12. Dec 21 Evidence Based Dentistry.pptx

Evidence-based decision making provides clinicians the skills to find, efficiently filter, interpret and apply research findings so that what is known is reflected in the care provided.

EBDM takes time and practice to learn to use.

When mastered, EBDM is an efficient way for clinicians to stay current, and it maximizes the potential for successful patient care outcomes.

1. GooD MoRNinG

2. Department of Periodontics and Implant Dentistry EVIDENCE BASED DECISION MAKING 2

3. Contents Basic terminologies Need for EBDM Principles of EBDM Process of EBDM Critical thinking Advantages of EBDM Evidence based Periodontology Conclusion

4. Evidence Based Decision Making

5. Evidence Based Decision Making (EBDM ) EBDM is the formalized process and structure for learning and using the skills for identifying, searching for, and interpreting the results of the best scientific evidence, which is considered in conjunction with the clinician’s experience and judgment, the patient’s preferences and values, and the clinical and patient circumstances when making patient care decisions . Newman and Carranza, 13 th Ed.

6. Aspects of EBDM The methods of generating high-quality evidence, such as randomized controlled trials and other well-designed methods The statistical tools for synthesizing and analyzing the evidence (systematic reviews and meta-analysis) The ways for accessing the evidence and applying it . Davidoff F, 1995 & Davidoff F, et al., 1999

7. Basic Terminologies

8. Evidence Evidence is considered the synthesis of all valid research that answers a specific question and that, in most cases, distinguishes it from a single research study. (American Academy on Pediatric Dentistry Council on Clinical Affairs, 2008-2009) Evidence-based medicine The integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances. (Straus SE, Tetroe JM, Graham ID. Knowledge translation is the use of knowledge in health care decision making. J Clin Epidemiol . 2011 Jan;64(1): 6-10)

9. Evidence-based dentistry 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. Policy on Evidence-Based Dentistry. Available from: http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/policy-on-evidence-based-dentistry .)

10. William Hunter’s Focal Infection Theory O riginally proposed in 1900s (L ack of proper evidence) R ejected in 1940’s (Studies provided the same with proper evidence) Accepted again in 1989. William Hunter, Surgeon, Medical Researcher (1861 – 1937 )

11. Need for EBDM To improve the quality of health care. Because there is Variations in practice pattern. Difficulties in assimilating scientific evidence into practices. Demonstrate best use of limited sources. Evidence Based Decision is sometimes described as doing the right thing, for the right patient, at the right time . ( Kale A et al., 2019)

12. Principles of EBDM EBDM focuses on solving clinical problems and involves two fundamental principles, as follows: 1. Evidence alone is never sufficient to make a clinical decision. 2. Hierarchies of quality and applicability of evidence exist to guide clinical decision making. Evidence-Based Medicine Working Group: Users’ guides to the medical literature: a manual for EB clinical practice, ed 2, Chicago, 2008, American Medical Association.

13. Scientific evidence Experience and judgment Patient preferences or values Clinical/ Patient circumstances

14. Process of EBDM

15. Asking good questions P - Population I- Intervention C- Comparison O- Outcome PICO forces the clinician to focus on what he or she and the patient believe to be the most important single issue and outcome. PICO facilitates the next step in the process, the computerized search , by identifying key terms that will be used in the search. Straus SE, Glasziou P, Richardson WS, et al: Evidence-based medicine: how to practice and teach it, ed 4, London, 2011, Churchill Livingstone Elsevier.

16. Becoming a Competent Consumer of the Evidence

17. Sources of evidence

18. L e v e l s 19

19. Searching for and Acquiring the Evidence Both primary and secondary sources can be found by conducting a search using such biomedical databases as MEDLINE, EMBASE, and Database of Abstracts of Review of Effectiveness (DARE) In addition, several other database can be used: Cochrane Collaboration ADA (American Dental Association) AAP (American Academy of Periodontology ) CDC (Centers for Disease Control and Prevention) Newman and Carranza, 13 th Ed.

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21. Appraising the evidence It is necessary to review the evidence to determine if the methods were conducted rigorously and appropriately. Guidelines that can be used for appraising are CONSORT (Consolidated Standards of Reporting Trials) QUOROM (Quality of Reporting of Meta-analysis) PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) CASP (Critical Appraisal Skills Program) Newman and Carranza, 13 th Ed.

