Evidence based dentistry

1
Crest® Oral-B
®
at dentalcare.com Continuing Education Course, Revised January 9, 2012
The primary learning objectives for this course are to: 1) increase your knowledge of evidence-based
concepts, principles and skills, and 2) specifically how to formulate a good clinical question in order to find
relevant evidence to answer that question.
Conflict of Interest Disclosure Statement
• Jane Forrest has done consulting work for P&G.
ADA CERP
The Procter & Gamble Company is an ADA CERP Recognized Provider.
ADA CERP is a service of the American Dental Association to assist dental professionals in identifying
quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses
or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
Concerns or complaints about a CE provider may be directed
to the provider or to ADA CERP at:
http://www.ada.org/prof/ed/ce/cerp/index.asp
Overview
The Evidence-based Decision Making (EBDM) process provides a mechanism for staying current in practice
by addressing gaps in knowledge so that the clinician can provide the best care possible. To accomplish
this EBDM requires understanding new concepts and skills, the first and often the most difficult is how to ask
Jane L. Forrest, EdD, BSDH
Continuing Education Units: 2 hours
Evidence-Based Decision Making: Introduction
and Formulating Good Clinical Questions

2
Crest® Oral-B
®
an answerable question. This question provides the basis for identifying the key terms for conducting an
efficient search, the second step of the EBDM process. These two steps provide the basis for the three that
follow: critically appraising the evidence, applying the results in clinical practice, and evaluating the outcome.
The EBDM approach recognizes that clinicians can never be completely current with all conditions,
medications, materials, or available products.
Learning Objectives
Upon the completion of this course, the dental professional will be able to:
• Define Evidence-Based Medicine/Practice.
• Define Evidence-based Decision Making and its purpose.
• Explain why evidence-based practice is not just a new term for an old concept.
• Identify two principles of EBDM.
• Discuss the need for EBDM.
• Identify the levels of evidence and premise upon which they are based.
• Describe the 5 steps and skills necessary for EBDM.
• Formulate a good question using the PICO process.
• Discuss the benefits of EBDM.
Course Contents
• Introduction - What is Evidence-Based
Decision Making?
• Is Evidence-based practice a new term for an
old concept?
• Principles of EBDM
• The Need for EBDM
• Levels of Evidence
• Evidence-Based Decision Making Skills and
the 5-Step Process
• Evidence-Based Decision-Making in Action
• Applying the PICO Process
• Structuring the PICO Question
• Benefits of EBDM
• Conclusion
• Course Test
• References
• About the Author
Introduction - What is Evidence-Based
Decision Making?
Evidence has always contributed to clinical
decision-making; however, with the proliferation
of clinical studies and journal publications,
keeping current with relevant research is nearly
impossible. Because we rely on well-designed
research studies to demonstrate the efficacy
and effectiveness of diagnostic tests, treatment
strategies, new materials, and products, knowing
how to find the scientific evidence is an essential
component for clinical practice.
Using evidence from the medical literature to
answer questions, direct clinical action and guide
practice was pioneered at McMaster University,
Ontario, Canada in the 1980’s. As clinical
research and the publication of findings increased,
so did the need to use the medical literature to
guide practice. The old clinical problem-solving
model based on individual experience or the use
of information gained by consulting authorities
(colleagues or text books) gave way to a new
methodology for practice and restructured the way
in which more effective clinical problem-solving
should be conducted. This new methodology was
termed Evidence-Based Medicine (EBM)
1
and is
defined as:
The integration of the best research
evidence with clinical expertise and
patient values.
2
Rather than refer to medicine, often this definition
has been broadened to mean ‘practice’ or
‘healthcare’ and is the definition we are using for
Evidence-Based Practice (EBP).
Several professions have adapted this definition
to make it specific to their discipline. For
example, the American Dental Association (ADA)
defines “evidence-based dentistry” (EBD) as: an

