean ‘practice’ or ‘healthcare’ and is the definition we are using for Evidence-Based Practice (EBP).

Several professions have adapted this definition to make it specific to their discipline. For example, the American Dental Association (ADA) defines “evidence-based dentistry” (EBD) as: an

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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 dentists’ clinical expertise and the patient’s treatment needs and preferences.3

Inherent in these definitions is the recognition that research evidence is a valued component of the clinical decision-making process, and the intent is that the use of current best evidence does not replace clinical skills, judgment, or experience but provides another dimension to the decision-making process that also considers the patient’s preferences.4-6 (Figure 1) It is this decision-making process that we refer to as Evidence-Based Decision Making (EBDM) and 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 clinician’s experience and judgment, the patient’s preferences and values, and the clinical/patient circumstances when making patient care decisions.

Again, EBDM is not unique to medicine or any specific health discipline, but represents a concise way of referring to the application of evidence to clinical decision-making.

Is Evidence-based practice a new term for an old concept? The use of evidence in practice is not new. What is new is the nature of the clinical evidence itself in terms of the methods for gathering it [randomized controlled trials and other well-designed methods], the statistical tools for synthesizing and analyzing it [systematic reviews and meta-analysis], and the ways for ways for accessing [electronic databases] and applying it [evidence-based decision-making and practice guidelines].7,8,9

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, and2. critical appraisal skills to rapidly evaluate and

sort out what is valid and useful, and what is not.10

EBDM is the formalized process and structure for learning these skills with the purpose of closing the gap between what is known and what is practiced in order to improve patient care based on informed decision-making.

Principles of EBDM Evidence-based decision-making is about solving clinical problems and involves two fundamental principles:1. Evidence alone is never sufficient to make a

clinical decision. Initially, the focus of EBM emphasized using randomized clinical trials and other quantifiable methods. However, as EBM has evolved, 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.11

2. A hierarchy of evidence exists to guide clinical decision-making.9 EBDM is a structured process which 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.9,12

Figure 1. EBDM Process©2001 Forrest, NCDHR

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The Need for EBDM 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.4,13 Forces driving the need to improve the quality of care include:1. variations in practice,2. slow translation and assimilation of the scientific

evidence into practice,4,14-16

3. managing the information overload, and4. changing educational competencies that require

students to have the skills for lifelong learning.6

1. Variations in Practice Patterns Substantial advances have been made in our knowledge of effective disease prevention measures and of new therapies, diagnostic tests, materials, techniques and delivery systems, and yet the translation of this knowledge into practice has not been fully applied. Variations in practices among dental clinicians are well documented, whether it involves diagnostic procedures, treatment planning17,18 and treatment,19 or prescribing antibiotics, such as was found among endodontists20 and general practitioners.21

2. Slow Translation and Assimilation of Research Findings into Practice Far too often variations in practice occur due to a gap between the time 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.22-25 One example has been the use, or lack of use, of dental sealants.24 Although their effectiveness have been well documented over the past 3 decades, only 18.5% of US children and youth ages 5-17 have one or more sealed permanent teeth (1988-1991 data)26 and goals for Healthy People 2020 have been retained, but modified to increase the proportion since the 2010 goals were only set at 50%.27

Assimilating scientific evidence into practice requires that clinicians keep up to date by reading extensively, attending courses and taking advantage of the Internet and electronic databases to search for published

scientific articles. However, colleagues and personal journal collections tend to be the primary information sources for treatment decisions, rather than the scientific literature.28-30 Treatment decisions tend to reflect the knowledge, skills and attitudes learned as a student,8,25,31 and trends indicating that the longer clinicians are out of school, the bigger the gap in their knowledge of up-to-date care,31-32 as demonstrated by the knowledge, opinions and practices of dentists and dental hygienists in providing oral cancer examinations.33,34 This reinforces the need to learn evidence-based information seeking behaviors and critical analysis skills while still in school.

3. Managing the Information Overload

In addition to influencing variations in practice and the slow translation and assimilation of scientific evidence into practice, it is physically impossible to keep up to date with the increasing number published articles. With the number of good clinical trials and meta-analyses increasing at a rate of 10% per year35 and located in over 700 dental journals world-wide, knowing which journals to subscribe to that have the relevant articles related to an individual’s practice is nearly impossible. To stay current in general dentistry, one would have to identify, obtain, read and appraise 6 articles per week, 52 weeks per year.35

A similar situation applies to keeping current with research studies related to clinical dental hygiene practice. A substantial number of articles, 112 meta-analyses (reviews and statistical analysis of already conducted research that address the same question) and 1707 RCTs, published between 1990 and 2003 were identified when searching MEDLINE36 (Table 1).

