Evidenced based dentistry - Dr Harshavardhan Patwal
Presented by ,
Dr Harshavardhan Patwal
The evolution of the dental knowledge base
The evolution and definition of evidence-based dentistry
The three components of EBD: scientific evidence, the
clinician’s expertise, and the patient’s needs and
Applying EBD in practice
Evidenced based periodontology
Dentists need to make clinical decisions based on limited
scientific evidence. In clinical practice, a clinician must
weigh a myriad of evidences every day.
The goal of evidence-based dentistry is to help practitioners
provide their patients with optimal care.This is achieved by
integrating sound research evidence with personal clinical
expertise and patient values to determine the best course of
According to the ADA…
Evidence-based dentistry (EBD) is 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.
Is an approach to oral health
Is a method to acquire,
understand and apply the most
A standard of care
A mandate of what must be done
A substitute for clinical judgment
The dental knowledge base is simply the collection of all that
is known about oral health and disease and treatment
methods and outcomes.
Its contents comprise all of the
extant dental journal articles
the minds of all oral health practitioners.
the foundation of the dental professions and the principal
determinant of how dentists and dental hygienists practice
informs professional decision making, and portions of it
comprise the content of predoctoral and postdoctoral dental
new information and
been contributed by
knowledge base has
grown over time
The age of the expert
The age of professionalization
The age of science
The age of evidence
Evidence of the treatment of teeth
extends far back into human
prehistory,and early writings
discuss “tooth worms,” the
supposed cause of toothache at
Ancient Roman, Greek, Egyptian,
and Asian cultures all contain
examples of dental technology
related to replacing, retaining, and
toothdrawers extracted teeth
for pain relief.
The knowledge and skills
underlying all of this early
activity was strictly experiential;
practitioners learned by doing
▪ This textbook exemplified a new era in
knowledge synthesis, enabled by better
access to knowledge created by other
Beginning of the 20th century,
presaging the profession’s gradual shift from proprietary to
university-based educational institutions
controlled experimentation became more common,
causes and prevention of dental diseases.
Synthesis of knowledge evolved from simple statements of
“fact” based on an expert’s experience and opinion to
identification and consideration of the available information
in the scientific literature.
Knowledge dissemination enjoyed its most active period yet
early rapid growth of university-based predoctoral and
postdoctoral dental curricula,
the proliferation of dental journals,
organized continuing dental education
knowledge creation in this era can
be characterized by the dominance
of the randomized controlled trial
represents the research design most
likely to produce an accurate and valid
The hallmark of the age of
evidence is the systematic review
represent a substantial change in
the paradigm of knowledge
ensuring inclusion of all relevant
de-emphasizing the role of the expert,
minimizing bias through strict
protocols demanding objectivity and
transparency in the review process
EBD is a direct descendent and analog of a similar evolution of
the medical knowledge base, termed evidence-based
Personal experience of a single
synthesized observations of multiple
the results of simple, single research
synthesized results of several research
studies (ie, literature review).
Scottish physician and epidemiologist
advocated the application of scientific methods, especially
RCTs, to evaluate the effectiveness and efficiency of medical
He is best known for his influential book
published in 1972
Effectiveness and Efficiency: Random Reflections on Health Services
The principles he clearly set out in this book were
Because resources would always be limited, they should be used to
provide those forms of health care that had been shown in properly
designed evaluations to be effective.
Evidence from RCTs, he stressed, are likely to provide much more
reliable information than other sources of evidence.
The Cochrane Collaboration, named after
Archie Cochrane, is an international
network of volunteers that prepares and
updates systematic reviews on a broad
variety of topics as well as maintains the
largest collection of records of RCTs in the
Created by Sackett
first used at McMaster University in 1990
describe “an attitude of enlightened
skepticism toward the application of
diagnostic, therapeutic, and prognostic
technologies in day-to-day patient
The term was first published in 1991 and reached widespread
visibility in 1992 with the publication of a description of the
concept in the Journal of theAmerican MedicalAssociation.
The classic definition of evidence-based medicine emerged a
few years later from the same group at McMaster University
who pioneered the movement:
“the conscientious, explicit and judicious use of current best
evidence in making decisions about the care of the individual
This definition focuses on the integration of individual clinical
expertise with the best available external clinical evidence.
This definition was refined a few years later to incorporate
patient preferences and values
“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.”