3
Crest® Oral-B
®
approach to oral health care that requires the
judicious integration of systematic assessments
of clinically relevant scientific evidence, relating to
patient’s oral and medical condition and history,
with the dentists’ clinical expertise and the
patient’s treatment needs and preferences.
3
Inherent in these definitions is the recognition that
research evidence is a valued component of the
clinical decision-making process, and the intent
is that the use of current best evidence does not
replace clinical skills, judgment, or experience
but provides another dimension to the decision-
making process that also considers the patient’s
preferences.
4-6
(Figure 1) It is this decision-making
process that we refer to as Evidence-Based
Decision Making (EBDM) and is defined as:
The formalized process of using the
skills for identifying, searching for
and interpreting the results of the
best scientific evidence, which is
considered in conjunction with the
clinician’s experience and judgment,
the patient’s preferences and values,
and the clinical/patient circumstances
when making patient care decisions.
Again, EBDM is not unique to medicine or any
specific health discipline, but represents a concise
way of referring to the application of evidence to
clinical decision-making.
Is Evidence-based practice a new term
for an old concept?
The use of evidence in practice is not new. What
is new is the nature of the clinical evidence
itself in terms of the methods for gathering it
[randomized controlled trials and other well-
designed methods], the statistical tools for
synthesizing and analyzing it [systematic reviews
and meta-analysis], and the ways for ways for
accessing [electronic databases] and applying it
[evidence-based decision-making and practice
guidelines].
7,8,9
In other words, evidence-based practice is not
just a new term for an old concept and as a result
of advances, practitioners need:
1. more efficient and effective online searching
skills to find relevant evidence, and
2. critical appraisal skills to rapidly evaluate and
sort out what is valid and useful, and what is
not.
10
EBDM is the formalized process and structure for
learning these skills with the purpose of closing
the gap between what is known and what is
practiced in order to improve patient care based
on informed decision-making.
Principles of EBDM
Evidence-based decision-making is about solving
clinical problems and involves two fundamental
principles:
1. Evidence alone is never sufficient to make a
clinical decision. Initially, the focus of EBM
emphasized using randomized clinical trials
and other quantifiable methods. However, as
EBM has evolved, so has the realization that
the evidence from clinical research is only one
key component of the decision making process
and does not tell a practitioner what to do.
11
2. A hierarchy of evidence exists to guide clinical
decision-making.
9
EBDM is a structured
process which incorporates a formal set of
rules for interpreting the results of clinical
research and places a lower value on
authority or custom. In contrast to EBDM,
traditional decision-making, relies more on
intuition, unsystematic clinical experience and
pathophysiologic rationale.
9,12
Figure 1. EBDM Process
©2001 Forrest, NCDHR

4
Crest® Oral-B
®
The Need for EBDM
An evidence-based approach has emerged in
response to the need to improve the quality of
health care and to demonstrate the best use of
limited resources.
4,13
Forces driving the need to
improve the quality of care include:
1. variations in practice,
2. slow translation and assimilation of the scientific
evidence into practice,
4,14-16
3. managing the information overload, and
4. changing educational competencies that require
students to have the skills for lifelong learning.
6
1. Variations in Practice Patterns
Substantial advances have been made
in our knowledge of effective disease
prevention measures and of new therapies,
diagnostic tests, materials, techniques and
delivery systems, and yet the translation of
this knowledge into practice has not been
fully applied. Variations in practices among
dental clinicians are well documented,
whether it involves diagnostic procedures,
treatment planning
17,18
and treatment,
19
or prescribing antibiotics, such as was
found among endodontists
20
and general
practitioners.
21
2. Slow Translation and Assimilation of
Research Findings into Practice
Far too often variations in practice occur due
to a gap between the time current research
knowledge becomes available and its
application to care. Consequently, there is
a delay in adopting useful procedures and in
discontinuing ineffective or harmful ones.
22‑25
One example has been the use, or lack of
use, of dental sealants.
24
Although their
effectiveness have been well documented
over the past 3 decades, only 18.5% of US
children and youth ages 5-17 have one or
more sealed permanent teeth (1988-1991
data)
26
and goals for Healthy People 2020
have been retained, but modified to increase
the proportion since the 2010 goals were
only set at 50%.
27
Assimilating scientific evidence into practice
requires that clinicians keep up to date
by reading extensively, attending courses
and taking advantage of the Internet and
electronic databases to search for published
scientific articles. However, colleagues
and personal journal collections tend
to be the primary information sources
for treatment decisions, rather than the
scientific literature.
28-30
Treatment decisions
tend to reflect the knowledge, skills and
attitudes learned as a student,
8,25,31
and
trends indicating that the longer clinicians
are out of school, the bigger the gap in their
knowledge of up-to-date care,
31-32
as
demonstrated by the knowledge, opinions
and practices of dentists and dental
hygienists in providing oral cancer
examinations.
33,34
This reinforces the need
to learn evidence-based information seeking
behaviors and critical analysis skills while
still in school.
3. Managing the Information Overload
In addition to influencing variations in
practice and the slow translation and
assimilation of scientific evidence into
practice, it is physically impossible to keep
up to date with the increasing number
published articles. With the number of good
clinical trials and meta-analyses increasing
at a rate of 10% per year
35
and located
in over 700 dental journals world-wide,
knowing which journals to subscribe to
that have the relevant articles related to an
individual’s practice is nearly impossible. To
stay current in general dentistry, one would
have to identify, obtain, read and appraise 6
articles per week, 52 weeks per year.
35
A similar situation applies to keeping current
with research studies related to clinical
dental hygiene practice. A substantial
number of articles, 112 meta-analyses
(reviews and statistical analysis of already
conducted research that address the
same question) and 1707 RCTs, published
between 1990 and 2003 were identified
when searching MEDLINE
36
(Table 1).
In this case, 50% of the 112 meta-analyses
were located in 7 journals and the Cochrane
Library with the remaining half found in
33 other journals. Of the 1700 RCTs,
70% were located in 32 journals with the
remaining 30% in 174 journals.
36