In this case, 50% of the 112 meta-analyses were located in 7 journals and the Cochrane Library with the remaining half found in 33 other journals. Of the 1700 RCTs, 70% were located in 32 journals with the remaining 30% in 174 journals.36

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Again, the challenge is to find relevant clinical evidence when it’s needed in order to help make well-informed decisions. Evidence-based practice is now possible due to increased access to relevant clinical findings via development of online databases and computers that enable quick access to the scientific literature. Being able to search electronically across hundreds of journals for specific answers to patient questions or problems solves this problem.

4. Changing Educational Requirements

Another need for EBDM is reflected in educational requirements and competencies for both dental and dental hygiene students. The ADA Accreditation Standards for Dental Education Programs37 now expect dental schools to develop specific competencies that are reflective of an evidence-based definition of general dentistry.37 In addition to the ADA, the American Dental Education Association’s Competencies for the New Dentist identifies general skills that reflect an evidence-based approach.38 These include being able to continuously analyze the outcomes of patient treatment to improve that treatment, evaluate scientific literature

and other sources of information to make decisions about dental treatment, and manage oral health based on an application of scientific principles.

Similar competencies for dental hygienists are incorporated in the ADEA Dental Hygiene Curriculum Guidelines.39 For example, “The process of care requires defined problem solving and critical thinking skills and supports evidenced-based decision-making.” Further support for EBDM is found in the curriculum guidelines under Research for Dental and Dental Hygiene Education (pp. 123-128)39 in that their aims are to provide both dentists and dental hygienists with the skills and knowledge to be able to access the most recent and relevant scientific evidence, critically appraise it, and determine if it is applicable to the problem being addressed. The clear intent of the accreditation standards and competencies contained within these documents is the focus on the importance of comprehensive patient-centered care and the need for adding evidence-based decision-making to the traditional experienced-based approach.

Table 1. Research Supporting Clinical Dental Hygiene Practice34

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Table 2 highlights the four forces driving the need for EBDM.

Levels of Evidence Sources regarded as strong evidence include meta-analyses and systematic reviews, individual randomized controlled trials (RCT), and well-designed non-randomized control studies (Figure 2). The hierarchy of evidence for treatment questions is based on the notion of causation and the need to control bias.13,40

Although each level may contribute to the total body of knowledge, “...not all levels are equally useful for making patient care decisions.”40 As you progress up the pyramid, the number of studies and correspondingly, the amount of available literature decreases, while at the same time their relevance to answering clinical questions increases40 (Figure 3).

Table 2. The Need For EBDM

Figure 2. Study Types and Levels of Clinical Evidence

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Knowing which segment of the literature is appropriate for clinical decision-making and how to quickly retrieve this information is important to evidence-based practice. For example, the study methodology and level of evidence will differ based on the type of question asked, such as those derived from issues of therapy/prevention, diagnosis, etiology, and prognosis. Table 3 reviews the type of question and the highest levels of evidence based on the study methodology. For example, for questions associated with therapy and prevention, the highest level of evidence will be from meta-analyses or systematic reviews of randomized controlled trials (RCTs), since the objective of these studies is to test interventions demonstrating cause and effect and to select treatments that improve the condition/disease and avoid adverse events.9

Correctly identifying the type of study to answer the question is an important skill to develop in order to access the appropriate evidence when searching the healthcare literature. For example, identifying the best implant technique for replacing a single maxillary molar is a treatment question. Ideally, a meta-analysis or systematic review of RCTs would be available on the treatment being considered. If one were not available, then the next best evidence would be from a well-conducted individual RCT. However, when the focus of the question is on long-term outcomes of treatment, then it is a question of prognosis where the highest level of evidence would be provided by a systematic review of inception cohort studies, which are studies that follows patients from when a disease or condition first manifests itself clinically. And again, if a meta-analysis or systematic review were not available, the next highest level would be an individual inception cohort study, and so on down the hierarchy (Table 3). Two important concepts to keep in mind are that: 1) for any type of question, having a well-conducted meta-analysis or systematic review provides stronger evidence than a single study, and 2) a meta-analysis or systematic review is only as good as the individual studies that comprise it.

An excellent website that graphically displays the different types of research methods and designs can be found at the SUNY Downstate Medical

Center, Evidence Based Medicine Course, Guide to Research Methods - The Evidence Pyramid: http://library.downstate.edu/EBM2/2100.htm.

Evidence-Based Decision Making Skills and the 5-Step Process The principles of EBDM methodology are based on the abilities to find, critically appraise, and correctly apply current evidence from relevant research to decisions made in practice so that what is known is reflected in the care provided. The EBDM skills and 5-step process are outlined in Table 4.

