Evidence-Based Practice

for the Dental Profession

ADA definition
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.
ADA, 2002
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EB Practice is a balance
EB
Care
Scientific
Evidence
Information
generated
through
scientific
methods

PATIENT

Clinical
Expertis
e

Clinician
experience
s,
education,
training, &
tradition
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All Evidence is not equal

Personal experience
Educational Training
Professional Network; colleague information
Internet; Study Clubs; Professional Publications
Scientific Journals(Peer Reviewed)
Observational Studies
Intervention studies
Systematic Reviews

Why should you be willing to look for

new information(evidence)?
(a) to help figure out what works;
(b) to pursue a topic, problem, or
question of professional and/or
personal interest;
(c) to pinpoint an area of further
study;
(d) to provide a rationale/background
for study;
(e) to survey or analyze research
methodology

Why Practice Evidence-Based Care?

A way of thinking
Improved patient outcomes
Patients and dentists save time and money by
utilizing protocols that work; not a
treatment/technique de jour
Improved patient, dentist and staff satisfaction
Patients, staff and dentists have pride in high
quality care; constantly evolving

Merijohn GK, 2006

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Barriers to Evidence-Based Practice

This is the way I learned to do it.

This is how I have always done it.
I cant use that protocol in my setting *
I dont know how to search for the evidence
I dont know how to evaluate and use the
evidence.

* This may be the case; can it be adapted? What is the

best alternative? Perhaps you can design a study to
contribute to the evidence

Framework for Using Evidence

Five common steps to obtain and use the best
available evidence

Ask
Acquire
Appraise
Apply
Assess

Steps of EB Practice

Identify a problem or area of uncertainty

Structure and pose a focused clinical question
Efficient search for the best available evidence
Critically appraise the information found
Apply information to patient problems,
questions, or clinical treatment; make a
decision
Evaluate your process/performance;
communication with patient

Ask, Acquire, Appraise, Apply,

Assess

ASK: Build a focused, searchable

clinical question using PICO
P , define chief complaint, patient characteristics,
disease/health status;
I, Intervention, what do you plan to do for the
patient (diagnostic, treatment, medication,
recommend a product/procedure)
Comparison, the alternative
Outcome, what you plan to accomplish, improve,
or affect; be specific

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Example of PICO
Outcome
What is the longevity of restorations placed in
permanent teeth by an ART approach
compared to amalgam restorations ?

Patient
population

Intervention
Comparison
ASK, Acquire,Appraise, Apply, Assess
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ACQUIRE: Gathering the Evidence

What to look for? Best available evidence
Systematic reviews;
Meta-analysis
Critical summaries of reviews;
Evidence-based Clinical Recommendations
& Guidelines
Where to look? The ADA special website
about evidence based practice is a good
place to start
http://ebd.ada.org

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What is a Systematic Review?

Thorough, systematic, exhaustive
literature search
Explicitly stated inclusion criteria
Rate the quality of included studies;
includes the strongest evidence
available
Objective summary of studies
Interpretation for clinicians and
researchers
13

Elements in a Systematic Review

Stated clinical question; (PICO format)
Clearly stated search strategy; databases,
journals, hand searching, gray literature
[examples, Medline, Embase, Cochrane..]
Explicit inclusion/exclusion criteria; # of
articles
At least two reviewers independently review
Evidence table that summarizes and
compares key features from included
studies (author, sample size, intervention,
outcomes.)
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Systematic Review (cont)

Narrative summary to accompany
evidence table
Direction and consistency of effects
If possible statistical combination of
evidence can yield an overall effect =
meta analysis
Interpretations/conclusion
Overall strength of the evidence****
Limitations
Implications for future research
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Meta Analysis
Extension of systematic review
statistical combination of evidence yields
an overall quantitative effect pooled
average
The calculation gives greater weight to
studies with more information
It has to make sense to pool the results
are study participants or methodologies
too different
Can be useful for similar studies with
varying results to provide the best
summary effect

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Find a systematic review

Important to remember that not all
reviews are created equal. Expert
reviews, content reviews,
background reviews are all useful for
their purpose.
A systematic review contains the
elements on the preceding slides; it
is an objective summary of the
available studies.

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See all
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Critical Evidence Summaries

Key Features
Further summaries the systematic review

Abstract of the review

One page in length in final presentation format
(longer in JADA; typically in EBD Journal)
600-800 words
Critical commentary of the systematic review
Clinical implications how to apply in practice
Very useful and user friendly

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Clinical Recommendations and

Guidelines
ADA website
Results from an expert panel using a
systematic review
Recommendations for a given clinical
situation
Consideration of alternatives based
on patient preferences or other
factors
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Recent Clinical Recommendation

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ADA website; Resources

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ADA website; Resources

cont

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SEARCH for
Systematic
Reviews and
Other Links:
ADA
http://ebd.ada.org
Concise;
User-friendly;
Critical
Summaries;
Commentaries for
implementation

On the toolbar on this

page is a tab called
Resources; it contains an
extensive list of links.

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Where to search?
Source

Website

EBD at ADA

http://ebd.ada.org

MEDLINE; PubMed

http://pubmed.gov

Journal of Evidence-Based
Dental Practice

http://journals.elsevierhealth.com/periodicals
/ymed

Evidence-based Dentistry

http://www.nature.com/ebd/archive/index.html

Centre for Evidence-Based

Dentistry

http://www.cebd.org

Database of Abstracts of
Reviews of
Effectiveness(DARE)

http://www.crd.york.ac.uk/CRDWeb/

Evidentista (Pan American

Centers for Evidence-Based
Dentistry)

http://us.evidentista.org

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MEDLINE
Question: What is MEDLINE, and how do I use it to
find information?

MEDLINE is:
a huge database of over 20 million references to articles
published in approximately 5,600 current biomedical journals
from the United States and over 80 foreign countries
a database you can search free using the NLM PubMed
system at http://pubmed.gov (this is the example provided
several slides back)
for finding references on specific medical topics using either
keywords or Medical Subject Headings (MeSH)
http://www.nlm.nih.gov/pubs/factsheets/mesh.html
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Resources
See the Resource page for other
dental resources pertaining to
Evidence-Based Dentistry