Module 2: Evidence-Based Dental Public Health

Toolkit for Dental Health Professionals Oral Health Information Tutorial for Dental Evidence-Based Dental Public Health Public Health Professionals Data Tools and Statistics Patient Information Purpose: Provides instruction for public health dental practitioners that focuses on finding and evaluating information relevant to public health dental practice. This project has been funded in whole or in part with Federal funds from the National Library of Medicine, National Institutes of Health, Department of Health and Human Services, under Contract No. N01-LM-6-3505 under the Houston Academy of Medicine-Texas Medical Center Library.

Evidence-Based Dental Public Health

Objectives Define evidence-based dental public health Learn a strategy for effective retrieval of evidence-based research Be able to critique and synthesize scientific literature and apply it to public health dental practice Identify evidence-based resources on the Web

What is Evidence-Based Dental Practice? “ 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.” - American Dental Association For additional information about evidence-based dentistry, refer to the American Dental Association

Why Practice Evidence-Based Dentistry?  Helps filter the immense amount of information that emerges in the literature  Effective method of keeping up with the most current research  Provides information on how similar cases have been treated

The 5 A’s of Evidence-Based Dentistry Assess the patient Ask clinical questions (Use PICO model) Acquire the best evidence Appraise the evidence Apply evidence to patient care

PICO Model: The well-built question for evidence–based research P= Population or problem or patient What are the characteristics of the patient or population? What is the condition or disease? I= Intervention or exposure What do you want to do with/for the patient or population? C= Comparison What is the alternative to the intervention? O= Outcome What are the relevant outcomes? Evidence Based Dentistry for Effective Practice, 2003.

Searching the Literature: PubMed  PubMed is a search engine for MEDLINE created by the U.S. National Library of Medicine (NLM).  PubMed is a free, easy-to-use database that is accessible by any computer with Internet service  Includes over 17 million citations from MEDLINE and other life science journals for biomedical articles back to the 1950s.  Citations are indexed, or coded, with the NLM's controlled vocabulary, called Medical Subject Headings or MeSH®  Contains bibliographic citations and author abstracts from more than 5,000 biomedical journals published in the United States and 80 other countries. PubMed includes links to full text articles and other related resources. PubMed also includes citations to newer articles that are not yet fully indexed. "PubMed Tutorial", this Web-based program will show you how t

The PubMed Search  Medical Subject Headings (MeSH) The papers in PubMed are indexed by a subject specialist who reads the paper and notes all the search terms that apply to that paper, cataloguing them as Medical Subject Headings (MeSH). The terms come from a standardized list of vocabulary and definitions. Click on the MeSH database link on PubMed's home page: ( http://www.nlm.nih.gov/mesh/meshhome.html), where a quick tutorial will take you step by step through using the search. MeSH can be more useful than performing a general search because it allows you to capture the synonyms associated with your topic across multiple fields. Once you've set up a MeSH search that pulls the papers you are looking for, save the search and get weekly alerts for any new citations.  Text words Include the words the author uses in the title or abstract. “Mouthguard" as a text word would retrieve articles that use the word “mouthguard" but would not necessarily retrieve other relevant articles that use the words “mouth protection" or “mouth pieces, protective." Text words are useful when there is no good match to a subject heading and as an addition to your MeSH searches. Text words can also help you find citations that have recently been added to PubMed but are not yet fully indexed.

Study Types  Systematic Reviews- "A type of scientific study that tries to answer a special question by finding, appraising and summarizing all published, and, if possible, unpublished work on a topic, according to predetermined criteria."  Randomized Controlled Trial (RCT)- "An experiment where eligible patients are randomly allocated into groups to receive (experimental group) or not receive (control group) one or more interventions that are being compared.“  Cohort Study- “Makes observations about the association between a particular exposure or risk factor and the development of a disease or condition.”  Case-Control Study- “Involves identifying patients who have had a particular outcome (cases), and control patients who do not have that outcome, and then establishing whether there had been a specified exposure or not.” Evidence-Based Decision Making : A Translational Guide for Dental Professionals, 2009

Hierarchical Levels of Evidence Table Rank Evidence Level Study Type 1 Systematic review & randomized Review of randomized controlled controlled trials trials, Experimental + control, Randomization 2 Cohort Studies Experimental + control, no randomization 3 Case-Control Studies Experimental + control, retrospective 4 Case Reports Experimental only, prospective 5 Narrative review, editorial N/A Epidemiology, Animal studies, In vitro studies

Hierarchical Levels of Evidence A well done study assigned a Level 1 rank is considered the most rigorous and least susceptible to bias, while a study ranked Level 5 is considered the least rigorous and is more susceptible to bias.

Try to find a systematic review to answer your question. If one is not available, you can choose other types of studies lower on the hierarchical pyramid of evidence.

