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
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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
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5. 5
HISTORY
During the mid-1970s, writers
questioned the effectiveness of
medicine.
Dr. McKeown (1976)- improved
health due to improved
nutrition and housing.
Archie Cochrane in his paper
titled “Effectiveness and
efficiency” in 1972 stated that
many medical treatments are
ineffective and inefficient-
proposed RCTs.
WHO European Working
Group on Health Promotion &
Evaluation- RCTs cannot be
used to evaluate health
promotion.
The 1990s showed a rise in
clinical research, biomedical
informatics and technology -
greater availability and access to
information.
In the same decade, ‘Problem-
based learning’ was developed
in McMaster Medical School,
Canada and the term ‘Evidence
based medicine’ was coined.
The movement spread through
the whole of Canada, North
America, UK and Europe.

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.”
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7. DIFFERENCES
Evidence based practise Traditional practise
Uses best evidence Unknown basis of evidence
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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
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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.
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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
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11. STEPS IN EVIDENCE BASED DENTISTRY
Identify the clinical problem
Formulate clear questions, clarify the
relevant outcomes
Search the evidence
Interpret the relevant evidence
Decide on the appropriate action
based on the best evidence available
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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
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13. ASK
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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?”

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

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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.
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Where do we search for evidence?
1. 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:

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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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How to search for evidence ?
• 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
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• Canadian Task Force on the Periodic Health Examination’s Levels of Evidence
• Grade Practice Recommendations

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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.
Higher
Lower
Lower
Higher

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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.
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APPRAISE

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CRITICAL APPRAISAL TOOLS

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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.
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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.
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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.
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34. o Hackshaw A, Paul E, Davenport E. Evidence-based dentistry-An introduction.
USA: Blackwell Munksgaard 2007.p.1-9.
o Murad MH, Asi N, Alsawas M, et al New evidence pyramid BMJ Evidence-
Based Medicine 2016;21:125-127.
o 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.
o Hiremath SS. Textbook of preventive and community dentistry. 3rd ed. India:
Elsevier 2015.p.424-7.
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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
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