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Ebd/cosmetic dentistry courses


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Ebd/cosmetic dentistry courses

  1. 1. EVIDENCE BASED DENTISTRY INDIAN DENTAL ACADEMY Leader in continuing Dental Education
  3. 3. INTRODUCTION • Everything old is new again. • In early 1990’s at “Mac Master University” a concept developed. • The use of scientific evidence to approach critical clinical problems. • Dr.David Sackett laid the foundation stone of evidence based health care. Though this concept was originally developed in medicine, soon its principle spread to all health specialities. • Dr.David Sackett was of strong opinion that scientific literature should be used as evidence and based on this evidence health care should be rendered. • Dr.David Sackett defined evidenced based practice as ‘Integrating individual clinical expertise with the best available external clinical evidence from systematic research.
  4. 4. DEFINITION • Evidence based medicine has been defined as “the conscientious, explicit and judicious use of current best evidence in making decision about the care of individual patients”. • ADA defined “Evidence based dentistry”. Evidence based dentistry is an approach to oral health that requires the judicious integration and systematic assessment of clinically relevant scientific evidence, relating to the patients oral and medical condition and history with the dentist’s clinical expertise and the patients treatment needs and preferences”.
  5. 5. DEFINITION Scientific Literature Dentists Clinical Expertise Patients Preference O OO
  6. 6. TRADITIONAL MODEL OF PRACTICE Complaint Training Symptoms Know ledge Signs Personal experience Patient Doctor Consultation w ith colleagues Advice Journal brow sing Decision CE Courses Burden Of I llness Treatments Hypothesis, etc.
  7. 7. TRADITIONAL MODEL OF PRACTICE • At present the treatment, a dental practitioner provide is based on his basic education, his experience, his knowledge and also the influence from his colleagues, CE courses and journal browsing. This is “However” sufficient to encounter routine problems…!!! • But in certain challenging situation, when patient is demanding or there is introduction of new materials, etc. the clinical abilities of dentist become limited… • At present there are about 2,43,500 article in dental literature, and the increment in number of articles per months is 5%. Hence, today’s busy practitioner don’t have time to access and read all of them. • Then how should he give quality treatment to his patient. • PROBLEM ORIENTED EVIDENCE SEARCH IS A POSSIBLE ANSWER!!!
  9. 9. STEPS IN EVIDENCE BASED DENTISTRYm • STEP-1: Translation of Clinical Problem into Answerable question. • STEP-2: Track down the best evidences to answer the question. • STEP-3: Critical Appraisal of the evidence for its validity and clinical applicability. • Step-4: Application of the results of critical appraisal in clinical practice. • STEP-5: Evaluation of One’s Performances.
  10. 10. THE QUESTION IN EVIDENCE BASED DENTISTRY • How Question arise? • Which question? • Types of questions? • Phrasing of Question? • How a question stress a search?
  11. 11. HOW QUESTION ARISE? • Everybody is ignorant, only on different subjects. • Practice by pattern recognition - with experience practitioner builds up a mental library based upon this, he is able to encounter critical clinical challenges. • But because of infinite variety of circumstances the clinician is venerable to confusion and then questions starts emerging, especially in encountering rare problems and latest treatment modalities.
  12. 12. WHICH QUESTION? • “An idle brain is devil’s workshop” • What should be given topmost priority and what should be addressed at last? • FIRST: Choose questions from the patients perspective. • SECOND: Those questions that are most likely to yield definitive answers. • THIRD: These question that help doctor to stay current and in preparing for next occasion. • FINALLY: Those interesting question that spark the learning process. • The advantages of these criteria are it helps us to balance between patients demands and clinician’s decision…!
  13. 13. TYPES OF QUESTIONS……. • Based upon the information the researcher or clinician is trying together. • Sackett et al suggested two types of questions: – Background questions? – Foreground questions? • Background questions? – They are less specific. – Often related to general understanding of a disease. – They have three components. Generally starts with why, who, what, when and a verb/adj that connects them to item of interest. – E.g., What is the wear rate of this post-composite. – What is the nerve pathways responsible for unlocalized pain.
