EVIDENCE BASED DENTISTRY - A REVIEW.
Objective: To provide awareness to the dental practitioners regarding Evidence Based Dentistry (EBD) which is a new paradigm shift in the field of medical science.
Study Design and Methodology: This paper is a review of literature written after thoroughly searching Pub Med for relevant articles as well as evidence based medicine and dentistry books.
Conclusion: EBD is practiced to validate our dental decision making in the best interest of patients.
Keywords: Evidence based Dentistry Guidelines Validity Clinical trials Best evidence.
The term evidence based dentistry (EBD) which evolved from evidence based medicine is a new paradigm but the main principles of the subject already existed for many decades as Claude Bernard established the use of scientific method in medicine1. EBD is defined as an approach to integrate the best available evidence to guide our decision related to providing the best possible treatment to the patient. The methods of practice initially established at McMaster University in Ontario Canada by Gordan Guyatt have been developing in medicine since 199223. Gordan Guyatt is known for his work on EBM a term he first used in his paper Evidence Based Medicine. A new approach to teaching the practice of medicine4. Then in 1996 David Sacket laid the foundation for evidence based practice by defining it as The conscientious explicit and judicious use of best evidence in making decisions about care of individual patients367".
The American Dental Association had also defined evidence-based dentistry as 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 together with the dentist's clinical expertise and the patient's treatment needs and preferences5" (fig-1). EBD is a patient centered approach to practice and make clinical decisions leading to the best treatment. EBD is about providing individualized dental care based on the most current scientific knowledge. Equipments processes and outcomes are influenced by EBD.
Vast volume of literature and lectures has created some problems for dental practitioners such as the knowledge transfer gap which has become a great concern because of inadequate access to electronic information at the point of care inadequate training and lack of time as well18. EBD has made it possible to resolve the often contradictory information and differentiates between useful and useless literature. When health care providers realize that knowledge deteriorates with time because of ongoing new researches here EBD has allowed dentists to keep abreast of new developments in diagnosis prevention and treatment of oral disease and newly discovered causes of disease and to make decisions that should improve their clinical practice10. As society has become more arguable if a dentist is sued some information is required to provide an adequate defense9.
In such a case treatment should be up to the current standards of practice and evidence based practice provides documentation of these standards. Similarly contemporary patients have become more demanding and they expect the best possible recommended treatment hence there is a sound need of evidence based practice2. In clinical decision making evidence rather than just personal experience should influence treatment because traditional practice sacrifices patient's care and health as it only focuses on personal experiences and motives. There are many personal and institutional errors in traditional practice while in EBD there is best quality statistical based evidence with less errors. EBD does not mask the same old inadequate research works but it also does not mean that the clinician need not to study basic dental sciences.
The concept of evidence based dentistry is based on best evidence research and the transfer of this to use in practice. It involves four basic phases which are formulating a question searching literature appraising the articles applying the results and the fifth phase as suggested by Carr and McGivney is assessing our performance9-12. These phases are discussed briefly for further understanding.
Ask clinical questions
In practice every day dentists face a need to know some new information about the prognosis treatment or management of a condition. Turning these clinical problems into an answerable focused and relevant questions is a key skill of evidence-based practice6. Example: fluoride supplementation a mother comes to the dentist asking whether or not she should give her 6 year old daughter fluoride supplements10. The arising well built clinical questions will be several. Firstly what is the role of fluoride in the prevention of dental caries Secondly what are the techniques of applying fluoride to the teeth Thirdly what alternative would be effective and appropriate Then what are the side effects of using fluoride supplements And lastly on which teeth fluoride should be applied for effectiveness
The criteria of formulating a question is based on PICO which implies patient problem intervention comparison and outcome.
Acquire the literature
Clinicians who want to stay up to date about the significant changes in their areas of health care need help in dealing with the massive volume of literature. Dentists are required to become efficient consumers of the literature. Computerized medical databases such as Medline have made it easier to disseminate and access information2. Evidence can be found through different gateways like Medline Embase Pub Med Medscape HealthGate IntelliHealth MedPortal and The Cochrane Collaboration1. Other strategies like books audio and video tapes and CDs professional and university continuing education meetings and study clubs also aid the dentist to be up to date with the current literature. But the Cochrane Collaboration is the most authentic resource as it contains meta analysis of systematic reviews. This site is named after Archie Cochrane a pioneer in the field of evaluation of medical interventions1.