5
Crest® Oral-B
®
Again, the challenge is to find relevant
clinical evidence when it’s needed in order
to help make well-informed decisions.
Evidence-based practice is now possible
due to increased access to relevant
clinical findings via development of online
databases and computers that enable quick
access to the scientific literature. Being able
to search electronically across hundreds
of journals for specific answers to patient
questions or problems solves this problem.
4. Changing Educational Requirements
Another need for EBDM is reflected in
educational requirements and competencies
for both dental and dental hygiene students.
The ADA Accreditation Standards for Dental
Education Programs
37
now expect dental
schools to develop specific competencies
that are reflective of an evidence-based
definition of general dentistry.
37
In addition
to the ADA, the American Dental Education
Association’s Competencies for the New
Dentist identifies general skills that reflect
an evidence-based approach.
38
These
include being able to continuously analyze
the outcomes of patient treatment to improve
that treatment, evaluate scientific literature
and other sources of information to make
decisions about dental treatment, and
manage oral health based on an application
of scientific principles.
Similar competencies for dental hygienists
are incorporated in the ADEA Dental
Hygiene Curriculum Guidelines.
39
For
example, “The process of care requires
defined problem solving and critical thinking
skills and supports evidenced-based
decision-making.” Further support for
EBDM is found in the curriculum guidelines
under Research for Dental and Dental
Hygiene Education (pp. 123-128)
39
in that
their aims are to provide both dentists
and dental hygienists with the skills and
knowledge to be able to access the most
recent and relevant scientific evidence,
critically appraise it, and determine if it is
applicable to the problem being addressed.
The clear intent of the accreditation
standards and competencies contained
within these documents is the focus on
the importance of comprehensive patient-
centered care and the need for adding
evidence-based decision-making to the
traditional experienced-based approach.
Table 1. Research Supporting Clinical Dental Hygiene Practice
34

6
Crest® Oral-B
®
Table 2 highlights the four forces driving
the need for EBDM.
Levels of Evidence
Sources regarded as strong evidence include
meta-analyses and systematic reviews, individual
randomized controlled trials (RCT), and well-
designed non-randomized control studies (Figure
2). The hierarchy of evidence for treatment
questions is based on the notion of causation and
the need to control bias.
13,40
Although each level may contribute to the total
body of knowledge, “...not all levels are equally
useful for making patient care decisions.”
40
As
you progress up the pyramid, the number of
studies and correspondingly, the amount of
available literature decreases, while at the
same time their relevance to answering clinical
questions increases
40
(Figure 3).
Table 2. The Need For EBDM
Figure 2. Study Types and Levels of Clinical Evidence

7
Crest® Oral-B
®
Knowing which segment of the literature is
appropriate for clinical decision-making and how
to quickly retrieve this information is important
to evidence-based practice. For example, the
study methodology and level of evidence will
differ based on the type of question asked,
such as those derived from issues of therapy/
prevention, diagnosis, etiology, and prognosis.
Table 3 reviews the type of question and the
highest levels of evidence based on the study
methodology. For example, for questions
associated with therapy and prevention, the
highest level of evidence will be from meta-
analyses or systematic reviews of randomized
controlled trials (RCTs), since the objective
of these studies is to test interventions
demonstrating cause and effect and to select
treatments that improve the condition/disease and
avoid adverse events.
9
Correctly identifying the type of study to answer
the question is an important skill to develop
in order to access the appropriate evidence
when searching the healthcare literature. For
example, identifying the best implant technique
for replacing a single maxillary molar is a
treatment question. Ideally, a meta-analysis or
systematic review of RCTs would be available
on the treatment being considered. If one
were not available, then the next best evidence
would be from a well-conducted individual RCT.
However, when the focus of the question is on
long-term outcomes of treatment, then it is a
question of prognosis where the highest level
of evidence would be provided by a systematic
review of inception cohort studies, which are
studies that follows patients from when a disease
or condition first manifests itself clinically. And
again, if a meta-analysis or systematic review
were not available, the next highest level would
be an individual inception cohort study, and so
on down the hierarchy (Table 3). Two important
concepts to keep in mind are that: 1) for any
type of question, having a well-conducted meta-
analysis or systematic review provides stronger
evidence than a single study, and 2) a meta-
analysis or systematic review is only as good as
the individual studies that comprise it.
An excellent website that graphically displays the
different types of research methods and designs
can be found at the SUNY Downstate Medical
Center, Evidence Based Medicine Course, Guide to
Research Methods - The Evidence Pyramid: http://
library.downstate.edu/EBM2/2100.htm.
Evidence-Based Decision Making Skills
and the 5-Step Process
The principles of EBDM methodology are based on
the abilities to find, critically appraise, and correctly
apply current evidence from relevant research to
decisions made in practice so that what is known
is reflected in the care provided. The EBDM skills
and 5-step process are outlined in Table 4.
The following procedures provide an overview of
the five steps and skills involved in establishing an
evidence-based practice.
1. Converting information needs/problems into
clinical questions so they can be answered –
the PICO process.
Asking the right question is a difficult skill to
learn, yet it is fundamental to evidence-based
practice. The process almost always begins
with a patient question or problem. A “well-built”
question should include four parts, referred to
as PICO that identify the Patient Problem or
Population (P), Intervention (I), Comparison (C),
and Outcome(s) (O).
2
2. Conducting a computerized search with
maximum efficiency for finding the best
external evidence with which to answer the
question.
This type of search requires a shift in thinking.
Often, especially now with fast web-based
search engines, health professionals can look
for “something” on a topic, a quick answer, or for
“everything.” Finding relevant evidence requires
conducting a focused search of the peer-
reviewed professional literature based on the
Figure 3. Available Literature and its Relevance

