Presentation brought to you by
www.indiandentalacademy.com
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www...
Department web site @
http://omr-cods.tripod.com/
www.indiandentalacademy.com
General skills for the new dentist:
1. Apply ethical principles to professional practice.
2. Provide empathetic care for a...
Defining EBD
“a conscientious, explicit, and judicious
use of current best evidence in
conjunction with clinical experienc...
“a conscientious, explicit, and judicious
use of current best evidence in
conjunction with clinical experience to
make dec...
www.indiandentalacademy.com
CRITICALLY
APPRAISED
TOPIC
CAT
Practical
Approach
to EBD
www.indiandentalacademy.com
What is critical appraisal?
“critical appraisal attempts to identify the
strengths and weaknesses of pieces of
information...
CA
T
Gaps in our knowledge about
etiology, diagnosis, prognosis or therapy.
Problem areas or controversial aspects of
oral...
Practice of evidence based dentistry: (begins with
identifying a problem or area of uncertainty)
1. Formulating a relevant...
CA
T
1. Formulating a relevant, focused, clinically
important question that is likely to be answered.
How to appraise a to...
CA
T
1. Formulating a relevant, focused, clinically
important question that is likely to be answered.
How to appraise a to...
CA
T
2. Finding the evidence.
How to appraise a topic critically:
Sources:
Primary research: articles in journals (& even
...
CA
T
How to appraise a topic critically:
2. Finding the evidence.
Levels of evidence:
• Systematic reviews and meta-analys...
CA
T
3. Appraising the evidence.
How to appraise a topic critically:
Was the assignment of patients
to treatment randomize...
CA
T
3. Appraising the evidence.
How to appraise a topic critically:
How large are the treatment
effects?
Absolute Risk Re...
CA
T
3. Appraising the evidence.
How to appraise a topic critically:
Can the results be applied to
my patient care?
‘Yes’
...
CA
T
How to appraise a topic critically:
How large are the treatment effects?
Absolute Risk Reduction ‘ARR’
Relative Risk ...
How precise was the estimate of
the treatment effect?
Confidence Interval ‘CI’ (95%)
CA
T
How to appraise a topic critical...
Are the likely treatment benefits
worth the potential harms and
costs?
Number Needed to Treat ‘NNT’
CA
T
How to appraise a...
CA
T
4. Summary of appraisal: creating a 1-page CAT
How to appraise a topic critically:
Title: Management of TMD with Prim...
Practice of evidence based dentistry: (begins with
identifying a problem or area of uncertainty)
1. Formulating a relevant...
CA
T
Defines the current acceptable standard of
dental care (medico-legal, health insurance &
health administration implic...
CA
T
CATs done by individuals can be wrong.
Limitations of a critically appraised topic :
CATs are based on a single artic...
CA
T
“There is something fascinating about
science. One gets such a wholesale return of
conjecture out of a trifling inves...
www.indiandentalacademy.com
GLOSSARY OF TERMS
AB CD
EFG ILN
OP R
S
www.indiandentalacademy.com
Absolute risk: The observed or calculated probability of an
event in the population under study. (Harm, Therapy)
Absolute ...
Bias (Syn: systematic error): Deviation of results or inferences
from the truth, or processes leading to such deviation. S...
Case-series: Report of a number of cases of disease. ( Harm)
Case-control study: Retrospective comparison of exposures of ...
Confidence interval (CI): The range of numerical values in which we can
be confident (to a computed probability, such as 9...
Effectiveness: a measure of the benefit resulting from an intervention for
a given health problem under usual conditions o...
Incidence: The number of new cases of illness commencing, or of
persons falling ill, during a specified time period in a g...
Odds: a proportion in which the numerator contains the number of times
an event occurs and the denominator includes the nu...
Prevalence: the proportion of persons with a particular disease within a
given population at a given time. ( Diagnosis)
Pr...
Randomized controlled trial: Study design where treatments,
interventions, or enrollment into different study groups are a...
Relative risk reduction (RRR): the extent to which a treatment reduces
a risk, in comparison with patients not receiving t...
Selection Bias: a bias in assignment or a confounding variable that arises
from study design rather than by chance. These ...