Appraise the literature
Analyzing the validity importance and usefulness of the evidence is called critical appraisal12. Critical appraisal is a way of rapidly assessing published papers in order to sort out the relevant or valid papers from poor quality or irrelevant ones. This is the most time-consuming step and is often seen as the most difficult aspect.
The hierarchy21314: Understanding strength of evidence and the idea of hierarchy of evidence is the basis of evidence-based dentistry. Evidence-based practice involves tracking down the available evidence assessing its validity and then using the best" evidence to take decisions regarding treatment. All evidence is not equal. In the ladder of evidence systematic reviews meta analysis and randomized controlled trials represent the highest levels of evidence whereas case reports/series and expert opinion are the lowest11 (fig-2). The systematic reviews of randomized controlled trials are considered as gold standard in evidence based practice13. In this way studies synthesis synopsis and system facilitate evidence based practice.
Apply the results
After gathering the information obtained from assessing the evidence one should be able to take decision to act. However the decision to act should be based on the evidence the willingness of the patient to receive the treatment and the practitioner's ability to provide the treatment. Therefore it is a careful decision and not a textbook approach which needs to be followed blindly as criticized by some opponents of EBD. Assess our performance
The final step of the evidence-based approach is self-evaluation. It is the evaluation of oneself in following the steps of EBD.
Clinicians can incorporate evidence into practice into three modes15. First is the doing mode in which all steps are done including appraising evidence ourselves. It is used for diseases we come across every day. Next is the using mode in which search is based on the evidence resources that have already undergone critical appraisal by others e.g. evidence summaries. It is for conditions we encounter less often. Last is the replicating mode which involves the decisions and opinions of experts and most authentic opinion leader. It is for rare diseases.
In this modern age in which we are required to be up to the minute and very sure of our responsibilities as a dentist EBD has become a vital part of dentistry. The main objective of EBD is to make ourselves lifelong self directed learners. This requires the dentist to think globally and act locally. It has generated an era of new studies research and practices. It's a challenge to bridge the evidence transfer gap1617. This purpose is fulfilled by establishing the fundamentals of EBD during undergraduate curriculum organizing conferences and workshops and formulating evidence teams and journal clubs18. It is necessary to learn to use research interpret statistics and understand that EBD is a real time patient care.
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2. Healey D Lyons K. Evidence based practice in dentistry. NZ Dent J 2002; 98(432): 32-5
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4. Guyatt GH. Evidence based medicine. A new approach to teaching the practice of medicine. JAMA 1992; 268(17):2420-5.
5. American Dental Association. Center for Evidence based dentistry. About EBD. [internet]. Chicago (US): ADA; [cited 2012 July 9]. Available from: http://ebd.ada.org/about.aspx
6. Goldstein GR. What is evidence based dentistry Dent clin North Am 2002; 46(1):1-9 7. American Dental Association. Policy on Evidence Based Dentistry. [internet]. Chicago(US):ADA; [updated 2013 Aug 29; Cited 2012 July 30]. Available from: http://www.ada.org/1754.aspx
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14. Guyatt GH. An introduction to Evidence-Based Medicine. In: Hajeer AH Al Knawy BA editors. Doctor's guide to evidence based medicine. Riyadh 2006;
15. Straus SE Richardson WS Haynes RB Glasziou P: Evidence based medicine. 3rd edition published by Churchill Livingstone 2005;
16. Sutherland SE: The building blocks of Evidence Based Dentistry. J Can Dent Assoc 2000; 66(5): 241-4.
17. Wyer PC. The critically appraised topic: closing evidence transfer gap. Ann Emerg Med 1997; 30: 639-40.
18. Sabir S Haq S. Impact on the health professionals after a workshop in first two steps of evidence based medicine. Pak Armed Forces Med J 2013; 63(2): 194-98.
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|Publication:||Pakistan Armed Forces Medical Journal|
|Date:||Jun 30, 2014|
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