8
Crest® Oral-B
®
Table 3. Type of Question Related to Levels of Evidence and Study Methodology
Table 4. Skills needed to apply the EBDM Process
2

9
Crest® Oral-B
®
good patient care decisions. Differences
between groups in clinical trials are generally
straight forward when expressed in terms
of the mean values; whereas, results
presented as proportions, such as relative
risk reduction, absolute risk reduction, odds
ratio and numbers needed to treat (NNT),
are more challenging to understand. Also,
understanding the difference between
statistical and clinical significance will help you
in translating and determining if the findings
apply to your patient.
5. Evaluating the process and your
performance
The final step in EBDM is evaluation of the
effectiveness of the process. Mastering the
skills of evidence based decision making takes
practice and reflection and a clinician who is
new to the steps should not be discouraged
by early difficulties encountered. Evaluating
the process of EBDM may include a range
of activities such as examining outcomes
related to the health/function of the patient
and patient satisfaction. Self-evaluation of
developing skills is a most critical aspect in
mastery of EBDM. With an understanding of
how to effectively use EBDM, you can quickly
and conveniently stay current with scientific
findings on topics that are important to you and
your patients.
Evidence-Based Decision-Making in
Action
The PICO Process (Skill/Step 1)
The formality of using PICO to frame the question
forces the questioner to focus on what the patient/
client believes is the most important problem
and the desired outcome. Doing this facilitates
selecting language or key terms for conducting
the computerized search, the second step in the
process. Next, it allows you to determine the type
of evidence and information required to solve
the problem and the outcome measures that will
be used to determine the effectiveness of the
intervention.
One of the greatest difficulties in developing
each aspect of the PICO question is providing an
adequate amount of information without being too
detailed. Each component of the PICO question
appropriate methodology. Online databases
and software that enable quick access to the
literature have made it easier to locate relevant
clinical evidence.
44
Knowing what constitutes the highest levels
of evidence and how to apply evidence-based
filters and limits will let you search the literature
with maximum efficiency. It is the combination
of technology and good evidence that allows
healthcare professionals to apply the benefits
from clinical research to patient care.
44
To assist professionals in keeping up with the
literature and in making it possible to quickly
find needed information without leaving your
location, online access to MEDLINE, provided
by the National Library of Medicine (NLM),
is now available. They also provide a free
version of MEDLINE called PubMed that can
be accessed at http://www.pubmed.gov
3. Critically appraising the evidence for
its validity and usefulness (clinical
applicability).
Once you have found the most current
evidence, the next step in the EBDM process is
to understand what you have and its relevance
to your patient and the PICO question.
Resources are available to help you critically
appraise individual research studies and
meta-analyses or systematic reviews. They
consist of a worksheet with a structured series
of questions that can help you determine the
strengths and weaknesses of how a study was
conducted and how useful and applicable the
evidence is to the specific patient problem or
question being asked.
45-47
4. Applying the results of the appraisal, or
evidence, in clinical practice.
Once the methods are determined to be valid,
the fourth step is to determine if the results,
potential benefits or harms, are important.
This is achieved by looking at whether
there is an association between specific
treatments and outcomes or exposures,
the strength of that association, and the
condition of interest, i.e., your patient problem
or question. Understanding how to present
statistical information to patients in a clear
and unambiguous manner will help in making