Survival curve: A graph of the number of events occurring over time or
the chance of being free of these events over time....
Systematic review: denotes any type of review that has been prepared
using strategies to avoid bias and that which include...
www.indiandentalacademy.com
Thank you
For more details please visit
www.indiandentalacademy.com
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Cat ortho /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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Cat ortho /certified fixed orthodontic courses by Indian dental academy

  1. 1. Presentation brought to you by www.indiandentalacademy.com INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
  2. 2. Department web site @ http://omr-cods.tripod.com/ www.indiandentalacademy.com
  3. 3. General skills for the new dentist: 1. Apply ethical principles to professional practice. 2. Provide empathetic care for all patients including members of diverse and vulnerable populations. 3. Apply the principles of jurisprudence to the practice of dentistry. 4. Continuously analyze the outcomes of patient treatment to improve that treatment. 5. Evaluate scientific literature and other sources of information to make decisions about dental treatment. 6. Manage oral health based on application of scientific principles. 7. Participate in professional organizations. American Association of Dental Schools, 1997 General skills for the new dentist: 1. Apply ethical principles to professional practice. 2. Provide empathetic care for all patients including members of diverse and vulnerable populations. 3. Apply the principles of jurisprudence to the practice of dentistry. 4. Continuously analyze the outcomes of patient treatment to improve that treatment. 5. Evaluate scientific literature and other sources of information to make decisions about dental treatment. 6. Manage oral health based on application of scientific principles. 7. Participate in professional organizations. One should be able to:  make the strongest possible conclusions from limited amounts of data  avoid human tendency to over-generalize www.indiandentalacademy.com
  4. 4. Defining EBD “a conscientious, explicit, and judicious use of current best evidence in conjunction with clinical experience to make decisions regarding patient care” www.indiandentalacademy.com
  5. 5. “a conscientious, explicit, and judicious use of current best evidence in conjunction with clinical experience to make decisions regarding patient care” Tools for Practicing EBD Systematic Reviews Meta-analysis Clinical Practice Guidelines NNTs, SpPins & SpNouts CAT www.indiandentalacademy.com
  6. 6. www.indiandentalacademy.com
  7. 7. CRITICALLY APPRAISED TOPIC CAT Practical Approach to EBD www.indiandentalacademy.com
  8. 8. What is critical appraisal? “critical appraisal attempts to identify the strengths and weaknesses of pieces of information, often research literature, so that readers may apply that information within the limits specified” CA T What is the ultimate goal of critical appraisal? “dissemination of valid clinical research findings and its incorporation into teaching & practice” www.indiandentalacademy.com
  9. 9. CA T Gaps in our knowledge about etiology, diagnosis, prognosis or therapy. Problem areas or controversial aspects of oral health sciences. Introduction of new diagnostic test, therapy (surgical procedure, medicaments, materials) or preventive measure. When to appraise a topic critically: Research in fundamental sciences suggests clinical application. www.indiandentalacademy.com
  10. 10. Practice of evidence based dentistry: (begins with identifying a problem or area of uncertainty) 1. Formulating a relevant, focused, clinically important question that is likely to be answered. 2. Finding the evidence. 3. Appraising the evidence. 4. Summary of appraisal: creating a 1-page CAT. 5. …… 6. …… 7. …… CA T How to appraise a topic critically: www.indiandentalacademy.com
  11. 11. CA T 1. Formulating a relevant, focused, clinically important question that is likely to be answered. How to appraise a topic critically: …would adding posture training to self-management instructions… Patient or Problem New Intervention Comparison Intervention Outcomes …lead to improvement in TMD symptoms and signs? …when compared with self- management instructions alone… In patients with TMD and a primary muscle disorder… www.indiandentalacademy.com
  12. 12. CA T 1. Formulating a relevant, focused, clinically important question that is likely to be answered. How to appraise a topic critically: In patients with TMD and a primary muscle disorder would adding posture training to self-management instructions when compared with self-management instructions alone lead to improvement in TMD symptoms and signs? www.indiandentalacademy.com
