What is Evidence Based Dentistry

Author: Gökhan Alpaslan DMD,Ph.D

e-vident

Objectives

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Evidence Based Dentistry

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Hierarchy Of Evidence

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Levels of Evidence in EBD

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Steps of Evidence Based Practice

Outline

        EBD definition Why Dentists Practice Evidence Based Dentistry Glossary of Terms Relating to EBD Hierarchy Of Evidence Levels of Evidence in EBD Steps of EBD Process The Stages in Evidence Based Practice References

Outcome

 Will learn what is EBD  Be familiar with EBD search tools  Understand the previlages of EBD approach  Will know the stages in Evidence Based Practice  Will seek for best evidence

Dentists are challenging to manage sophisticated patient needs and demands.

On the other hand keeping the advances in dentistry and medical dental sciences up to date, following the current techniques and relevant literature and applying knowledge to daily practice is practicioners’ priority.

What is Evidence Based Dentistry?

Evidence-based dentistry is the practice evidence of dentistry with that integrates the best available clinical experience decisions.

and patient preference in making clinical Sutherland S., J Can Dent Assoc 2001; 67:204-6 Evidence-based dentistry is an approach to oral health that requires the judicious integration assessments relevant of of scientific systematic clinically evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise treatment preferences.

and the needs patient’s and ADA Policy on Evidence-Based Dentistry

Why Practice EBD?

 Helps filter immense amount of information that emerges in the literature  Effective method of keeping up with the most current research  Provides information on how similar cases treated

What is Evidence Based Practice?

Evidence-based practice has been defined as the practice of dentistry that integrates the best available evidences with clinical experience and what a patient prefer in making clinical decisions. The EBD process is not a rigid methodological evaluation of scientific evidence that dictates what practitioners should or should not do. Rather, the EBD process is based on integrating the scientific basis for clinical care, using thorough, unbiased reviews and the best available scientific evidence at any one time, with clinical and patient factors to make the best possible decisions about appropriate health care for specific clinical circumstances.

     Glossary of Terms Relating to EBD Best evidence is a term that refers to information obtained from randomized controlled clinical trials, non-randomized controlled clinical trials, cohort studies, case-control studies, crossover studies, cross-sectional studies, case studies or, in the absence of scientific evidence, the consensus opinion of experts in the appropriate fields of research or clinical practice. The strength of the evidence follows the order of the studies or opinions listed above.

Case-control study involves identifying subjects with a clinical condition (cases) and subjects free from the condition (controls), and investigating if the two groups have similar or different exposures to risk indicator(s) of factor(s) associated with the disease.

Case-series is a report on a series of patients with an outcome of interest. No control group is involved.

Clinical practice guideline (parameter of care) is a systematically developed statement designed to assist both practitioner and patient with decisions about appropriate health care for specific clinical circumstances.

Clinical protocol is a step-by-step decision-making tool that describes how a health condition outcome of interest.

is diagnosed and managed.

Cohort study involves identifying two groups (cohorts) of subjects, one that did receive the exposure of interest and another that did not, and following these cohorts forward for the 

Glossary of Terms Relating to EBD       Controlled clinical trial is a study that uses the same design features of a randomized controlled clinical trial (see definition below), but, for reasons beyond the control of the investigators, the subjects are assigned using a non-random process into control or experimental groups.

Crossover study design is the administration of two or more experimental therapies, one after the other in a specified or random order, to the same group of patients.

Cross-sectional study is the observation of a defined population at a single point in time or in a specified time interval. Exposure and outcome are determined simultaneously.

Evidence-based dentistry is an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences.

Evidence-based health care extends the application of the principles of evidence based medicine to all professions associated with health care, including purchasing and management.

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.

Glossary of Terms Relating to EBD     Meta-analysis is a review that uses quantitative methods to combine the statistical measures from two or more studies and generates a weighted average of the effect of an intervention, degree of association between a risk factor and a disease, or accuracy of a diagnostic test.