10
Crest® Oral-B
®
Applying the PICO Process
The first step in developing a well-built question is
to identify the patient problem or population [P] by
describing either the patient’s chief complaint or
by generalizing the patient’s condition to a larger
population. The problem is further shaped or
refined by the most important characteristics that
might influence the results such as:
• Level of disease or health status
• Age, race, gender, previous conditions, past
and current medications
In Mr. Logan’s case, we know the chief complaint
is discoloration of his front teeth and that coffee
and tobacco are contributing factors. So, in
addition to the chief complaint, age, and current
habits, previous behaviors may influence the
decision as to which treatment might be most
appropriate.
Identifying the Intervention [I] is the second step
in the PICO process. It is important to identify
what you plan to do for that patient. This may
include the use of a specific diagnostic test,
treatment, adjunctive therapy, medication, or the
recommendation to the patient to use a product
or procedure. The intervention is the main
consideration for that patient.
4
In Mr. Logan’s
case, the intervention being considered is the
Crest Whitestrips™ since he has specifically
asked about them. This also keeps the process
patient-centered.
The third phase of the well-built question is the
Comparison [C], which is the main alternative
(intervention) you are considering.
2
It should be
specific and limited to one alternative choice,
usually the gold standard, in order to facilitate an
effective computerized search. The Comparison
is the only optional component in the PICO
question since there may not be an alternative,
however when there is one, it should be used. In
our case, we have selected the custom trays for
at-home bleaching as the main alternative.
The final aspect of the PICO question is the
outcome [O]. This specifies the result(s) of what
you plan to accomplish, improve, or affect, and it
should be measurable. Examples of outcomes
are relieving or eliminating specific symptoms,
should be stated as a concise short phrase as
illustrated in the following case example.
Case Example
Your new patient, Mr. Jim Logan, is a 48-year
old marketing executive. His chief complaint
is the/discoloration of his front teeth, which he
feels is getting worse as he gets older. He would
like them to be as white as they were when he
was 25 and even brought in a picture to show
you. He would like them whitened within one
week before he attends his 30-year high school
reunion. When reviewing his health history
and behaviors, you learn that Mr. Logan is a
coffee drinker and recently stopped smoking.
Upon examination, you determine his only
treatment needs are preventive care and suggest
you re-evaluate the discoloration after that
appointment since the stain could be removed
during his prophylaxis. If additional treatment is
needed, you can make him custom trays for use
with an at-home whitening/bleaching system.
You present the bleaching procedure options
and related fees to Jim. He questions you about
the differences between them and the Crest
Whitestrips™ that do not require a tray and can
be purchased at the local grocery store. Jim
insists the whitening strips are just as effective
and cost considerably less.
You are not familiar with the latest scientific
literature on the whitening strips to answer
Mr. Logan’s questions thoroughly. You tell
him you know the bleaching procedures you
have suggested are safe, effective, and can
produce the desired outcomes within the desired
time. However, you tell him you will be glad to
investigate the Whitestrips option so each of
you are fully informed about the pros and cons
of each method before selecting a treatment.
With the popularity of these treatment options
and new products introduced quite frequently,
this information will be a valuable addition to the
evidence-based “library” you are creating in your
office. To find the answer, you must define Jim’s
question so it facilitates an efficient search of
the literature. To guide this process, the PICO
Worksheet and Search Strategy form can assist
you. (Table 5)

11
Crest® Oral-B
®
Structuring the PICO Question
After understanding the elements of PICO and
identifying the patient’s concerns, you are now
ready to structure the PICO question for Mr.
Logan’s case.
P = Patient Problem or Population
The first part of the PICO question begins
with the following phrase: For a patient with...
Inserting the patient’s chief complaint or condition
completes this phrase. For Mr. Logan, this
phrase can be completed as follows:
“For a patient with tooth discoloration due to
coffee and tobacco”.
improving or maintaining function, and enhancing
esthetics. In Mr. Logan’s case, you are seeking
evidence to demonstrate the effectiveness of
the whitening/bleaching treatment under a given
set of conditions, i.e., effective in whitening his
teeth within one week so they appear as white as
they were when he was 25 years old. Outcomes
yield better search results when defining them
in specific terms. “More effective or just as
effective” is not acceptable unless it describes
how the intervention is more effective. For our
example, just as effective in whitening teeth within
one week is the desired outcome.
Table 5. PICO Worksheet for Mr. Logan’s Case
©2001 SA Miller, PICO Worksheet, National Center for Dental Hygiene Research