  13. 13. CA T 2. Finding the evidence. How to appraise a topic critically: Sources: Primary research: articles in journals (& even unpublished research work) Secondary research: systematic reviews (with or without meta-analysis), non-systematic reviews, guidelines, decision analysis, economic analysis Search strategy: Manual search: library, correspondence Electronic search: Medline, SilverPlatter, Embase, AIDSline, Toxline & MeSH, Ovid www.indiandentalacademy.com
  14. 14. CA T How to appraise a topic critically: 2. Finding the evidence. Levels of evidence: • Systematic reviews and meta-analysis • Randomized controlled trials • Cohort studies • Case-control studies • Cross-sectional surveys • Case reports “Usefulness of posture training for patients with temporomandibular disorders” Wright, Domenech, Fischer JADA, Vol.131, February 2000, 202-210 “Usefulness of posture training for patients with temporomandibular disorders” Wright, Domenech, Fischer JADA, Vol.131, February 2000, 202-210 www.indiandentalacademy.com
  15. 15. CA T 3. Appraising the evidence. How to appraise a topic critically: Was the assignment of patients to treatment randomized? Validity of study Was the follow-up complete? Were patients analyzed in the groups to which they were randomized? Was blinding done? Were the groups similar at the start of the trial? Aside from the intervention were the groups treated equally? Overall are the results of the study valid? Yes Yes Yes Yes Yes Yes Yes www.indiandentalacademy.com
  16. 16. CA T 3. Appraising the evidence. How to appraise a topic critically: How large are the treatment effects? Absolute Risk Reduction ‘ARR’ Relative Risk Reduction ‘RRR’ ARR = 0.7 RRR = 70% What are the results? How precise was the estimate of the treatment effect? Confidence Interval ‘CI’ (95%) ARR = 0.536 to 0.864 RRR = 54% to 86% www.indiandentalacademy.com
  17. 17. CA T 3. Appraising the evidence. How to appraise a topic critically: Can the results be applied to my patient care? ‘Yes’ Will the results help my patients? Were all clinically important outcomes considered? ‘Yes’ Are the likely treatment benefits worth the potential harms and costs? Number Needed to Treat ‘NNT’ ‘Yes’ 2 www.indiandentalacademy.com
  18. 18. CA T How to appraise a topic critically: How large are the treatment effects? Absolute Risk Reduction ‘ARR’ Relative Risk Reduction ‘RRR’ Absolute risk reduction (ARR): the difference in the absolute risk (rates of adverse events) between control (‘x’) and experimental (‘y’) populations. ARR = x - y Relative risk reduction (RRR): expresses the percent reduction in events in experimental (‘y’) compared to controls (‘x’) RRR = x - y x x 100% www.indiandentalacademy.com
  19. 19. How precise was the estimate of the treatment effect? Confidence Interval ‘CI’ (95%) CA T How to appraise a topic critically: Confidence interval (CI): The range of numerical values in which we can be confident (to a computed probability, such as 90 or 95%) that the population value being estimated will be found. Confidence intervals indicate the strength of evidence; where confidence intervals are wide, they indicate less precise estimates of effect. www.indiandentalacademy.com
  20. 20. Are the likely treatment benefits worth the potential harms and costs? Number Needed to Treat ‘NNT’ CA T How to appraise a topic critically: Number Needed to Treat (NNT): the number of patients who must be exposed to an intervention before the clinical outcome of interest occurred; for example, the number of patients needed to treat to prevent one adverse outcome www.indiandentalacademy.com
  21. 21. CA T 4. Summary of appraisal: creating a 1-page CAT How to appraise a topic critically: Title: Management of TMD with Primary Muscle Disorder Clinical bottom line: In patients with TMD and a primary muscle disorder, posture training and self- management instructions are significantly more effective than self-management instructions alone. Citation: Three-part clinical question: The study: The evidence: Comments: Appraised by: Dr. Shailesh Lele Date: 24 April 2000 Kill by or update by: 24 April 2001www.indiandentalacademy.com
  22. 22. Practice of evidence based dentistry: (begins with identifying a problem or area of uncertainty) 1. Formulating a relevant, focused, clinically important question that is likely to be answered. 2. Finding the evidence. 3. Appraising the evidence. 4. Summary of appraisal: creating a 1-page CAT. How to appraise a topic critically: CA T 5. Deciding whether or not to act on the evidence. Depends upon one’s clinical judgement & experience. 6. Assessing the outcomes of your actions. 7. Summarizing and storing records for future reference. www.indiandentalacademy.com
