This ppt will help dentists in taking Evidence Based decision in daily practice and will also help researchers to categorized result of research on the basis of hierarchy of Evidence Based Dentistry

1. Dr. VAIBHAV BANSAL
Dept. of Public Health Dentistry
EVIDENCE BASED DENTISTRY

2. EBD
2
“Facts are stubborn things and
whatever may be our wishes, our
inclinations, or the dictates of our
passions, they cannot alter the state
of facts and evidence.”- John Adams

3. Contents
Terminology
Introduction
What is Evidence Based Dentistry
Traditional Vs Evidence Based Dentistry
How to do EBD
Advantages & limitations
Applications
Summary & Conclusion
References

4. Terminology
 Evidence is anything used to determine or
demonstrate the truth of an assertion.
 Scientific evidence is evidence which serves to
either support or counter a scientific theory or
hypothesis.
 In scientific research evidence is accumulated
through observations of phenomena occur in the
natural world, or created as experiments in a
laboratory

5.  ‘Level of evidence’: The extent to which one can
be confident that an estimate of effect or
association is correct (unbiased).
 Best research evidence : clinically relevant,
unbiased, reproducible & patient centered research
 Critical appraisal: a systematic process used to
identify the strengths and weaknesses of a research
article.

6. Introduction
Science + art = Quality dental care
Deterioration of expertise and effectiveness
Dilemma of decision making.

7. Introduction
Undergraduate dentistry
Source of information;
 Teachers, textbooks and occasionally journal
articles.
 Rare literature search
 Difficulty in effective clinical practice
“The slippery slope of clinical competence”

8. Knowledge Gap
Time to meet
information needs
decreasing
Amount of Information
is rising
Knowledge Gap

9. Evolution of the Dental Knowledge
Base
Era Knowledge
Creation
Knowledge
Synthesis
Knowledge
Dissemination
Age of the Expert Experiential Experimental Apprenticeship
Age of
Professionalization
Experiential
limited
observational
Shared
Experimental
Texts, societies,
journals, schools
Age of Science Experiential Traditional
literature review
Texts, journals,
schools,
Age of Evidence Experiential Systematic review Texts, journals,
schools,
Systematic review

11. 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 2000

12. Process that restructures the way in which we
think about clinical problems” and is
characterized by;
“making decisions based on known evidence”
(Richard and Lawrence 1995)

13. EBD - What is it?
Clinical
Expertise
Research
Evidence
Patient
Preferences
EBD

14. Traditional Practice
Experiences Pathophysiology,
references,…
Patient value

15. EBP vs. Traditional Practice
Similarities
1. Clinical skills & experience
2. Integrating evidence with patient values

16. EBP vs Traditional practice
Differences
EBP traditional practice
Uses best evidence available Unclear basis of evidence
Systematic appraisal of
quality of evidence
Unclear or absent appraisal
of quality of evidence
More objective ,transparent &
less biased
More subjective, opaque &
biased
Greater acceptance of
uncertainty
Greater tendency to black
& white conclusion

17. Steps of EBD
Ask
Acquire
Appraise
Apply
Analyze
&Adjust
Patient
Assessment
Evaluation,
Disseminat
ion &
Follow up
5 STEPS OF EBD

18. Patient{B
urden of
illness
Complaint
s
Ask an
answerable
question
Search for
best
evidence
Critical
appraisal
Apply to
the
patient
Treatment
decision

19. How to do EBD
(Sackett and Strauss 2000)
IDENTIFYING THE CLINICAL
PROBLEM
LOCATING THE EVIDENCE
HIERARCHY OF EVIDENCE
MAKING SENSE OF EVIDENCE
ACTING ON THE EVIDENCE

20. 1. Identifying the Clinical Problem
Ask a clear question about the problem.
Background Questions{Why, how,
when}
Foreground Questions{Specific}
2 type of Questions can be asked

21. Asking Good Questions: the PICO process
P{Problem} I{Intervention}
O{Outcome} C{Comparison}
PICO

22. Mr. X, reveals that he is at risk for infective
endocarditits and is allergic to penicillin.
Typically amoxicillin is used. Knowing that
erythromycin and clindamycin may be alternatives,
a search is conducted to determine the antibiotic
and regime most appropriate to prescribe before
scaling and rootplaning.

23. PICO Format for Clinical Questions
Question Element Example
Patient or problem Infective endocarditis &
penicillin allergy
Intervention Clindamycin
Comparison Erythromycin
Outcome Provide effective antibiotic
prophylaxis in terms of
safety, better absorption,
and more sustained serum
levels.

24. The question is structured as ---
“For a patient at risk for infective endocarditis and a
penicillin allergy, does clindamycin as compared to
erythromycin provide more effective antibiotic
prophylaxis in terms of safety, better absorption,
and more sustained serum levels?”

25. Key terms can be identified to use in conducting
the search
 infective’ or ‘endocarditis
 ‘penicillin allergy’, ‘clindamycin’, ‘erythromycin’
and ‘antibiotic prophylaxis’.

26. 2.Locating the Evidence:
Four basic routes to find an evidence
Expert Textbook
Database
Journal
Article

27. Searching for Evidence
 Google
 Pub med
 Allow at least 30 minutes for first time search.
 With practice, a shorter search time will be
possible.

28. 3. Hierarchy of Evidence
SRs&
MAs
RCTs
Cohort Studies
Case –Control Studies
Case Series, Case Reports
Editorials, Expert Opinion
Sackett DL et al. Evidence-Based Medicine: How to Practice and
Teach EBM. 2nd ed. Churchill Livingstone; 2000
SRs- systematic reviews, MA-
meta-analyses
RCTs- Randomized
controlled trials

33. Systematic Review
Combined
Results
Study 1
Study 2 Study 3
Study 4

35. Meta-Analysis
 “Conducting research about research.”
 It is often of value when several RCTs have been
performed ,which individually, lack the power to
detect statistically significant differences between
interventions, but are capable of doing so in the
aggregate.

