The evolution of the dental knowledge base The evolution and definition of evidence-based dentistry
(EBD) The three components of EBD: scientific evidence, the
clinician’s expertise, and the patient’s needs and preferences
Best evidence Applying EBD in practice Evidenced based periodontology
Dentists need to make clinical decisions based on limited scientific evidence. In clinical practice, a clinician must weigh a myriad of evidences every day.
The goal of evidence-based dentistry is to help practitioners provide their patients with optimal care. This is achieved by integrating sound research evidence with personal clinical expertise and patient values to determine the best course of treatment.
According to the ADA…
Evidence-based dentistry (EBD) 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.
Is an approach to oral health care
Is a method to acquire, understand and apply the most current science
Evidence
Patient
preferences
& needs
Clinical
expertise
Cookbook dentistry A standard of care A mandate of what must be done A substitute for clinical judgment
The dental knowledge base is simply the collection of all that is known about oral health and disease and treatment methods and outcomes.
Its contents comprise all of the
extant dental journal articles
textbooks,
the minds of all oral health practitioners.
the foundation of the dental professions and the principal determinant of how dentists and dental hygienists practice
informs professional decision making, and portions of it comprise the content of predoctoral and postdoctoral dental school curricula.
new information andunderstandings have been contributed by
researchers, practitioners, and
manufacturers.
the dental knowledge base has
grown over time
Evidence of the treatment of teeth extends far back into human prehistory,and early writings discuss “tooth worms,” the supposed cause of toothache at that time.
Ancient Roman, Greek, Egyptian, and Asian cultures all contain examples of dental technology related to replacing, retaining, and crowning teeth.
Barber-surgeons and toothdrawers extracted teeth for pain relief.
The knowledge and skills underlying all of this early activity was strictly experiential; practitioners learned by doing
18th century Pierre Fauchard
comprehensive textbook▪ This textbook exemplified a new era in
knowledge synthesis, enabled by better access to knowledge created by other
Beginning of the 20th century, presaging the profession’s gradual shift from proprietary to
university-based educational institutions Scientific studies
protocol-based
controlled experimentation became more common,
causes and prevention of dental diseases.
Synthesis of knowledge evolved from simple statements of “fact” based on an expert’s experience and opinion to
identification and consideration of the available information in the scientific literature.
Knowledge dissemination enjoyed its most active period yet early rapid growth of university-based predoctoral and
postdoctoral dental curricula, the proliferation of dental journals, organized continuing dental education congress
knowledge creation in this era can be characterized by the dominance of the randomized controlled trial (RCT),
represents the research design most likely to produce an accurate and valid finding
The hallmark of the age of evidence is the systematic review
represent a substantial change in the paradigm of knowledge synthesis by ensuring inclusion of all relevant
evidence, de-emphasizing the role of the expert, minimizing bias through strict
protocols demanding objectivity and transparency in the review process
EBD is a direct descendent and analog of a similar evolution of the medical knowledge base, termed evidence-based medicine (EBM).
Personal experience of a single individual
synthesized observations of multiple practitioners
the results of simple, single research studies
synthesized results of several research studies (ie, literature review).
Scottish physician and epidemiologist advocated the application of scientific methods, especially
RCTs, to evaluate the effectiveness and efficiency of medical treatments.
He is best known for his influential book
published in 1972
Effectiveness and Efficiency: Random Reflections on Health Services
The principles he clearly set out in this book were straightforward:
Because resources would always be limited, they should be used to provide those forms of health care that had been shown in properly designed evaluations to be effective.
Evidence from RCTs, he stressed, are likely to provide much more reliable information than other sources of evidence.
The Cochrane Collaboration, named after Archie Cochrane, is an international network of volunteers that prepares and updates systematic reviews on a broad variety of topics as well as maintains the largest collection of records of RCTs in the world
Created by Sackett first used at McMaster University in 1990 describe “an attitude of enlightened
skepticism toward the application of diagnostic, therapeutic, and prognostic technologies in day-to-day patient management.
The term was first published in 1991 and reached widespread visibility in 1992 with the publication of a description of the concept in the Journal of the American Medical Association.
The classic definition of evidence-based medicine emerged a few years later from the same group at McMaster University who pioneered the movement: “the conscientious, explicit and judicious use of current best
evidence in making decisions about the care of the individual patient.”
This definition focuses on the integration of individual clinical expertise with the best available external clinical evidence.
This definition was refined a few years later to incorporate patient preferences and values
“An approach to oral healthcare 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.”
Validity
measures how accurately the evidence reflects what is true, and it is an essential characteristic of evidence.