The following procedures provide an overview of the five steps and skills involved in establishing an evidence-based practice.1. Converting information needs/problems into

clinical questions so they can be answered – the PICO process.

Asking the right question is a difficult skill to learn, yet it is fundamental to evidence-based practice. The process almost always begins with a patient question or problem. A “well-built” question should include four parts, referred to as PICO that identify the Patient Problem or Population (P), Intervention (I), Comparison (C), and Outcome(s) (O).2

2. Conducting a computerized search with maximum efficiency for finding the best external evidence with which to answer the question.

This type of search requires a shift in thinking. Often, especially now with fast web-based search engines, health professionals can look for “something” on a topic, a quick answer, or for “everything.” Finding relevant evidence requires conducting a focused search of the peer-reviewed professional literature based on the

Figure 3. Available Literature and its Relevance

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Table 3. Type of Question Related to Levels of Evidence and Study Methodology

Table 4. Skills needed to apply the EBDM Process2

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good patient care decisions. Differences between groups in clinical trials are generally straight forward when expressed in terms of the mean values; whereas, results presented as proportions, such as relative risk reduction, absolute risk reduction, odds ratio and numbers needed to treat (NNT), are more challenging to understand. Also, understanding the difference between statistical and clinical significance will help you in translating and determining if the findings apply to your patient.

5. Evaluating the process and your performance

The final step in EBDM is evaluation of the effectiveness of the process. Mastering the skills of evidence based decision making takes practice and reflection and a clinician who is new to the steps should not be discouraged by early difficulties encountered. Evaluating the process of EBDM may include 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. With an understanding of how to effectively use EBDM, you can quickly and conveniently stay current with scientific findings on topics that are important to you and your patients.

Evidence-Based Decision-Making in Action

The PICO Process (Skill/Step 1)The formality of using PICO to frame the question forces the questioner to focus on what the patient/client believes is the most important problem and the desired outcome. Doing this facilitates selecting language or key terms for conducting the computerized search, the second step in the process. Next, it allows you to determine the type of evidence and information required to solve the problem and the outcome measures that will be used to determine the effectiveness of the intervention.

One of the greatest difficulties in developing each aspect of the PICO question is providing an adequate amount of information without being too detailed. Each component of the PICO question

appropriate methodology. Online databases and software that enable quick access to the literature have made it easier to locate relevant clinical evidence.44

Knowing what constitutes the highest levels of evidence and how to apply evidence-based filters and limits will let you search the literature with maximum efficiency. It is the combination of technology and good evidence that allows healthcare professionals to apply the benefits from clinical research to patient care.44

To assist professionals in keeping up with the literature and in making it possible to quickly find needed information without leaving your location, online access to MEDLINE, provided by the National Library of Medicine (NLM), is now available. They also provide a free version of MEDLINE called PubMed that can be accessed at http://www.pubmed.gov

3. Critically appraising the evidence for its validity and usefulness (clinical applicability).

Once you have found the most current evidence, the next step in the EBDM process is to understand what you have and its relevance to your patient and the PICO question. Resources are available to help you critically appraise individual research studies and meta-analyses or systematic reviews. They consist of a worksheet with a structured series of questions that can help you determine the strengths and weaknesses of how a study was conducted and how useful and applicable the evidence is to the specific patient problem or question being asked.45-47

4. Applying the results of the appraisal, or evidence, in clinical practice.

Once the methods are determined to be valid, the fourth step is to determine if the results, potential benefits or harms, are important. This is achieved by looking at whether there is an association between specific treatments and outcomes or exposures, the strength of that association, and the condition of interest, i.e., your patient problem or question. Understanding how to present statistical information to patients in a clear and unambiguous manner will help in making

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Applying the PICO Process The first step in developing a well-built question is to identify the patient problem or population [P] by describing either the patient’s chief complaint or by generalizing the patient’s condition to a larger population. The problem is further shaped or refined by the most important characteristics that might influence the results such as:• Level of disease or health status• Age, race, gender, previous conditions, past

and current medications

In Mr. Logan’s case, we know 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 decision as to which treatment might be most appropriate.

Identifying the Intervention [I] is the second step in the PICO process. It is important to identify what you plan to do for that patient. This may include the use of a specific diagnostic test, treatment, adjunctive therapy, medication, or the recommendation to the patient to use a product or procedure. The intervention is the main consideration for that patient.4 In Mr. Logan’s case, the intervention being considered is the Crest Whitestrips™ since he has specifically asked about them. This also keeps the process patient-centered.