12
Crest® Oral-B
®
could be used in the search are ‘tooth bleaching’
or ‘tooth whitening’ or ‘Crest Whitestrips’ or
‘whitening strips’ as well as ‘hydrogen peroxide’ or
‘carbamide peroxide.’ An example of a completed
PICO Worksheet for Mr. Logan’s case is shown in
Table 6.
Benefits of EBDM
EBDM provides a strategy for improving the
efficiency of integrating new evidence into patient
care more rapidly by helping you manage an
increasing amount of information. EBDM assists
you in developing treatment plans and providing
treatment and advice that are scientifically
defensible. In addition, it helps insure that your
practice is continually informed and strengthened
by current research findings, helping to close the
gap between what is known (research evidence)
and what is practiced.
EBDM is not about knowing all the answers,
but rather about knowing how to structure good
questions to be able to find relevant information to
better inform your decision making, and how and
when to integrate new thinking and action into
everyday practice.
Conclusion
Recognizing that clinicians have time constraints
and yet want to provide the best possible care
to their patients, an evidence-based approach
offers clinicians a convenient method of finding
current research to support clinical decisions,
answer patient questions, and explore alternative
treatments, procedures, or materials. With an
understanding of how to effectively use EBDM,
practitioners can quickly and conveniently stay
current with scientific findings on topics that are
important to them and their patients.
I = Intervention
The main intervention being considered is Crest
Whitestrips™, so the question now reads:
coffee and tobacco, will Crest Whitestrips”.
C = Comparison
The comparison phrase is stated “as compared
to” the main alternative, which in this case is
custom trays for use with an at-home whitening/
bleaching system. The question now reads:
coffee and tobacco, will Crest Whitestrips,
as compared to custom trays for use with an
at-home whitening/bleaching system”.
O = Outcome(s)
Mr. Logan’s main concern is the discoloration of
his teeth and having his teeth as white as they
were when he was 25 years old within a 1 week
period. The outcome(s) is then phrased as, be
as effective in whitening his teeth within 1 week.
Based on these four parts, the complete PICO
question can be stated as:
coffee and tobacco, will Crest Whitestrips,
as compared to custom trays for use with an
at-home whitening/bleaching system, be as
effective in whitening his teeth within 1 week?”
Following the PICO Worksheet (Table 5), you
would then identify the type of question and study
and then list any additional terms or phrases
related to the already identified P, I, C, and O.
By generating these words, alternative key terms
are identified that facilitate finding evidence to
answer your question, Step 2, conducting a
computerized search with maximum efficacy, in
the EBDM process. For example, key terms that

13
Crest® Oral-B
®
Table 6. Completed PICO Worksheet for Mr. Logan’s Case
©2001 SA Miller, PICO Worksheet, National Center for Dental Hygiene Research

14
Crest® Oral-B
®
Course Test Preview
To receive Continuing Education credit for this course, you must complete the online test. Please go to
www.dentalcare.com and find this course in the Continuing Education section.
1. The following components define evidence-based practice:
a. Clinical expertise
b. Patient values
c. Scientific research
d. A and C
e. A, B, and C
2. The purpose of EBDM is to _______________.
a. emphasize new research findings
b. close the gap between research and practice
c. defer to patients wishes
d. use expert opinions
e. None of the above.
3. EBDM is just a new term for clinical decision-making.
a. True
b. False
4. EBDM requires online searching skills and understanding research methods.
a. True
b. False
5. Evidence can change over time as new research studies are conducted.
a. True
b. False
6. All of the following reasons have contributed to the need of EBDM except:
a. Variations in practice patterns
b. Delays in adopting useful procedures
c. Keeping current in practice
d. Managing the information overload
e. Incorporated in accreditation standards
7. The highest level of evidence is the same for treatment and prognosis questions.
a. True
b. False
8. Which of the following provides the highest level of evidence for therapy questions?
a. Case Control Study
b. Cohort Study
c. Systematic Review of RCTs
d. Randomized Controlled Trial
e. Case Report
9. Systematic reviews provide a higher level of evidence than a single study.
a. True
b. False

15
Crest® Oral-B
®
10. As you progress up the levels of evidence, the amount of available literature also increases.
a. True
b. False
11. As you progress up the levels of evidence, the literature becomes more relevant for
answering therapy related questions.
a. True
b. False
12. The first step in the EBDM process is _______________.
a. finding the best evidence
b. applying the results to patient care
c. asking a good clinical question
d. evaluating the results
e. critically appraising the evidence
13. Which of the following characteristics describes the Intervention in the PICO process?
a. What you plan to do
b. Main concern or chief complaint
c. Measurable result
d. Alternative
14. The only optional component of the PICO question is:
a. P (Patient Problem or Population)
b. I (Intervention)
c. C (Comparison)
d. O (Outcomes)
15. Select the most appropriate PICO question:
a. Is using Mouthwash ‘x’ as effective as flossing?
b. For a patient, is Mouthwash ‘x’ as compared to flossing as effective?
c. For mild gingivitis is Mouthwash ‘x’ as effective compared to flossing?
d. For a patient with mild gingivitis, is rinsing with Mouthwash ‘x’ as compared to flossing as
effective in reducing plaque and eliminating gingivitis?
16. Select the PICO component that is missing or incomplete from this question: For a patient
with periodontal disease, will antimicrobial therapy (minocycline HCI) in conjunction with
scaling and root planing be more effective in preventing further attachment and bone loss?
a. P (Patient Problem or Population)
b. I (Intervention)
c. C (Comparison)
d. O (Outcomes)
17. Benefits of the EBDM process include:
a. Provides a strategy for improving the efficiency of integrating new research evidence into
patient care more rapidly by helping you manage an increasing amount of information.
b. Assists in developing treatment plans and providing treatment and advice that are scientifically
defensible.
c. Helps insure that practice is continually informed and strengthened by current research findings.
d. All of the above.
e. A and C

