Evidence Based Dentistry

Prof. Beena Rani Goel

Even in this age of information explosion, it is possible to find dentists who continue to use the same treatments and techniques learned in dental school, which represented the best practice at the time. When a new technique or material is developed, dilemma arises in deciding whether it is better than the current clinical management strategy. For a busy practitioner, finding the time to acquire the knowledge to make these decisions is next to impossible.

To keep up-to-date with latest advances in dentistry and manage patients who have complex needs and demands is a challenge for the practicing dentists, because each day, they are inundated with information on new techniques, tests, procedures, materials or products1. The information explosion and the consumer movement, both of which are fortified by the extraordinary advance of the Internet, further complicate the matters. Patients are starting to come to the dental operatory with information downloaded from the Internet, some of which may be unfamiliar to the dentist.

Evidence-Based Dentistry (EBD) helps general dental practitioners to keep abreast of the best available evidence on the latest developments in various aspects of clinical dentistry.

The definition of evidence-based practice, “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients,”2 suggests that the primary aim of the evidence-based approach to the practice of dentistry is “to encourage the ordinary dental practitioner in primary dental care to look for and make sense of the evidence available in order to apply it to every day problems.”3 To do this successfully, many practicing dentists need to acquire certain skills not previously taught in most undergraduate dental curricula.

When a patient problem is bothering you, when you come across some new treatment, or when you want to update your knowledge in some area, Evidence Based Dentistry will come to your help. The solution for your problem may be present in the Internet. Since Internet is an ocean of information, to get a specific answer, you have to formulate an exact, specific question and search the appropriate site in the Internet. The Application of Evidence-based Methods

Formulating a Clear Question

Many important clinical questions arise during our day to day dental practice. These questions may be related to:

Diagnosis- is this test accurate and reliable?
Causation (what is the etiology of this condition, is this treatment harmful?)⁴
Treatment (which technique is most reliable, which material is superior, what drug should I prescribe?), and
Prognosis (what is this patient’s likely clinical course over time, what is the expected longevity of this restoration?)

Very often, the original question will be too broad. The first step consists in narrowing the question by deciding which elements are the most important to answer with a “hit and run search.”5

To focus the question, we have to use the PICO format. ‘P’ is identifying the Patient or population (for example, children) with the Problem or condition (e.g., caries), the Intervention (e.g., fluoride application), Comparison (e.g., fissure sealant application), and the specific Outcome (e.g., caries progression). In this example, these elements form the question, ‘Will the application of fluoride or fissure sealants prevent caries progression in child patients?’

While defining each of the key elements of the question, be as specific as possible. For example, when specifying the population, decide whether you want information on all patients or only children, adults or the elderly. Are you interested in all stages and causes of the condition? Will the results be useful if the study took place in a specialized setting, such as a dental clinic or university, rather than a community-based practice setting? This focus will make it easier for you to limit your electronic search and to discard research that is not pertinent.

Diagrammatic representation of Evidence Based Clinical Practice

Finding, Evaluating and Applying the Evidence

The key to answering a clinical question lies in finding, evaluating and applying the evidence. One of the tools to find the evidence is MEDLINE, which is the most relevant and readily available one. This multipurpose database, 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. Through the Internet, the full MEDLINE database is available free of charge to anyone. The NLM offers free Internet access through PubMed.6 You can access PubMed easily on www.dentalmedline.com , www.pubmed.com

The Foundation of Evidence Based Dentistry

Evidence-based dentistry closes the gap between clinical research and real world dental practice and provides dentists with powerful tools to interpret and apply research findings7.

Evidence Based Dentistry requires the integration of the best evidence with clinical expertise and patient preferences and, therefore, it informs, but never replaces, clinical judgement.5

Central to evidence-based practice is the systematic literature review, which synthesizes the best evidence and provides the basis for clinical practice guidelines. The randomized, double-blind, placebo-controlled clinical trial is generally considered to provide the strongest evidence. The next level provides clinical data but requires a research design that precludes the use of a double-blind approach. Next are longitudinal studies, which follow group(s) of patients over time. Cross-sectional studies provide another level of data because the information is gathered at a single point in time. Finally, at the bottom of the hierarchy of strength is the case report. The case report is beneficial as an initial report of a technique or idea, but certainly should have virtually no weight in evidence-based decision making.

Scientific research evidence has built the knowledge base and has always provided the foundation for sound practice of dentistry. The practice of Evidence Based Dentistry is possible because of the electronic revolution. The research evidence can now be readily accessed at the “user” level by dentists or patients. The quality of research reports and the accuracy of the conclusions drawn, vary tremendously. Therefore, tools are needed to help dentists to properly interpret and apply the evidence. The “information explosion” and the limited amount of time for keeping up with the literature has made the evidence-based approach valuable and effective for efficiently filtering what is truly important for clinical decision making from what is not. ⁸

The Cochrane Collaboration

The Cochrane Collaboration is an international organization that aims to help people make well-informed decisions about health by preparing, maintaining and ensuring the accessibility of systematic reviews of the benefits and risks of healthcare interventions. This not-for-profit organization prepares, maintains and promotes the accessibility of systematic reviews of the effects of health care. The Cochrane Library contains regularly updated evidence-based healthcare databases.

( Eg., of a Cochrane Review :- Nadin G, Goel BR, Yeung CA, Glenny AM. Pulp treatment for extensive decay in primary teeth. The Cochrane Database of Systematic Reviews 2003, Issue 1.)

The Cochrane Oral Health Group aims to produce systematic reviews which primarily include all Randomized Controlled Trials (RCTs) of oral health. This site can be accessed at http://www.cochrane-oral.man.ac.uk/

You can also visit website www.healthmantra.com/ebd / for more information and extra links. If you have any questions send email to profgoel@gmail.com

References:

Susan E. Sutherland, DDS Evidence-based Dentistry: Part I. Getting Started J Can Dent Assoc 2001; 67:204-6
Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312(7023):71-2.
Richards D, Lawrence A. Evidence based dentistry. Br Dent J 1995; 179(7):270-3.
Oxman AD, Sackett DL, Guyatt GH. Users’ guides to the medical literature. I. How to get started. The Evidence-Based Medicine Working Group. JAMA 1993; 270(17):2093-5.
Sackett D, Richardson W, Rosenberg W, Haynes R. Evidence-based medicine: how to practice and teach EBM. London: Churchill Livingstone; 1997.
National Center for Biotechnology Information. National Library of Medicine, National Institutes of Health. Available from URL: http://www.ncbi.nlm.nih.gov.
Susan E. Sutherland, DDS The Building Blocks of Evidence-based Dentistry J Can Dent Assoc 2000; 66:241-4
Glowniak JV, Bushway MK. Computer networks as a medical resource. Accessing and using the Internet. JAMA 1994; 271:1934-9.