  23. 23. CA T Defines the current acceptable standard of dental care (medico-legal, health insurance & health administration implications). Value of a critically appraised topic : Concise and portable. Immediately applicable clinically. Improves one’s skills in acquisition and critical assessment of information. Educational value. Points out areas for further research. www.indiandentalacademy.com
  24. 24. CA T CATs done by individuals can be wrong. Limitations of a critically appraised topic : CATs are based on a single article and therefore may not be representative of the entire body of evidence. CATs may have a short shelf life and have to be updated on the basis of newer and better evidence. The scope of a CAT is often too narrow to be applicable to the clinical situation one is facing. www.indiandentalacademy.com
  25. 25. CA T “There is something fascinating about science. One gets such a wholesale return of conjecture out of a trifling investment of fact.” Mark Twain Life on the Mississippi, 1850 www.indiandentalacademy.com
  26. 26. www.indiandentalacademy.com
  27. 27. GLOSSARY OF TERMS AB CD EFG ILN OP R S www.indiandentalacademy.com
  28. 28. Absolute risk: The observed or calculated probability of an event in the population under study. (Harm, Therapy) Absolute risk difference: the difference in the risk for disease or death between an exposed population and an unexposed population. (Harm) Absolute risk reduction (ARR): the difference in the absolute risk (rates of adverse events) between study and control populations. (Therapy) Adjustment: A summarizing procedure for a statistical measure in which the effects of differences in composition of the populations being compared have been minimized by statistical methods. (Harm) Association: Statistical dependence between two or more events, characteristics, or other variables. An association may be fortuitous or may be produced by various other circumstances; the presence of an association does not necessarily imply a causal relationship. ( Harm) GLOSSARY OF TERMS www.indiandentalacademy.com
  29. 29. Bias (Syn: systematic error): Deviation of results or inferences from the truth, or processes leading to such deviation. See also Referral Bias, Selection Bias. ( Harm, Therapy) Blind(ed) study (Syn: masked study): A study in which observer(s) and/or subjects are kept ignorant of the group to which the subjects are assigned, as in an experimental study, or of the population from which the subjects come, as in a nonexperimental or observational study. Where both observer and subjects are kept ignorant, the study is termed a double- blind study. If the statistical analysis is also done in ignorance of the group to which subjects belong, the study is sometimes described as triple blind. The purpose of "blinding" is to eliminate sources of bias. (Diagnosis, Harm, Therapy) GLOSSARY OF TERMS www.indiandentalacademy.com
  30. 30. Case-series: Report of a number of cases of disease. ( Harm) Case-control study: Retrospective comparison of exposures of persons with disease (cases) with those of persons without the disease (controls) (see Retrospective study). (Harm) Causality: The relating of causes to the effects they produce. Most of epidemiology concerns causality and several types of causes can be distinguished. It must be emphasized, however, that epidemiological evidence by itself is insufficient to establish causality, although it can provide powerful circumstantial evidence. ( Harm) Co-interventions: Interventions other than the treatment under study that are applied differently to the treatment and control groups. Cointervention is a serious problem when double blinding is absent or when the use of very effective non-study treatments is permitted. ( Therapy) Cohort study: Follow-up of exposed and non-exposed defined groups, with a comparison of disease rates during the time covered. ( Harm, Prognosis) Comparison group: Any group to which the index group is compared. Usually synonymous with control group. ( Harm, Therapy) Co-morbidity: Coexistence of a disease or diseases in a study participant in addition to the index condition that is the subject of study. ( Harm) GLOSSARY OF TERMS www.indiandentalacademy.com
  31. 31. Confidence interval (CI): The range of numerical values in which we can be confident (to a computed probability, such as 90 or 95%) that the population value being estimated will be found. Confidence intervals indicate the strength of evidence; where confidence intervals are wide, they indicate less precise estimates of effect. ( Harm) Confounding variable, Confounder: A variable that can cause or prevent the outcome of interest, is not an intermediate variable, and is associated with the factor under investigation. A confounding variable may be due chance or bias. Unless it is possible to adjust for confounding variables, their effects cannot be distinguished from those of factor(s) being studied. ( Harm, Therapy). Dose-response relationship: A relationship in which change in amount, intensity, or duration of exposure is associated with a change-either an increase or decrease-in risk of a specified outcome. ( Harm) Determinant: Any definable factor that effects a change in a health condition or other characteristic. ( Harm) GLOSSARY OF TERMS www.indiandentalacademy.com