16
Crest® Oral-B
®
References
1. Evidence-Based Medicine Working Group. Evidence-based medicine. A new approach to teaching the
practice of medicine. JAMA. 1992 Nov 4;268(17):2420-5.
2. Sackett D, Straus S, Richardson W. Evidence-Based Medicine: How to Practice & Teach EBM.
London, England: Churchill Livingstone, 2000.
3. American Dental Association. Professional Issues and Research, ADA Guidelines, Positions and
Statements, ADA Policy on Evidence-based Dentistry. 2002.
4. Eisenberg J. Statement of health care quality before the house subcommittee on health and the
environment, 10/28/97. Agency for Health Care Policy and Research Archive 97 A.D.
5. Haynes RB. Some problems in applying evidence in clinical practice. Ann N Y Acad Sci. 1993 Dec
31;703:210-24.
6. Institute of Medicine. Dental education at the crossroads, challenges and change. Washington, DC:
National Academy Press, 1995.
7. Davidoff F. In the teeth of the evidence: the curious case of evidence-based medicine. Mt Sinai J Med.
1999 Mar;66(2):75-83.
8. Davidoff F, Case K, Fried PW. Evidence-based medicine: why all the fuss? Ann Intern Med. 1995
May 1;122(9):727.
9. Evidence-based Medicine Working Group. Users’ Guides to the Medical Literature, A Manual for EB
Clinical Practice. Chicago: AMA, 2002.
10. Palmer J, Lusher A, Snowball R. Searching for the evidence. Genitourin Med. 1997 Feb;73(1):70-2.
11. Greco PJ, Eisenberg JM. Changing physicians’ practices. N Engl J Med. 1993 Oct 21;329(17):1271-3.
12. NHS Centre for Reviews and Dissemination, University of York. Undertaking Systematic Reviews of
Research on Effectiveness. University of York website. 1997. Accessed: 9/10/04
13. Long A, Harrison S. The balance of evidence. Evidence-based decision making. Health Services
Journal, Glaxo Welcome Supplement 1995;6:1-2.
14. Bader JD, Shugars DA. Variation in dentists’ clinical decisions. J Public Health Dent. 1995
Summer;55(3):181-8.
15. Committee on Quality of Health Care in America, IOM. Crossing the Quality Chasm: A New Health
System for the 21st Century. Washington DC: The National Academy of Sciences, 2000.
16. Verdonschot EH, Angmar-Månsson B, ten Bosch JJ, Deery CH, Huysmans MC, Pitts NB, Waller E.
Developments in caries diagnosis and their relationship to treatment decisions and quality of care.
ORCA Saturday Afternoon Symposium 1997. Caries Res. 1999;33(1):32-40.
17. Bader JD, Shugars DA. Variation, treatment outcomes, and practice guidelines in dental practice.
J Dent Educ. 1995 Jan;59(1):61-95.
18. Ecenbarger W. How honest are dentists? Reader’s Digest, February 1997. 50-6.
19. Bogacki RE, Hunt RJ, del Aguila M, Smith WR. Survival analysis of posterior restorations using an
insurance claims database. Oper Dent. 2002 Sep-Oct;27(5):488-92.
20. Yingling NM, Byrne BE, Hartwell GR. Antibiotic use by members of the American Association of
Endodontists in the year 2000: report of a national survey. J Endod. 2002 May;28(5):396-404.
21. Epstein JB, Chong S, Le ND. A survey of antibiotic use in dentistry. J Am Dent Assoc. 2000
Nov;131(11):1600-9.
22. Anderson G, Allison D. Intrapartum electronic fetal heart rate monitoring: A review of current status for
the Task Force on the Periodic Health Examination. Preventing Disease. Beyond the Rhetoric. New
York: Springer-Verlag, 1990: 19-26.
23. Crowley P, Chalmers I, Keirse MJ. The effects of corticosteroid administration before preterm delivery:
an overview of the evidence from controlled trials. Br J Obstet Gynaecol. 1990 Jan;97(1):11-25.
24. Frazier P, Horowitz A. Prevention: A public health perspective. Oral Health Promotion and Disease
Prevention. Copenhagen, Denmark: Munksgaard, 1995.
25. Grimes DA. Graduate education. Evidence-Based Medicine 1995; 86(3):451-457.
26. Selwitz RH, Winn DM, Kingman A, Zion GR. The prevalence of dental sealants in the US population:
findings from NHANES III, 1988-1991. J Dent Res. 1996 Feb;75 Spec No:652-60.
27. Healthy People 2010. Oral Health Section, #21. Accessed January 21, 2008. PDF document