22. Applying the evidence Evidence-Based Dentistry in Action The application of evidence in clinical decision making. The clinician uses the EBDM process to answer clinical questions. Several relevant resources are incorporated into the decision-making process and the treatment of the patient. Newman and Carranza, 13 th Ed.

23. Evaluating the outcomes EBDM is a valuable tool that guides practice decisions to achieve optimal results. The final steps in the EBDM process are to evaluate the effectiveness of the intervention and clinical outcomes and to determine how effectively the EBDM process was applied. Newman and Carranza, 13 th Ed.

24. Critical thinking 12 tools that may be useful in assessing causality in clinical sciences

25. Be Skeptical Skepticism is required in the evaluation of scientific evidence. First, the large number of “effective” periodontal treatments may be an indicating sign of a challenging chronic disease. Second, periodontal diseases that were thought to be the simple, plaque-related diseases are no longer considered same, but rather as complex diseases. Third, the scientific quality of periodontal studies has been rated as low. ( Antczak AA, et al., 1986) 1.

26. Do Not Trust Biologic Plausibility If Streptococcus mutans causes dental decay and if chlorhexidine can eradicate S. mutans , then chlorhexidine can wipe out dental decay. A causes B, B causes C, therefore A causes C These examples of treatment rationales, although seemingly reasonable and biologically plausible, turned out not to help but to harm patients. 2.

27. What Level of Controlled Evidence Is Available? Rational thought requires reliance on either deductive reasoning (biologic plausibility) or systematic experiments (sometimes referred to as inductive reasoning). Three systematic experiments are now routine in clinical research: the case-control study, the cohort study, and the RCT. Exposure Endpoint 3.

28. Did the Cause Precede the Effect? This refers to the typical dilemma of whether the egg came first or the chicken did. The cause needs to precede the effect . Lopez R et al., 2015 4.

29. No Betting on the Horse After the Race Is Over An essential characteristic of science is that hypotheses or ideas predict observations , not that hypotheses or ideas can be fitted to observations. A wealth of data-generated ideas can be created by exploring patient subgroups, exposures, and endpoints. Yusuf S et al., 1991 5.

30. What Is a Clinically Relevant Pretrial Hypothesis? Clinically relevant questions are designed to have an impact on improving patients’ outcomes. Usually, these share four important characteristics: a clinically relevant endpoint, relevant exposure comparisons, a study sample representative of real-world clinical patients, and small error rates. 6.

31. Size Does Matter To a large extent, the size of the association drives the interpretation of causality. The larger an association, the less likely it is to be caused by bias, and the more likely it is causal. One simple way to calculate the size of the association is to calculate an odds ratio . 7.

32. Is a Better Alternative Explanation Available? For a factor to explain away an observed association, two criteria need to be fulfilled. First , the factor must be related to the exposure, but not necessarily in causal way. Second , the factor must be causally related to the outcome and must not be in the causal pathway. 8.

33. Was the Study Properly Randomized? Randomization can be a counterintuitive process because it creates heterogeneity, takes control over treatment assignment away from the physician, and leads to apparently illogical situations in which patients randomly assigned to a treatment but refusing compliance still are analyzed as if they received the treatment. 9.

34. First, subjects are enrolled into a study before randomization, important baseline disease characteristics are recorded and provided to an independent person or organization. Subsequently, an independent person or organization randomly assigns subjects to treatments and informs the clinician regarding the treatment assignment. The concealment of the randomization process ensures that clinicians cannot crack the code and that they will enroll only those patients they think are suited for the treatment that will be assigned. Finally, the outcome in the subject is evaluated regardless of follow-up time or compliance and according to the treatment assigned, not the treatment received.

35. When to Rely on Nonrandomized Evidence The initiation of randomized trials can become difficult because of ethical considerations and expensively large sample sizes. Ethical principles play an important role in determining which clinical questions are sufficiently important to warrant the conduct of an RCT. Sample size requirements represent another consideration that may prevent the conduct of RCTs. The smaller the rate at which endpoints occur in an RCT, the larger the required sample size will be. 10.

36. Did the Investigators Take Into Account the Placebo or Nocebo Effects? It is suspected that the placebo or nocebo effect may be related to the balance of the parasympathetic and sympathetic nervous system. Sufficient evidence is available to suggest that placebo effects can be real and measurable, and that the magnitude of the placebo effect may depend on the treatment under study and the type of outcome evaluated. Kok BE et al., 2013 11.

