Evidenced based dentistry - Dr Harshavardhan Patwal

Presented by ,Dr Harshavardhan Patwal

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

The age of the expert

The age of professionalization

The age of science

The age of evidence

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).

Archie Cochrane David Sackett

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.”

Scientific

evidence

Patient’s

needs and

preferences

Clinician’s

expertise

best evidence and systematic reviews

Not all evidence is created equal. Some evidence is more likely to be valid than other evidence

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.

Access

systematically access the most current scientific evidence on the clinical question

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 .

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