17
Crest® Oral-B
®
28. Gravois SL, Bowen DM, Fisher W, Patrick SC. Dental hygienists’ information seeking and computer
application behavior. J Dent Educ. 1995 Nov;59(11):1027-33.
29. Covington P, Craig BJ. Survey of the information-seeking patterns of dental hygienists. J Dent Educ.
1998 Aug;62(8):573-7.
30. Schleyer TK, Forrest JL, Kenney R, Dodell DS, Dovgy NA. Is the Internet useful for clinical practice?
J Am Dent Assoc. 1999 Oct;130(10):1501-11.
31. Ramsey PG, Carline JD, Inui TS, Larson EB, LoGerfo JP, Norcini JJ, Wenrich MD. Changes over
time in the knowledge base of practicing internists. JAMA. 1991 Aug 28;266(8):1103-7.
32. Forrest JL, Horowitz AM, Shmuely Y. Caries preventive knowledge and practices among dental
hygienists. J Dent Hyg. 2000 Summer;74(3):183-95.
33. Yellowitz JA, Horowitz AM, Drury TF, Goodman HS. Survey of U.S. dentists’ knowledge and
opinions about oral pharyngeal cancer. J Am Dent Assoc. 2000 May;131(5):653-61.
34. Forrest JL, Drury TE, Horowitz AM. U.S. dental hygienists’ knowledge and opinions related to
providing oral cancer examinations. J Cancer Educ. 2001 Autumn;16(3):150-6.
35. Niederman R, Chen L, Murzyn L, Conway S. Benchmarking the dental randomized controlled
literature on MEDLINE. EBD 2002; 3:5-9.
36. Forrest JL, Miller S. A bibliometric study of research related to clinical dental hygiene practice.
Unpublished research report, 2006. PDF document
37. American Dental Association Commission on Dental Accreditation. Accreditation Standards for
Dental Education Programs. Chicago: ADA, 2002, pp.6-7. PDF document
38. ADEA Center for Educational Policy and Research. Competencies for the New Dentist (As approved
by the 1997 House of Delegates). Journal of Dental Education 2003; 67(7):1-3. PDF document
39. American Dental Education Association. Compendium of curriculum Guidelines for Allied Dental
Education Programs. ADEA Website 2005;123-8. Accessed January 22, 2008
40. McKibbon A, Eady A, Marks S. PDQ, Evidence-Based Principles and Practice. Hamilton, Ontario:
B.C. Decker Inc., 1999.
41. Phillips B, Ball C, Sackett D, Badenoch D, Straus S, Haynes RB et al. Levels of Evidence and
Grades of Recommendations. Centre for Evidence-Based Practice, 2001. Accessed January 22,
2008.
42. Haynes RB, Wilczynski N, McKibbon KA, Walker CJ, Sinclair JC. Developing optimal search
strategies for detecting clinically sound studies in MEDLINE. J Am Med Inform Assoc. 1994 Nov-
Dec;1(6):447-58.
43. Duke University Medical Center Library, Health Sciences Library University of North Carolina at
Chapel Hill. Introduction to Evidence-Based Medicine, The Well-build Clinical Question. Duke
University Medical Center Library and Health Sciences Library University of North Carolina at Chapel
Hill. Accessed January 22, 2008.
44. Rosenberg W, Donald A. Evidence based medicine: an approach to clinical problem-solving. BMJ.
1995 Apr 29;310(6987):1122-6.
45. Critical Appraisal Skills Programme. 10 Questions to help make sense of the literature. CASP
Institute of Health Sciences . Public Health Resources Unit. Accessed 8-29-07. PDF document
46. Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving
the quality of reports of parallel-group randomised trials. Lancet. 2001 Apr 14;357(9263):1191-4.
47. Moher D, Cook DJ, Eastwood S, Olkin I, Rennie D, Stroup DF. Improving the quality of reports of
meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of
Meta-analyses. Lancet. 1999 Nov 27;354(9193):1896-900.

18
Crest® Oral-B
®
About the Author
Jane L. Forrest, EdD, BSDH
Dr. Forrest is the Chair of the Behavioral Science Section, Division of Dental Public
Health and Pediatric Dentistry, at the University of Southern California Herman
Ostrow School of Dentistry, Los Angeles, CA and is the Director of the National
Center for Dental Hygiene Research & Practice. Dr. Forrest has served as the
pre-Conference workshop chair for both the 1st and 2nd International Conferences
on Evidence-Based Dentistry and as an instructor for the ADA’s Evidence-Based
Champion’s Conferences.
Dr. Forrest is the lead co-author on a new book, “Evidence-Based Decision Making: A Translational
Guide for Dental Professionals” and has chapters published on EBDM in the recent editions of Clinical
Periodontology and in the 2nd edition Dental Hygiene Concepts, Cases and Competencies. She is
active in professional associations and serves on several editorial boards including as an Associate
Editor for the Journal of Evidence-Based Dental Practice.
Email: jforrest@usc.edu

Evidence based dentistry

More Related Content

What's hot

Viewers also liked

Similar to Evidence based dentistry

Recently uploaded

Evidence based dentistry