  14. 14. TYPES OF QUESTIONS……. • Foreground Questions? – They are most specific. – Often related to management of the patient. – It usually has four components • A population • An intervention • A comparative intervention • An outcome – “PICO” • E.g. In patients with unlocalized dental pain is a cold test more sensitive than an electric pulp test in identifying pulpitis? • In patients with asymptomatic impacted third molar is removing the teeth cause greater loss of bone support at the distal of second molar than not removing them?
  15. 15. TYPES OF QUESTIONS……. • However, another classification has grouped all questions based upon where they arise like…. Question of? – Clinical evidence: How to gather clinical findings properly and interpret them soundly. – Diagnosis: Low to select and interpret diagnostic tests. – Prognosis: How to anticipate the patients likely course. – Therapy: How to select treatment that do more good than harm. – Prevention: How to screen and reduce the risk of disease. – Education: How to teach yourself the patient and the family what is
  16. 16. TYPES OF QUESTIONS……. • Examples: – Would a specific appliance reduce chronic snoring in a middle aged man - A QUESTION OF THERAPY? – Would a selective group of probing depths performed in all patients equal to the diagnosis of periodontal disease as accurately as complete mouth probing - A QUESTION OF DIAGNOSIS. – Does a single episode of unilateral facial pain in 22 year old patient increase the likelihood of developing future TMJ dysfunction? - A QUESTION OF PROGNOSIS.
  17. 17. TYPES OF QUESTIONS……. • Examples: – Do over the counter whitening agents increase the likelihood of tooth sensitivity in patients who use them regularly? - A QUESTION OF HARM. – In 65 years old edentulous patients would implant supported denture be more beneficial then conventional denture - A QUESTION OF THERAPY. – And sooooooooo on……..! – In certain situations the clinical problem could not be described in a single question hence in such condition first the question is split into background question and then into foreground
  18. 18. WHY TO SPLIT? FOREGROUND A B C A - Learner B - Increase knowledge + Experience C - Extensive knowledge + Extensive
  19. 19. PHRASING THE QUESTION…..! • TIPS – Don’t worry about the classification. – Don’t worry about the type of question. – Find what patient wants! – Ask yourself what best you can offer. – Frame in simple terms. – Remember PICO.
  20. 20. HOW A QUESTION STEERS A SEARCH • The direction of search is enhanced by the very question itself. • If question is specific, search for its answer becomes easy. • Hence, foreground questions are easy to search then background questions.
  21. 21. CONDUCTING A SEARCH OF LITERATURE • This is the second step in EBD. • This is time consuming and tedious. However, no search is complete until it is comprehensive. • The search can be grouped under three headings. – Traditional reference sources. – Peer - Reviewed journal sources. – Electronic data
  22. 22. Traditional Reference Source: • Textbooks • Index Cards • Index Medicus • Index to Dental Literature • Expert opinion. • All have few advantages and lot of disadvantages…….!
  23. 23. Peer Reviewed Journal • They are one of the best source of information. • Large number of journals in dental and medicine are membership organization. One need to subscribe them. • However, out of these very few are “Peer Reviewed Journal”. • Previously these journals were in printed format until 1990s at present they are compelled in CD ROM as per each year, all of these CD-ROM has search engine. • It has few limitations as journal displays topic of particular edition. • Different organizations have only articles of there speciality without provision of sharing the articles to other specialities…! • Hence, one has to subscribe all articles from all organizations which is not possible. • Hence, search is limited.