The third phase of the well-built question is the Comparison [C], which is the main alternative (intervention) you are considering.2 It should be specific and limited to one alternative choice, usually the gold standard, in order to facilitate an effective computerized search. The Comparison is the only optional component in the PICO question since there may not be an alternative, however when there is one, it should be used. In our case, we have selected the custom trays for at-home bleaching as the main alternative.

The final aspect of the PICO question is the outcome [O]. This specifies the result(s) of what you plan to accomplish, improve, or affect, and it should be measurable. Examples of outcomes are relieving or eliminating specific symptoms,

should be stated as a concise short phrase as illustrated in the following case example.

Case ExampleYour 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 one week before he attends his 30-year high school reunion. 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.

You present the bleaching procedure options and related fees to Jim. He questions you about the differences between them and the Crest Whitestrips™ that do not require a tray and can be purchased at the local grocery store. Jim insists the whitening strips are just as effective and cost considerably less.

You are not familiar with the latest scientific literature on the whitening strips to answer Mr. Logan’s questions thoroughly. You tell him you know the bleaching procedures you have suggested are safe, effective, and can produce the desired outcomes within the desired time. However, you tell him you will be glad to investigate the Whitestrips option so each of you are fully informed about the pros and cons of each method before selecting a treatment. With the popularity of these treatment options and new products introduced quite frequently, this information will be a valuable addition to the evidence-based “library” you are creating in your office. To find the answer, you must define Jim’s question so it facilitates an efficient search of the literature. To guide this process, the PICO Worksheet and Search Strategy form can assist you. (Table 5)

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Structuring the PICO QuestionAfter understanding the elements of PICO and identifying the patient’s concerns, you are now ready to structure the PICO question for Mr. Logan’s case.

P = Patient Problem or PopulationThe first part of the PICO question begins with the following phrase: For a patient with... Inserting the patient’s chief complaint or condition completes this phrase. For Mr. Logan, this phrase can be completed as follows:“For a patient with tooth discoloration due to coffee and tobacco”.

improving or maintaining function, and enhancing esthetics. In Mr. Logan’s case, you are seeking evidence to demonstrate the effectiveness of the whitening/bleaching treatment under a given set of conditions, i.e., effective in whitening his teeth within one 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. “More effective or just as effective” is not acceptable unless it describes how the intervention is more effective. For our example, just as effective in whitening teeth within one week is the desired outcome.

Table 5. PICO Worksheet for Mr. Logan’s Case

©2001 SA Miller, PICO Worksheet, National Center for Dental Hygiene Research

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could be used in the search are ‘tooth bleaching’ or ‘tooth whitening’ or ‘Crest Whitestrips’ or ‘whitening strips’ as well as ‘hydrogen peroxide’ or ‘carbamide peroxide.’ An example of a completed PICO Worksheet for Mr. Logan’s case is shown in Table 6.

Benefits of EBDMEBDM provides a strategy for improving the efficiency of integrating new evidence into patient care more rapidly by helping you manage an increasing amount of information. EBDM assists you in developing treatment plans and providing treatment and advice that are scientifically defensible. In addition, it helps insure that your practice is continually informed and strengthened by current research findings, helping to close the gap between what is known (research evidence) and what is practiced.

EBDM is not about knowing all the answers, but rather about knowing how to structure good questions to be able to find relevant information to better inform your decision making, and how and when to integrate new thinking and action into everyday practice.

ConclusionRecognizing that clinicians have time constraints and yet want to provide the best possible care to their patients, an evidence-based approach offers clinicians a convenient method of finding current research to support clinical decisions, answer patient questions, and explore alternative treatments, procedures, or materials. With an understanding of how to effectively use EBDM, practitioners can quickly and conveniently stay current with scientific findings on topics that are important to them and their patients.

I = InterventionThe main intervention being considered is Crest Whitestrips™, so the question now reads:“For a patient with tooth discoloration due to coffee and tobacco, will Crest Whitestrips”.

C = ComparisonThe comparison phrase is stated “as compared to” the main alternative, which in this case is custom trays for use with an at-home whitening/bleaching system. The question now reads:“For a patient with tooth discoloration due to coffee and tobacco, will Crest Whitestrips, as compared to custom trays for use with an at-home whitening/bleaching system”.