Probability of success is a ratio of the number of patients who benefit from an intervention to all those who receive an intervention. A probability figure, such as 0.5

or 50%, means that out of 100 patients, 50 would benefit from an intervention and 50 would not benefit. Neither the dentist nor the patient can determine beforehand to which of the two groups a patient will belong.

Randomized controlled clinical trial is a study in which participants are randomly (i.e., by chance) assigned to either an experimental group or control group. The experimental group receives the new intervention and the control group receives a placebo or standard intervention. These groups are followed up for the outcomes of interest.

Systematic review is a process of systematically locating, appraising and synthesizing evidence from scientific studies in order to obtain a reliable overview.

The aim is to ensure a review process that is comprehensive and unbiased. Findings from systematic reviews may be used for decision-making about research and the provision of health care.

The goal of the EBM process is to help practitioners provide the best care for their patients. This process uses clinical and methodological experts to synthesize all of the evidence relative to a defined "question of interest.

“ Information from systematic reviews is then made available to practitioners for integration with their clinical experience and other factors relevant to specific patient needs and preferences.

Hierarchy Of Evidence

Oxford Centre for Evidence-based Medicine      At least one systematical review prepared from many number of well designed RCT’s.

At least one systematical review well designed with sufficient number of subjects.

Study results well designed but not randomised cohort studies, time series, compared case/control studies.

Well designed but not experimental research center or group studies.

Clinical evidence driven specialist view or expert committee reports.

McQuay HJ, Moore RA. Evidence-based resource for pain relief. Oxford:Oxford University Press, 1988.

Hierarchy Of Evidence

Levels of Evidence

Dave Sackett and colleagues who generated "levels of evidence" for ranking the validity of evidence.

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. British Medical Journal. 1996;312:71–72.

Levels of Evidence in EBD

Different types of evidence have different kinds of authority.

    Level I – Evidence from Systematic Reviews of Randomized Controlled Trials Level II – Evidence from Randomized Controlled Trials Level III – Evidence from Non-randomized controlled trials or cohort studies Level IV – Evidence from Case Series Articles such as single case reports, technical notes, animal studies, laboratory studies, non-systematic literature reviews, and expert opinion are all considered lower classes of evidence within EBD.

Stronger Weaker Medical Center Library, Duke University EBP: Library Tools for Clinical Content. Christina L Wissinger, MS, MLIS, Clinical Informationist

Four steps of EBD Process

I.

Define a clinically relevant and focused question in the interest of finding the best available evidence to promote the oral health of patients. "Best evidence" is a term that refers to information obtained from randomized controlled clinical trials, non-randomized controlled clinical trials, cohort studies, case-control studies, crossover studies, cross-sectional studies, case studies, or the consensus opinion of experts in appropriate fields of research or clinical practice.

II. Focuse on systematically conducting searches for all studies and databases, published or unpublished, that may help to answer a clinically relevant question. After selecting, summarizing, and synthesizing all relevant studies that directly answer the focused clinical question, the strength of the available scientific evidence is graded using predefined criteria, and qualitative or quantitative analyses are conducted. Conclusions on the quality and strength of evidence are made, and gaps in the knowledge base that require further research are identified.

III. Translate the findings from systematic reviews for use by practitioners.

IV. Assess the health care outcomes following the findings of the previously outlined steps. This evaluation is conducted as part of the outcome assessment that health care providers integrate into their practices. This four-step process aims to help practitioners make the best-informed decisions with their patients.

The Stages in Evidence-Based Practice

Identify Clinical Problem Produce a Focused Clinical Question Search for Evidence Evaluate the Evidence Incorporate Evidence into Practice Evaluate the Impact on Practice

References

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Elliot Abt; The Basics of Evidence Based Dentistry ADA Policy on Evidence Based Dentistry Sutherland S.; J Can Dent Assoc 2001; 67:204-6 McQuay HJ, Moore RA; Evidence-based resource for pain relief. Oxford:Oxford University Press, 1988.

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS; Evidence based medicine: what it is and what it isn't. BMJ. 1996;312:71–72.

UT Health Science Center; Oral Health Information Tutorial for Dental Public Heath Professionals.