EVIDENCE BASED DENTISTRY (EBD)

MDS (PUBLIC HEALTH DENTISTRY)

1. EVIDENCE-BASED DENTISTRY SEMINAR NO:3

2. CONTENTS Introduction History Definition Goals of EBD Steps of EBD Implications Benefits Conclusion References 2

3. 3 INTRODUCTION “the slippery slope of clinical competence.” Evidence based practice research influences professional practice.

4. EVIDENCE BASED PRACTICE (EBP) IN HEALTH SCIENCES Evidence-based Medicine Evidence-based Nursing Evidence-based Public health And…. Evidence-based Dentistry First mention in professional dental literature of EBD 4

5. 5 HISTORY

6. DEFINTION The American Dental Association (ADA) defines Evidence-based Dentistry (EBD) as “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 .” 6

7. Differences Evidence based practise Traditional practise Uses best evidence Unknown basis of evidence 7 Systematic appraisal of quality of evidence Limited/incomplete appraisal of quality of evidence Objective, transparent, less biased Subjective, opaque, potentially biased Acceptance of levels of uncertainty Black and white conclusions

8. Why EBD? Information Overloaded Resources Finite Focus is on quality and consistency of treatment Plus avoid unnecessary treatment Questioning attitude of traditional beliefs Lifelong learning Patient empowerment 8

9. GOALS OF EVIDENCE BASED DENTISTRY These include: Best evidence/research. The transfer of research to use in practice. Filter the immense amount of information that emerges in the literature. Act as an effective method of keeping up with the most current research. Provide information on how similar cases have been treated. 9

10. PATIENT CLINICIAN Complaint Signs Symptoms Clinical appraisal of evidence Search for best evidence Ask an answerable questions Treatment decisions Apply the evidence to the patient. EVIDENCE BASED MODEL 10

11. STEPS IN EVIDENCE BASED DENTISTRY 11 Ignore irrelevant information

12. THE EBD CYCLE: THE 5 A’S Within clinical practice, EBD is a 5-step process: 1. Ask: Turn your clinical problem into a question. 2. Acquire: Search for the best evidence. 3. Appraise: Critically appraise the evidence found. 4. Apply: Apply the results of the appraisal into clinical practice. 5. Assess: Evaluate the outcomes in the clinical setting 12

13. ASK 13 There are 2 main categories of questions: Background questions Foreground questions General, established knowledge questions Specific knowledge Informational in nature. Applied to a clinical decision Who, What, Where, When And Why Patient -oriented Often answered with textbooks Often answered with journal articles Eg : “What causes TMJ?” and “What are the side-effects of Metformin?” Eg : “Do patients with a partially edentulous maxilla report higher satisfaction with an implant retained RPD than patients with a conventional RPD?”

14. 14 P.I.C.O.(T.T) MODEL FOR CLINICAL QUESTIONS:

15. 15 1. Therapy or prevention: assessing effect of interventions on patient-important outcomes. 2. Harm or Etiology: how exposure to risk factors influences patient important outcomes 3. Diagnosis: assessing performance of a test in differentiating between patients with and without a condition or disease 4. Prognosis: estimating a patient’s future course of disease on the basis of prognostic factors FRAMING THE QUESTION FOR A CLINICAL PROBLEM – PICO model

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17. ACQUIRE Search for evidence: What do we search for ? Evidence can be classified as: Primary evidence : All original articles retrieved from database search (MEDLINE, PubMed, etc.) Secondary evidence : These are the “studies of studies” These include: Systematic review and Meta-analysis Review Articles. 17

18. 18 The Cochrane Library databases —which include the Cochrane database of systematic reviews , have been reviewed by high standard and quality by Cochrane approved reviewers. Search engines like Google and google scholar Disadvantage- retrieved information is based on the popularity than quality or authenticity. Meta search engines which search the search engines and the databases. Eg : SUM search and BIOME Databases:

19. 19 3. PubMed Is a freely available database Contains the journals indexed by the MEDLINE Developed by the U.S National Library of Medicine and National Center of Biotechnology Information 2. Medline indexes over 5000 journals based on quality review by U.S National Library of Medicine. 4. Embase Broad scope and in-depth update on drugs and pharmacology Produced by Elsevier includes journal articles and conference abstracts.

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23. 23 True keyword searching allows an individual to select their own words or phrases. A thesaurus search uses a consistent list of vocabulary for standardisation and searching efficiency. Eg : MeSH or the Medical Subjects Headings system used with the Medline (PubMed) database.

24. LEVELS OF EVIDENCE 24 Canadian Task Force on the Periodic Health Examination’s Levels of Evidence Grade Practice Recommendations

25. 25 THE HIERARCHY OF EVIDENCE Hierarchy of research designs indicates increased quality of evidence up the pyramid Levels of evidence depends not only on the strength of the study design but also on the study quality , consistency and directiveness. Hence the level of evidence refers to the quality of evidence from an individual study. Quality of evidence Higher Lower Lower Higher Risk of bias

26. 26 Murad MH,  Asi  N,  Alsawas  M , et al New evidence pyramid BMJ Evidence-Based Medicine  2016; 21: 125-127.

27. Critical appraisal is the ability to apply principles of analysis to identify those studies which are unbiased and valid. Validity - is the degree to which the results of the study are likely to be true, believable and free from bias. Bias - is any factor (other than the experimental factor) that could change the study results in a non-random way. 27 APPRAISE

28. 28 CRITICAL APPRAISAL TOOLS

29. 29 CLINICAL PRACTISE GUIDELINES

30. IMPLICATIONS: A primary advantage of the evidence-based practice model is that it provides the least-biased, best-validated information on which to base decisions. However, the available scientific evidence for many aspects of clinical dentistry is either weak or nonexistent. This presents the dental profession with a major hurdle as it begins to implement an evidence-based model of clinical practice. 30

31. WHO BENEFITS FROM EBD? Public: Reap the rewards of better care. Dentists: Practitioners will have more valid research to predicate their clinical decisions. Researchers: Do the clinical testing necessary before new products are placed on the market. 31

32. 32 Example: www.dentalcare.com/en-us/professional-education/ce-courses/ce311 Identify the clinical problem Formulate clear questions, clarify the relevant outcomes Search the evidence Ignore irrelevant information

33. CONCLUSION Evidence-based practice is driven by a practical, quality-rich, updated, ethical, and patient- centered dental service approach. Clinical expertise, high quality evidence and patient preferences are the promising combinations for a successful clinical and community dental practice. 33

34. Hackshaw A, Paul E, Davenport E. Evidence-based dentistry-An introduction. USA: Blackwell Munksgaard 2007.p.1-9. Murad MH,  Asi  N,  Alsawas  M , et al New evidence pyramid BMJ Evidence-Based Medicine  2016; 21: 125-127. Durr -E-Sadaf. How to apply evidence-based principles in clinical dentistry. J Multidiscip Healthc . 2019 Feb 11;12:131-136. doi : 10.2147/JMDH.S189484. PMID: 30804675; PMCID: PMC6375114. Hiremath SS. Textbook of preventive and community dentistry. 3 rd ed. India: Elsevier 2015.p.424-7. 34 REFERENCES

35. Sackett DL. Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest. 1986 Feb;89(2 Suppl):2S-3S. PMID: 3943408. Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence-based medicine.  Plast Reconstr Surg . 2011;128(1):305-310. doi:10.1097/PRS.0b013e318219c171 https://researchguides.library.tufts.edu/EBD/tutorials https://ebm.bmj.com/content/21/4/125 35