  32. 32. Effectiveness: a measure of the benefit resulting from an intervention for a given health problem under usual conditions of clinical care for a particular group; this form of evaluation considers both the efficacy of an intervention and its acceptance by those to whom it is offered, answering the question, "Does the practice do more good than harm to people to whom it is offered?" See Intention to treat. ( Therapy) Efficacy: a measure of the benefit resulting from an intervention for a given health problem under the ideal conditions of an investigation; it answers the question, "Does the practice do more good than harm to people who fully comply with the recommendations?" ( Therapy) Exclusion Criteria: Conditions which preclude entrance of candidates into an investigation even if they meet the inclusion criteria. ( Diagnosis, Harm, Prognosis, Therapy) Follow-up: Observation over a period of time of an individual, group, or initially defined population whose relevant characteristics have been assessed in order to observe changes in health status or health-related variables. ( Harm, Prognosis) Gold standard: A method, procedure, or measurement that is widely accepted as being the best available. ( Diagnosis) GLOSSARY OF TERMS www.indiandentalacademy.com
  33. 33. Incidence: The number of new cases of illness commencing, or of persons falling ill, during a specified time period in a given population. See also Prevalence. ( Harm) Intention to treat analysis: A method for data analysis in a randomized clinical trial in which individual outcomes are analyzed according to the group to which they have been randomized, even if they never received the treatment they were assigned. By simulating practical experience it provides a better measure of effectiveness. (versus efficacy) ( Therapy) Interviewer bias: Systematic error due to interviewer's subconscious or conscious gathering of selective data. ( Harm) Lead-time bias: If prognosis study patients are not all enrolled at similar, well-defined points in the course of their disease, differences in outcome over time may merely reflect differences in duration of illness. ( Harm, Prognosis) Likelihood ratio: Ratio of the probability that a given diagnostic test result will be expected for a patient with the target disorder rather than for a patient without the disorder. ( Diagnosis) Number Needed to Treat (NNT): the number of patients who must be exposed to an intervention before the clinical outcome of interest occurred; for example, the number of patients needed to treat to prevent one adverse outcome. ( Therapy) GLOSSARY OF TERMS www.indiandentalacademy.com
  34. 34. Odds: a proportion in which the numerator contains the number of times an event occurs and the denominator includes the number of times the event does not occur. ( Harm) Odds Ratio (Syn: cross-product ratio, relative odds): a measure of the degree of association; for example, the odds of exposure among the cases compared with the odds of exposure among the controls. ( Harm) Precision: The range in which the best estimates of a true value approximate the true value. See Confidence interval. ( Diagnosis, Harm, Prognosis, Therapy) Predictive value: In screening and diagnostic tests, the probability that a person with a positive test is a true positive (i.e., does have the disease), or that a person with a negative test truly does not have the disease. The predictive value of a screening test is determined by the sensitivity and specificity of the test, and by the prevalence of the condition for which the test is used. (Diagnosis) GLOSSARY OF TERMS www.indiandentalacademy.com
  35. 35. Prevalence: the proportion of persons with a particular disease within a given population at a given time. ( Diagnosis) Prognosis: the possible outcomes of a disease or condition and the likelihood that each one will occur. ( Prognosis) Prognostic factor: Demographic, disease-specific, or co-morbid characteristics associated strongly enough with a condition's outcomes to predict accurately the eventual development of those outcomes. Compare with risk factors. Neither prognostic or risk factors necessarily imply a cause and effect relationship. ( Prognosis) Prospective study: Study design where one or more groups (cohorts) of individuals who have not yet had the outcome event in question are monitored for the number of such events which occur over time. ( Prognosis, Harm) GLOSSARY OF TERMS www.indiandentalacademy.com