  24. 24. Electronic Database or Bibliographic Database • Pubmed • Medline • Internet Grateful Med. • PUB-MED: – Developed by National Library of Medicine, USA. – Excellent tool for accessing dental, medical and biomedical journals. – It is regularly updated and has wide array of networking. – Full text with figures and photographs. • MEDLINE: – It is Pub-Meds premier bibliographic database exclusively for medicine, dentistry, nursing. – 11,000,000 articles as old as 1960s 4000 medical journals across 72 countries. – Dentistry alone consists of 2,43,500 articles. – All articles are listed as per keywords given by
  25. 25. Electronic Database or Bibliographic Database • Internet Grateful Med. – It provides free access to MEDLINE, AIDSLINE, AIDS DRUGS, BIO- ETHICS LINE, DIR LINE, HISTLINE, POPLINE. • Digital Library: – Converting entire information of library into digital format. • The Search Proper – Clinical situation – Question: In edentulous patients with fixed implant supported prosthesis is the risk of implant failure greater when it is supported by only four implants. Then when it is supported by more implants?” • Search is done on Medline – Keyword: The first term entered is “edentulous”. The software maps “Jaw” “edentulous” “edentulous mouth”. – Population: Specific population implies to those “implant supported prosthesis” Software maps dental prosthesis implant supported and dental implants.
  26. 26. Electronic Database or Bibliographic Database • The next word would be “4 implants” versus more but “4” is not selected. • The next word “implant failure” software maps prosthesis failure and finally gets 5 articles. • Hence, the search question has resulted in 5 articles. • 4 were not useful. • 1 was by “Brane mark et al” that “compare the use of four implants against six implants in edentulous patients”. • It is a cross-sectional study carried out for a period of 11 years. • It concluded that the result obtained with 4 implants and 6 implants were equal. • Hence the problem was solved.
  27. 27. 10 STEPS FOR EFFECTIVE SEARCHING • STEP-1: Never rely on single term. Use synonyms… • STEP-2: Begin with a MeSH terms. • STEP-3: Consider alternate terms e.g., use $ or * - injur$ will search injury, injuries or injured. – Use wild card ? E.g. h?emorrhage will retrieve both haemorrhage and hemorrhage. • STEP-4: Combine search results e.g., ALL (or) AND to include both terms or ANY to include either terms or NOT to exclude. • STEP-5: If you retrieve too many references. – FILTER by using more specific terms. – Restricted text word. – MeSH text. More specific, more relevant MeSH terms.
  28. 28. 10 STEPS FOR EFFECTIVE SEARCHING • STEP-6: If you retrieve to few references. – Broaden your search. – Use synonyms and broader terms. Combine MeSH terms with text word. – Use Sub-headings. • STEP-7: Limited search results at the end of our search by: – Language of articles. – Check tags such as age groups, human, female, etc. – Publication types such as reviews meta analyses, RCTs. • STEP-8: Browse through retrieved references and select relevant references for printing and downloading to disc. • STEP-9: Be flexible. • STEP-10: Ask you library staff for
  29. 29. CRITICAL APPRAISAL OF THE EVIDENCE FOR ITS VALIDITY AND APPLICABILITY • It helps in making the sense of the evidence. • Need of making sense. – To make judicious use. – To check for its scientific validity. – To check for clinical applicability to one’s patient. – To statistical analysis of the results may further quantify the strength of evidence. • How to make Sense: – Critical appraisal of a topic “CAT”. • Advantages of Critical Appraisal: – Defines the current acceptable standard of health care. – Concise and portable. – Immediate applicability. No need to repeat experiment. – Improves one’s skills. – Educational values. – Points out areas for further
  30. 30. CRITICAL APPRAISAL OF THE EVIDENCE FOR ITS VALIDITY AND APPLICABILITY • Limitations of Critical Appraisal: – CATs done by individuals can be wrong. – CATs are based on a single – Scope of a CAT is often too narrow. – CATs may have a short shelf-life. Need to be updated. • CRITICAL APPRAISAL OF TOPIC – The CATs basically revolve around three broad issues. • What are the results? • Are the result of the trial valid? • Will the result help me in caring for my patients?