Some types of evidence are more vulnerable to bias than others,
bias is the principal enemy of validity
Bias is the existence of factors or processes that can influence the results or conclusions of a trial.
Bias occurs when there are important differences in
(1) the way in which subjects or groups of subjects are treated or observed or
(2) how data is measured or analyzed.
evolution of the dental knowledge base
single observer
RCT
reduce the risk of bias in the information, or
evidence, that is created.
EBD demands that the evidence upon which treatment decisions are based have the lowest possible risk of bias.
Systematic
reviews
Randomized
controlled trials
Cohort studies
Case-control studies
Case series/reports
Ideas, editorials, Expert opinion
Animal research
In vitro (test tube) research
Levels of evidence for preventive or therapeutic studies.
RCTs or other low-bias evidence are not available to support every decision a
practitioner must make.
the term best evidence really means the best available evidence based on this hierarchy of study designs.
If higher levels of evidence are not available (ie, systematic reviews or RCTs), then one must seek studies lower in the hierarchy while at the same time acknowledging the potential for increased bias.
In some instances, little more than expert opinion may be the best evidence currently available.
The systematic review is quickly surpassing (exceeding) the traditional literature review as the preferred method for summarizing and synthesizing relevant research evidence.
Advantage providing clinically relevant information to aid in decision
making
reducing the biases inherent in traditional literature reviews.
follow strict protocols
Traditional review Systematic review
not to be well-focused on a specific problem focus on specific clinical questions
not including all of the relevant studies including all of the relevant studies
Not combining the information from the studies
combining the information from the studies
Subjective Objective
identifying the problem or disease of interest, the intervention or treatment in question, the comparison treatment (usually the alternative treatment), the outcome through which the intervention and comparison
treatments will be evaluated
narrower focus permits a much more careful and complete search and selection process to identify and include all relevant studies that have addressed the question of interest.
Because the topic is limited, the number of articles that contain information is also usually quite limited so that their careful analysis is feasible
Systematic review is to think of it as a scientific study that is guided by the development of a protocol that outlines all steps in the review process
Systematic reviews are not simple surveys of the
literature
systematic reviews are designed to minimize bias, they require the prior determination of
search methods, inclusion criteria, and evaluation criteria, which reduces the chance
of bias in deciding what studies to include and in evaluating the strength of those studies
Advantages of a
systematic review
Follow strict protocols
Require prior
determination
of search
methods
Reduce bias
Include only
clinically
relevant
information
Focus on specific clinical
questions
Have
evaluation
criteria
Evaluate the
strength of
the available
evidence
The results of a systematic review will represent the
best, most current evidence available that addresses a specifi c clinical question
Using EBD in clinical practice essentially involves identifying and using the best available scientific evidence in caring for patients
EBD also incorporates the clinician’s expertise and the individual patient’s needs and personal preferences during treatment decision making.
These decisions are ultimately made by the patient and are very personal, and thus they will vary from patient to patient.
!!!! accessing and using current best
available evidence is at the forefront of the decision-
making process.
to help patients make individual decisionsregarding the treatment that is right for them
1. Ask
2. Access
3. Appraise
4. Apply
5. Assess
Ask
relevant to the condition of the patient.
The clinical question is frequently described in a PICO format.
critically appraise the identified literature. provides insight into the strengths and weaknesses of the
study, which is necessary when deciding if and how to use evidence from a study in practice.
Efficient use of research and scholarship needs to be a part of periodontal practice
Aims to facilitate an approch , accelerating the introduction of the best research in patient care .
Built upon developments in clinical research design through 18th, 19th and 20th centuries .
Evidenced based periodontology was coined by ALEXIA ANTEZAK BOUCHKOMS and colleagues in Boston , in the oral health group part of cochrane collaboration in 1994.
1996- World Workshop On Periodontology (AAP) included elements of evidenced based healthcare , supported by MichealNewman .
2001- First cochrane systemic review in periodontology ( researched the effect of GTR for infra-bony defects ).
2002- European Workshop on periodontology – First international workshop to use rigorous systemic reviews to inform the consensus.
2003- International Center for Evidenced Based Oral Health was launched to produce high quality , evidenced based research with an emphasis on, but not limited to periodontology and implants .
Clinicians need to continually update on options , modalities and rationale as new research emerges .
By following a systemic approch , evidence can be considered and applied to clinical practice. This approch is standardisedand repeatable , and facilitates the practice of Evidenced-Based dentistry .
The application of evidence is essential in modern dentistry , and this approch is the core of the evolution towards an Evidence – Driven practice .