O = Outcome(s)Mr. Logan’s main concern is the discoloration of his teeth and having his teeth as white as they were when he was 25 years old within a 1 week period. The outcome(s) is then phrased as, be as effective in whitening his teeth within 1 week. Based on these four parts, the complete PICO question can be stated as:“For a patient with tooth discoloration due to coffee and tobacco, will Crest 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 (Table 5), you would then identify the type of question and study and then list any additional terms or phrases related to the already identified P, I, C, and O. By generating these words, alternative key terms are identified that facilitate finding evidence to answer your question, Step 2, conducting a computerized search with maximum efficacy, in the EBDM process. For example, key terms that

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Table 6. Completed PICO Worksheet for Mr. Logan’s Case

©2001 SA Miller, PICO Worksheet, National Center for Dental Hygiene Research

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Course Test PreviewTo receive Continuing Education credit for this course, you must complete the online test. Please go to www.dentalcare.com and find this course in the Continuing Education section.

1. The following components define evidence-based practice:a. Clinical expertiseb. Patient valuesc. Scientific researchd. A and Ce. A, B, and C

2. The purpose of EBDM is to _______________. a. emphasize new research findingsb. close the gap between research and practicec. defer to patients wishesd. use expert opinionse. None of the above.

3. EBDM is just a new term for clinical decision-making.a. Trueb. False

4. EBDM requires online searching skills and understanding research methods.a. Trueb. False

5. Evidence can change over time as new research studies are conducted.a. Trueb. False

6. All of the following reasons have contributed to the need of EBDM except:a. Variations in practice patternsb. Delays in adopting useful proceduresc. Keeping current in practiced. Managing the information overloade. Incorporated in accreditation standards

7. The highest level of evidence is the same for treatment and prognosis questions.a. Trueb. False

8. Which of the following provides the highest level of evidence for therapy questions?a. Case Control Studyb. Cohort Studyc. Systematic Review of RCTsd. Randomized Controlled Triale. Case Report

9. Systematic reviews provide a higher level of evidence than a single study.a. Trueb. False

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10. As you progress up the levels of evidence, the amount of available literature also increases.a. Trueb. False

11. As you progress up the levels of evidence, the literature becomes more relevant for answering therapy related questions.a. Trueb. False

12. The first step in the EBDM process is _______________.a. finding the best evidenceb. applying the results to patient carec. asking a good clinical questiond. evaluating the resultse. critically appraising the evidence

13. Which of the following characteristics describes the Intervention in the PICO process?a. What you plan to dob. Main concern or chief complaintc. Measurable resultd. Alternative

14. The only optional component of the PICO question is:a. P (Patient Problem or Population)b. I (Intervention)c. C (Comparison)d. O (Outcomes)

15. Select the most appropriate PICO question:a. Is using Mouthwash ‘x’ as effective as flossing?b. For a patient, is Mouthwash ‘x’ as compared to flossing as effective?c. For mild gingivitis is Mouthwash ‘x’ as effective compared to flossing?d. For a patient with mild gingivitis, is rinsing with Mouthwash ‘x’ as compared to flossing as

effective in reducing plaque and eliminating gingivitis?

16. Select the PICO component that is missing or incomplete from this question: For a patient with periodontal disease, will antimicrobial therapy (minocycline HCI) in conjunction with scaling and root planing be more effective in preventing further attachment and bone loss?a. P (Patient Problem or Population)b. I (Intervention)c. C (Comparison)d. O (Outcomes)

17. Benefits of the EBDM process include:a. Provides a strategy for improving the efficiency of integrating new research evidence into

patient care more rapidly by helping you manage an increasing amount of information.b. Assists in developing treatment plans and providing treatment and advice that are scientifically

defensible.c. Helps insure that practice is continually informed and strengthened by current research findings.d. All of the above.e. A and C

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29. Covington P, Craig BJ. Survey of the information-seeking patterns of dental hygienists. J Dent Educ. 1998 Aug;62(8):573-7.

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About the Author

Jane L. Forrest, EdD, BSDHDr. Forrest is the Chair of the Behavioral Science Section, Division of Dental Public Health and Pediatric Dentistry, at the University of Southern California Herman Ostrow School of Dentistry, Los Angeles, CA and is the Director of the National Center for Dental Hygiene Research & Practice. Dr. Forrest has served as the pre-Conference workshop chair for both the 1st and 2nd International Conferences on Evidence-Based Dentistry and as an instructor for the ADA’s Evidence-Based Champion’s Conferences.

Dr. Forrest is the lead co-author on a new book, “Evidence-Based Decision Making: A Translational Guide for Dental Professionals” and has chapters published on EBDM in the recent editions of Clinical Periodontology and in the 2nd edition Dental Hygiene Concepts, Cases and Competencies. She is active in professional associations and serves on several editorial boards including as an Associate Editor for the Journal of Evidence-Based Dental Practice.

Email: [email protected]

Health & Medicine

Evidence based dentistry