  31. 31. QUESTIONS TO HELP YOU MAKE SENSE OF A TRIAL: • SCREENING QUESTION: – Did the trial address a clearly focused issue? – Was the assignment of patients to treatment randomized? – Were all the patients who entered the trial properly accounted for at its conclusion. • Detailed Questions: – Were patients, health workers and study personnal ‘blind’ to treatment? – Were the groups similar at the start of the trial? – Aside from the experimental intervention, were the groups treated equally?
  32. 32. QUESTIONS TO HELP YOU MAKE SENSE OF A TRIAL: – How large was the treatment effect? – How precise was the estimate of the treatment effect? – Can the result apply to local population. – Were all clinically important outcomes considered? – Are the benefits worth the harms and the costs?
  33. 33. GRADING OF EVIDENCE: • Grade-I: Evidence from systemic review (SRs) of randomized control trials (RCTs). Large well conducted RCTs with narrow confidence intervals. • Grade-II: SRs of Cohort studies, individual cohort and case-control studies. Low quality RCTs. • Grade-III: Evidence from case series and poor quality cohort and case control studies. • Grade-IV: Expert opinion.
  34. 34. HIERARCHY OF EVIDENCE • Comparative studies. • Descriptive studies. • COMPARATIVE STUDIES (ANALYTICAL STUDIES) Prospective studies RCTs, assignment to therapy is under the control of the investigator Cohort study Retrospective studies – case control study
  35. 35. HIERARCHY OF EVIDENCE • DESCRIPTIVE STUDIES – Case series – Case reports • Descriptive studies: – Describe the general characteristics of a disease. – Commonly seen are “case reports and case series”. – Cross-sectional surveys: Report the status of an individual w.r.t. both exposure and diseases assessed at one point in time. – It is also impossible to conclude what caused the disease or casualty in disease.
  36. 36. HIERARCHY OF EVIDENCE • ANALYTICAL STUDIES • Testing of Hypothesis: – Two broad sub-categories I.e., intervention and observational studies. – Intervention Studies: Gold standard for clinical research because it is possible to blind and assign subjects randomly into treatment groups. • Double blinded, RCT offer a strongest evidence for validity of results. – Observational Studies: Investigator observe the natural course of events, noting which subjects are exposed or not exposed, which have had a particular treatment and which have not and which have or have not developed the outcome. • Two sub-categories i.e., Cohort and Case Control studies.
  37. 37. SYSTEMIC REVIEWS OF LITERATURE • The overview and meta-analysis: • Anatomy of Systemic Review: – Preparation of a detailed research protocol that outlines the clinical question of interest. – Selection of criteria for inclusion of articles in the reviews. – Systematic search of relevant published and unpublished research. – Determination of articles that meet pre-defined inclusion criteria. – Critical appraisal of the quality of selected articles. – Extraction of outcomes data from the selected article. – Data combination.
  38. 38. SYSTEMIC REVIEWS OF LITERATURE • What to look for in a Useful Systematic Review – Was a clinical question clearly stated and addressed? – Were the search methods comprehensive enough to find all relevant articles? – Were explicit methods used to evaluate which articles to include in the review. – Was validity of the article assessed and was this assessment reliable and free from bias? – Were inconsistencies in the findings of the included studies analyzed. – Were the findings of the primary studies combined appropriately. – Were the reviewer’s conclusions supported by the data?
  39. 39. EVIDENCE BASED PERIODONTAL THERAPY • Introduction: – Dr.P.Ramjford is considered the father of Evidence based Periodontal therapy. – Evidence based periodontal therapy was incorporated in periodontics in AAP workshop, 1996. – Great technological advances in the area of data access, retrieval and management have made data search easy. – The www has exploded greater possibilities for gathering data from many source. – Evaluation meta-analysis and modeling have like-wise improved. – Hence E.B.P. is incorporated in periodontics.
  40. 40. EVIDENCE BASED PERIODONTAL THERAPY • The Design Model: It is basically the same – 5 stepped procedure. – Step-1: Create answerable question. – Step-2: Conduct an efficient search of literature – Step-3: Critical appraisal of the evidence for its validity. – Step-4: Applying same to the patient. – Step-5: Evaluation of once performance.