37. Was Protection in Place Against Conflict of Interest? Conflict of interest has been defined as “a set of conditions in which professional judgment concerning a primary interest (such as patient’s welfare or validity of research) tends to be unduly influenced by a secondary interest.” (Angell M, 2000) A common secondary interest is financial but can include others, such as religious or scientific beliefs, ideologic or political beliefs, or academic interests (e.g., promotion). 12.

38. Advantages of EBDM 1. Objective 2. Scientifically sound 3. Patient focused 4. Incorporates clinical experience 5. Stresses good judgment 6. Is thorough and comprehensive 7. Uses transparent methodology

39. Chiappelli F. Evidence-Based Dentistry: Two Decades and Beyond. J Evid Based Dent Pract . 2019 Mar;19(1):7-16. doi : 10.1016/j.jebdp.2018.05.001. Epub 2018 May 25. PMID: 30926103. 41

40. Evidence Based Periodontology To help the periodontist provide the best care for their patient

41. The application of evidence-based health care to Periodontology . It is a tool to support decision-making and integrating the best evidence available with clinical practice. Needleman, Moles, et al, Perio 2000

42. Triad of EBP Clinician’s skill Patient prefrencs and views Best available evidence Evidence based Periodontology How evidence-based periodontology fits into healthcare. Reproduced with permission from Clarkson, J, Harrison, JE, Ismail, AI, Needleman, IG, Worthington, H, eds. Evidence Based Dentistry for Effective Practice. London: Martin Dunitz , 2003

43. DEVELOPMENT OF EVIDENCE BASED PERIODONTOLOGY

44. Evidence-based periodontology , systematic reviews and research quality IAN NEEDLEMAN et al perio 2000, vol 37 , 2005

45. Advantages of EBP By evaluating the scientific data, to minimize the faults for the final diagnosis, to reduce the wrong diagnosis possibility, To choose the best treatment for the patient, To increase at knowledge and experience due to the literature surveillance by the clinicians To observe and develop the clinical performance To increase at patient satisfaction To decrease in the legal liabilities of the doctors. Yerda Özkan et al., 2016

46. EVIDENCE BASED PERIODONTOLOGY VS TRADITIONAL PERIODONTOLOGY High value of clinical skills and experience. Fundamental importance of integrating evidence with patient values. Kale T et al., 2015

47. Differences Kale T et al., 2015

48. Components of evidence based Periodontology How evidence-based periodontology fits into healthcare. Reproduced with permission from Clarkson, J, Harrison, JE, Ismail, AI, Needleman, IG, Worthington, H, eds. Evidence Based Dentistry for Effective Practice. London: Martin Dunitz , 2003

49. Conclusion Evidence-based decision making provides clinicians the skills to find, efficiently filter, interpret and apply research findings so that what is known is reflected in the care provided. EBDM takes time and practice to learn to use. When mastered, EBDM is an efficient way for clinicians to stay current, and it maximizes the potential for successful patient care outcomes.

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51. References Newman and Carranza’s Clinical Periodontology, 13 th Ed . Davidoff F, Haynes B, Sackett D, Smith R. Evidence based medicine. BMJ. 1995 Apr 29;310(6987):1085-6. American Academy on Pediatric Dentistry Clinical Affairs Committee-Pulp Therapy subcommittee; American Academy on Pediatric Dentistry Council on Clinical Affairs. Guideline on pulp therapy for primary and young permanent teeth. Pediatr Dent. 2008-2009;30(7 Suppl ):170-4 . Straus SE, Tetroe JM, Graham ID. Knowledge translation is the use of knowledge in health care decision making. J Clin Epidemiol . 2011 Jan;64(1):6-10. ADA. Policy on Evidence-Based Dentistry. Available from: http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/policy-on-evidence-based-dentistry .

52. Evidence-Based Medicine Working Group: Users’ guides to the medical literature: a manual for EB clinical practice, ed 2, Chicago, 2008, American Medical Association. Sackett DA, Strauss SE, Richardson WS. Evidence-based medicine: How to practice and teach EBM. London: Churchill Livingstone;2000. Kale T, Mirchandani N, Raghavan M. Evidence Based Periodontology : An Overview . IOSR-JDMS, 2015; Vol. 14(7): 47-58 . Özkan Y, Orbak R (2016) The Evidence-Based Periodontology . JSM Dent 4(5): 1075. Evidence-based periodontology , systematic reviews and research quality IAN NEEDLEMAN et al perio 2000, vol 37 , 2005

53. Thank You!