Not all evidence is created equal.
Some evidence is more likely to be valid than other evidence
measures how accurately the evidence reflects what is true, and it is
an essential characteristic of evidence.
Some types of evidence are more vulnerable to bias than
bias is the principal
enemy of validity
Bias is the existence of factors or processes that can influence
the results or conclusions of a trial.
Bias occurs when there are important differences in
(1) the way in which subjects or groups of subjects are treated or
(2) how data is measured or analyzed.
evolution of the dental
reduce the risk of bias in
the information, or
evidence, that is created.
EBD demands that the evidence upon which treatment
decisions are based have the lowest possible risk of bias.
Ideas, editorials, Expert opinion
In vitro (test tube) research
Levels of evidence for preventive or therapeutic studies.
RCTs or other low-bias
evidence are not available
to support every decision a
practitioner must make.
the term best evidence really means the best available
evidence based on this hierarchy of study designs.
If higher levels of evidence are not available (ie, systematic
reviews or RCTs), then one must seek studies lower in the
hierarchy while at the same time acknowledging the potential
for increased bias.
In some instances, little more than expert opinion may be the
best evidence currently available.
The systematic review is quickly
surpassing (exceeding) the
traditional literature review as the
preferred method for
summarizing and synthesizing
relevant research evidence.
providing clinically relevant information to aid in decision
reducing the biases inherent in traditional literature reviews.
follow strict protocols
Traditional review Systematic review
not to be well-focused on a specific problem focus on specific clinical questions
not including all of the relevant studies including all of the relevant studies
Not combining the
information from the studies
information from the studies
identifying the problem or disease of interest,
the intervention or treatment in question,
the comparison treatment (usually the alternative treatment),
the outcome through which the intervention and comparison
treatments will be evaluated
narrower focus permits a much
more careful and complete
search and selection process to
identify and include all relevant
studies that have addressed the
question of interest.
Because the topic is limited, the
number of articles that contain
information is also usually quite
limited so that their careful
analysis is feasible
Systematic review is to think of it
as a scientific study that is
guided by the development of a
protocol that outlines all steps in
the review process
are not simple
surveys of the
systematic reviews are designed to minimize
bias, they require the prior determination of
search methods, inclusion criteria, and
evaluation criteria, which reduces the chance
of bias in deciding what studies to include
and in evaluating the strength of those studies
The results of a systematic
review will represent the
best, most current evidence
available that addresses a
specifi c clinical question
Using EBD in clinical practice essentially involves identifying
and using the best available scientific evidence in caring for
EBD also incorporates the clinician’s expertise and the
individual patient’s needs and personal preferences during
treatment decision making.
These decisions are ultimately made by the patient and are very
personal, and thus they will vary from patient to patient.
accessing and using current best
available evidence is at the
forefront of the decision-
to help patients
treatment that is
right for them
relevant to the condition
of the patient.
The clinical question is
frequently described in a
systematically access the most current scientific evidence on the
critically appraise the identified literature.
provides insight into the strengths and weaknesses of the
study, which is necessary when deciding if and how to use
evidence from a study in practice.
Efficient use of research and scholarship needs to be a part of
Aims to facilitate an approch , accelerating the introduction of
the best research in patient care .
Built upon developments in clinical research design through
18th, 19th and 20th centuries .
Evidenced based periodontology was coined by ALEXIA
ANTEZAK BOUCHKOMS and colleagues in Boston , in the
oral health group part of cochrane collaboration in 1994.
1996- World Workshop On Periodontology (AAP) included
elements of evidenced based healthcare , supported by Micheal
2001- First cochrane systemic review in periodontology (
researched the effect of GTR for infra-bony defects ).
2002- EuropeanWorkshop on periodontology – First international
workshop to use rigorous systemic reviews to inform the
2003- International Center for Evidenced Based Oral Health was
launched to produce high quality , evidenced based research with
an emphasis on, but not limited to periodontology and implants .
Clinicians need to continually update on options , modalities
and rationale as new research emerges .
By following a systemic approch , evidence can be considered
and applied to clinical practice.This approch is standardised
and repeatable , and facilitates the practice of Evidenced-
Based dentistry .
The application of evidence is essential in modern dentistry ,
and this approch is the core of the evolution towards an
Evidence – Driven practice .