  41. 41. EVIDENCE BASED PERIODONTAL THERAPY • Can subjects with gingivitis learn how to perform adequate oral hygiene and achieve better outcome of gingival health. – After viewing an oral hygiene video OR – After receiving personal hygiene instructions only. • Do subjects with poor oral hygiene have more bleeding on probing of their gingival collar than subjects with good oral hygiene?
  42. 42. EVIDENCE BASED PERIODONTAL THERAPY • Do root coverage procedure offer better result in those cases where root is conditioned prior to procedure than those cases where root conditioning is not done? • Do root coverage by free gingival graft superior than lateral pedicle graft? • Do prognosis of implants in non-smokers has better prognosis than in smokers?
  43. 43. EVIDENCE BASED PERIODONTAL THERAPY • AAP has stressed on systemic review of literature for efficient Evidence Based Periodontal Approaches. E.g., “Critical review of literature of root coverage procedures. • All articles from 1970 to 2000 were gathered. • In all 290 article were found. • Each article was “critically appraised”. • Only 90 out of 290 articles met inclusion criteria.
  44. 44. EVIDENCE BASED PERIODONTAL THERAPY • RESULTS: – The overall clinical outcome of different technique appear to be satisfactory. – No procedure was superior to another however all procedure had its own limitations. – The published evidence is of little help in deciding which procedure is best suited for each clinical situation.
  45. 45. EVIDENCE BASED PERIODONTAL THERAPY • SUGGESTIONS – More homogenous way of collecting and reporting clinical data and especially outcome measures will allow for an effective re- analysis. – Studies should be carried out keeping in mind that the published results of sound clinical studies will sooner or later be reviewed and compared with other studies. • CONCLUSIONS: A standard format with minimum requirements for data collection and presentation should be established and imposed by International Journals in order to provide reader and researcher useful information.
  46. 46. EVIDENCE BASED PERIODONTAL THERAPY • UNIQUE CONSTRAINTS IN PERIODONTICS FOR EVIDENCE BASED PRACTICE: – Improper terminology. – Classification confusion. – Diagnosis confusion. – Etiopathogenesis is not well understood. – Genetic and periodontitis - casual or linked. • CONCLUSION: In near feature such constraints may become less and Evidence Based Periodontics will grow by leaps and bounds.
  47. 47. LIMITATIONS OF EVIDENCE BASED DENTISTRY • Authoritarian clinicians & teachers perceive it as a threat!! • Access to information is limited. Suitable evidence (studies) may not be available. • Some of the tools of EBHC are time consuming and difficult to master. • Evidence-based practice may increase rather than decrease the cost of health care.
  48. 48. CONCLUSION • It would be unwise to conclude without clearing the misconceptions about Evidence Based Dentistry. – Evidence Based Dentistry is not a veil to mask the same old inadequate research. – Evidence Based Dentistry does not take the clinical decisions out of clinician hands and put them into the hands of literature. In fact the opposite is true. Evidence Based Dentistry gives guidelines for the clinician and relics first on clinical expertise. – Evidence Based Dentistry does not mean the clinician need not study basis. In fact the opposite is true. To evaluate research presented clinician need sound basics.
  49. 49. CONCLUSION – Evidence Based Dentistry does not mean clinicians abandon everything they learned in dental school. It does not force clinicians to go backwards to justify things to profession universally accepted. • Hence, at present the current concept of Evidence Based Dentistry is applicable to all specialities of dentistry not only to justify the treatment rendered but also to offer better service to the patient.
  50. 50. REFERENCES • Evidence Based Dentistry - G.R.Golostein • User’s Guide to Evidence Based Dentistry - JPD 2000, Jan. Vol. 83. • Evidence Based Dentistry - JPD 2000, April. Vol. 83.
  51. 51. THANK ‘U’ •“A man of words and not of deeds is like a garden full of weeds”