  36. 36. Randomized controlled trial: Study design where treatments, interventions, or enrollment into different study groups are assigned by random allocation rather than by conscious decisions of clinicians or patients. If the sample size is large enough, this study design avoids problems of bias and confounding variables by assuring that both known and unknown determinants of outcome are evenly distributed between treatment and control groups. ( Therapy) Recall bias: Systematic error due to the differences in accuracy or completeness of recall to memory of past events or experiences. ( Harm) Referral filter bias: The sequence of referrals that may lead patients from primary to tertiary centres raises the proportion of more severe or unusual cases, thus increasing the likelihood of adverse or unfavorable outcomes. ( Prognosis) Relative risk (RR): the ratio of the probability of developing, in a specified period of time, an outcome among those receiving the treatment of interest or exposed to a risk factor, compared with the probability of developing the outcome if the risk factor or intervention is not present. ( Therapy, Harm) GLOSSARY OF TERMS www.indiandentalacademy.com
  37. 37. Relative risk reduction (RRR): the extent to which a treatment reduces a risk, in comparison with patients not receiving the treatment of interest. ( Therapy) Reproducibility (Repeatability, Reliability): the results of a test or measure are identical or closely similar each time it is conducted. ( Diagnosis) Retrospective study: study design in which cases where individuals who had an outcome event in question are collected and analyzed after the outcomes have occurred (see also Case-control study). ( Harm) Risk factor: patient characteristics or factors associated with an increased probability of developing a condition or disease in the first place. Compare with prognostic factors. Neither risk or prognostic factors necessarily imply a cause and effect relationship. ( Harm) GLOSSARY OF TERMS www.indiandentalacademy.com
  38. 38. Selection Bias: a bias in assignment or a confounding variable that arises from study design rather than by chance. These can occur when the study and control groups are chosen so that they differ from each other by one or more factors that may affect the outcome of the study. ( Harm, Therapy) Sensitivity (of a diagnostic test): the proportion of truly diseased persons, as measured by the gold standard, who are identified as diseased by the test under study. ( Diagnosis) Specificity (of a diagnostic test): the proportion of truly nondiseased persons, as measured by the gold standard, who are so identified by the diagnostic test under study. ( Diagnosis) Stratification: division into groups. Stratification may also refer to a process to control for differences in confounding variables, by making separate estimates for groups of individuals who have the same values for the confounding variable. ( Therapy) Strength of Inference: the likelihood that an observed difference between groups within a study represents a real difference rather than mere chance or the influence of confounding factors, based on both p values and confidence intervals. Strength of inference is weakened by various forms of bias and by small sample sizes. ( Harm, Therapy) GLOSSARY OF TERMS www.indiandentalacademy.com
  39. 39. Survival curve: A graph of the number of events occurring over time or the chance of being free of these events over time. The events must be discrete and the time at which they occur must be precisely known. In most clinical situations, the chance of an outcome changes with time. In most survival curves the earlier follow-up periods usually include results from more patients than the later periods and are therefore more precise. ( Prognosis) Validity: the extent to which a variable or intervention measures what it is supposed to measure or accomplishes what it is supposed to accomplish. ( Diagnosis, Harm, Prognosis, Therapy) The internal validity of a study refers to the integrity of the experimental design. The external validity of a study refers to the appropriateness by which its results can be applied to non-study patients or populations. GLOSSARY OF TERMS www.indiandentalacademy.com
  40. 40. Systematic review: denotes any type of review that has been prepared using strategies to avoid bias and that which includes a material and methods section. Systematic reviews may or may not include formal meta-analyses. meta-analysis: statistically combining and analysing data from separate studies. p1: event rate from the control group p2: event rate from the experimental group n1: number of patients analysed from the control group n2: number of patients analysed from the experimental group GLOSSARY OF TERMS www.indiandentalacademy.com
  41. 41. www.indiandentalacademy.com Thank you For more details please visit www.indiandentalacademy.com

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