36. Clinical Decision Support
System(CDSS)
 Link the patient’s electronic health record to
current best-evidence based on the individual
patient’s clinical circumstances.
 There are few such systems currently available
 E.g.. Dental practice based research network
Pearl

37. Type of Evidence
 TYPE I: At least one good systematic review
(including at least one RCT)
 TYPE II: At least one good RCT
 TYPE III: Well designed intervention studies
without randomization
 TYPE IV: Well designed observational studies
 TYPE V: Expert opinion, influential reports and
studies
NHS Wales (1998). Oral health. Cardiff,
Health Evidence Bulletins

38. Strength of Evidence
Classification Strength of recommendations
A Directly based on category I evidence
B Directly based on category II evidence or
extrapolated recommendation from category
I
C Directly based on category III evidence or
extrapolated recommendation from category
I or II
D Directly based on category IV evidence or
extrapolated recommendation from category
I, II or III

39. 4. Making Sense of the Evidence
 To evaluate or appraise the evidence for its validity
and clinical usefulness.
DARE
COCHRANE
CASP

40. DARE( Database of abstracts of reviews of
effectiveness)includes structured abstracts which
have been critically appraised by the NHS Centre
for reviews and Dissemination.
Cochrane collaboration oral health group:
Database of relevance to oral health

41. Critical Appraisal Skills
Program(CASP)
Independent evaluation of strength
of evidence
Studies include RCTs, cohort, case
controls &case reports
CASP tool starts with some
screening questions

42. For RCTs important questions for appraisal involves
 Type of population group, intervention
 Inclusion & exclusion criteria
 Random allocation
 Blinding
 Precision of the results
 Outcomes

43. 5. Acting on the Evidence
 Apply the evidence on your patient’s situation or
problem.
 Individual practitioners judgment is key.
 Evidence based practice therefore seeks to inform
clinical decisions, not to impose them

44. Evaluation
Relevant
Store
Update
Non relevant Discard

45. Barriers in Transmission &
Dissemination of Evidence
Limited access to
scientific
information
Lack of time
Information
Overload

47. Timing of evidence discussion with patients
 During patient education as part of hygiene
appointments.
 At fees and payment arrangements with patients.
 Dedicated treatment planning appointments.

48. Advantages
1. It help us updating our knowledge continuously
instead of reading lots of irrelevancy &
unreliable literature, so time saving.
2. It helps policy makers through development of
clinical guidelines', providing them with enough
documents & evidence.

49. 3. Instead of teaching students current standard
treatment method, it teach them how to find the
best current therapy for their disease.
4. EBD promote evidence instead of persons
authority.
5. It decreases medical errors.

50. What are the Limitations of EBD?
 First, the need to develop new skills in searching
and critical appraisal can be daunting.
 Second, busy clinicians have limited time to
master and apply these new skills, and the
resources required for instant access to evidence
are often woefully inadequate in clinical setting.

51. Applications
Concept of harm:
1. Situations of adverse outcomes in pregnancy by
any intervention
2. Treatment decisions on medically compromised
patients
3. Any drug causing probable serious harm

52. Q. Is there any association between periodontitis and
adverse pregnancy outcomes?
What should be the answer????

53.  We do not have enough data to say with certainty
that periodontal disease causes health problems in
the newborn.
 There is evidence that nonsurgical periodontal
treatment is safe during pregnancy.
 However, without treatment, your gum disease
may become worse, which will likely result in loss
of bone and perhaps teeth.
 There is no evidence that such treatment is harmful
to the unborn child.

54. Day to Day Treatment Decisions
 Does single-visit root canal treatment without
calcium hydroxide dressing, compared to multiple-
visit treatment with calcium hydroxide dressing for
1 week or more, result in a lower healing (success)
rate.

55.  Effectiveness of single- versus multiple-visit
endodontic treatment of teeth with apical
periodontitis: a systematic review and meta-
analysis.(Sathorn C, Parashos P, Messer H H)
 CONCLUSION: Single-visit root canal treatment
did not significantly increase healing(success) in
comparison with multiple visits.
 There was a lack of evidence of a difference
between single and multiple visits for root canal
treatment.

56. Summary & Conclusion
Identify Clinical
Problem
Search for evidence
Make sense of
evidence
Act on evidence
Discard
Store
Update
evidence

57.  EBD involves the systematic collection and
incorporation of research evidence into clinical
practice, to improve the quality and effectiveness
of interventions for consumers and providers of
health care.
 It has implications for the delivery of health care at
both the individual & community level.

58. References
 Daly B. Evidence based dentistry. In Daly B, Watt
GR, Batchelor P, Treasure TE. Essential dental
public health. New York, Oxford University Press
Inc.,2002;107-17.
 Thomas VM. Evidence Based Dentistry. Dental
Clinics of North America;2009:53(1).
 Richards D, Lawrence A. Evidence Based
Dentistry. BDJ 1995;7:270-3.
 Available from www.ada.org/definition of ebd.

59.  Sackett DL et al. Evidence-Based Medicine: How
to Practice and Teach EBM. 2nd ed. Churchill
Livingstone; 2000
 Available from-http://www.ebbp.org/steps.html.
 Anderson J. Need for evidence-based practice in
prosthodontics. J Prosthet Dent 2000;83:58-65.
 Oxford Centre for Evidence Based Medicine.
Levels of evidence and grades of recommendation.
Available from http://www.cebm.net/levels
_of_evidence.asp