Evidence-Based Tools The Centre for Evidence-Based Medicine, provides useful information and downloads for critical appraisal of medical evidence: Example critical appraisal sheets- Step-by-step guidelines for critical appraisal Calculators- Designed to calculate statistical data related to evidence-based dentistry CATmaker- Download a wizard that guides you through a critical appraisal, then calculates appropriate evidence-based medicine values Explanations & Examples- Learn how to apply statistical applications and terms to evidence-based dentistry To access the detailed critical appraisal section from the Centre for Evidence-Based Medicine: www.cebm.net/critical_appraisal.asp

Guide to Reading Research Articles The University of Southern California Health Science Center developed this four question guide to help researchers critically analyze content in articles: What is the purpose of the study? Does the purpose of the study relate to an important problem? How was the purpose investigated? Was the question studied in a credible and rigorous manner? What are the findings and conclusions? Do the findings and conclusions relate the data to the purpose?  Are the findings of this study applicable to my practice?

Further Study: Overviews of Evidence-Based Practice  Evidentista  Academic Center for Evidence-Based Practice, UTHSCSA Sc  Agency for Healthcare Research and Quality (AHRQ)  Centre for Evidence Based Medicine

Sample Clinical Question Are school-based fluoride varnish programs effective in preventing dental caries? P= Children I= School-based fluoride varnish programs C= Implied O= Reduce incidence of approximal caries

MeSH Search Terms In the sample clinical question, the “key concepts” or PICO parts must be identified with their MeSH terms: Key Concept MeSH Term P Children All Child 0-18 years (limit) I School-based programs School health services Fluoride varnish Topical fluoride C Implied Implied O Reduced incidence of Dental caries dental caries

Practice Case Study #1 Sam is a 49-year old man with moderate periodontitis, who was recently diagnosed with type 2 diabetes mellitus. Sam’s glycosylated hemoglobin is 12%, which places him in the category of poorly controlled diabetes. Sam is worried that his diabetes will increase his chance of losing his teeth. He wants to know the impact diabetes now has on his oral health. Write down an answerable question, then put it in the PICO format. Evidence-Based Decision Making : A Translational Guide for Dental Professionals, 2009

Clinical Question: Case Study #1 What impact will Type 2 diabetes mellitus have on the oral health, specifically tooth loss, of a 49- year old man with moderate periodontitis? P= 49-year old man with moderate periodontitis? I= Type 2 diabetes mellitus C= Implied O= Tooth Loss

Case Study #1: MeSH Search Terms In the practice case study, the “key concepts” or PICO parts must be identified with their MeSH terms: Key Concept MeSH Term P 49-year old man with Middle Aged: 45-64 years moderate periodontitis (limit) Periodontitis I Type 2 Diabetes Mellitus Diabetes Mellitus, Type 2 C Implied Implied O Tooth Loss Tooth Loss

Practice Case Study #2 A partnership between your community dental clinic and the dental school is establishing an oral cancer screening program as part of an outreach initiative. To justify the new program, you must find research that supports the objective to increase patients’ chance of early oral cancer detection. Write down an answerable question, then put it in the PICO format.

Clinical Question: Case Study #2 Do community oral cancer screening programs increase a patient’s chance of early oral cancer detection? P= Adults I= Community oral cancer screenings C= No screenings O= Increase a patient’s chance of early oral cancer detection

Case Study #2: MeSH Search Terms In the practice case study, the “key concepts” or PICO parts must be identified with their MeSH terms: Key Concept MeSH Term P Adult Adult: 19-44 years (limit) I Community Community Health Services Cancer Screening Early Detection of Cancer C Implied Implied O Early Detection Already Stated Oral Cancer Mouth Neoplasms

Databases  American Dental Association’s Directory of Systematic Reviews Links to systematic review abstracts available on PubMed  The Cochrane Database of Systematic Reviews Full-text of systematic reviews prepared by the Cochrane Collaboration  Cochrane Central Register of Controlled Trials (CENTRAL) Contains over 300,000 bibliographic references to controlled trials that have been identified by the distinguished contributors to the Cochrane Collaboration

Databases (cont.)  DARE( Database of Abstracts of Reviews of Effects) Contains 15,000 abstracts of systematic reviews that focus on the effects of interventions used in health and social care.  PubMed/MEDLINE Principal biomedical database that contains bibliographic citations and author abstracts from over 4,900 medical journals (250 journals are specific to the field of Dentistry)  PubMed Clinical Queries Provides specialized PubMed searches for clinicians

Examples of Evidence-Based Journals  Evidence-Based Dentistry Publishes quarterly, some FREE, full-text available online. Publishes articles on the latest developments in oral health.  Journal of Evidence-Based Dental Practice FREE Table of Contents and Abstracts available online. Publishes original articles and review articles about clinical procedures and their outcomes.

Additional Tutorials on Evidence-Based Practice  UNC-Chapel Hill Evidence-Based Dentistry Tutorial  Boston University, Alumni Medical Library  University of Illinois at Chicago

References Clarkson, Jan, Harrison, Jayne E., Ismail, Amid I., Needleman, Ian & Worthington, Helen. (2003). Evidence Based Dentistry for Effective Practice. New York, New York: Martin Dunitz, an imprint of the Taylor & Francis Group. Forrest, Jane L, Miller, Syrene A., Overman, Pamela R. & Newman, Michael G. ( 2009). Evidence-Based Decision Making: A Translational Guide for Dental Professionals. Philadelphia, PA: Lippencott Williams & Wilkins, a Wolters Kluwer business.

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Module 2: Evidence-Based Dental Public Health

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