. Evidence-based dentistry (EBD) is the integration and interpretation of the available current research evidence, combined with personal experience. It allows dentists, as well as academics researchers, to keep update of the new developments and to make decisions that should improve their clinical practice.

1. DR.ANNTHERESATOMY
1STYEAR P.G
EVIDENCE BASED PERIODONTICS

2. INTRODUCTION
Traditionally, clinical decisions in dentistry have been based on the experience of the clinical dentist.
If a given treatment seemed to work, it was utilized again; if the results were disappointing, the procedure was
deserted.
Evaluating clinical treatment in this fashion is difficult because it is hard to know which factors are important for
success and which ones contribute to failure.
This came with the concept of evidence based approach which facilitates conclusions for clinical practice based
on sound research studies.
 The ability to find, discriminate, evaluate, and use information is the most important skill that can be learned as a
professional. Becoming excellent at this skill will provide a rewarding and fulfilled professional career.

3. What is evidence?
What was the need for evidence?
▪ Evidence is based on the existence of at least one well-conducted
randomized control trial (RCT) – Triveni et al IOSR-JDMS(july2015)
▪ The classic example for the need for evidence is William Hunter’s
focal infection theory which was originally proposed in 1900, but was
later discarded in 1940s due to lack of proper evidence.
▪ Again the theory was accepted in 1989, due to studies which proved
the same with proper evidence.

4. Evidence based medicine
▪ EBM is defined as “the integration of the best research evidence with clinical expertise and
patient values.”
 EBDM focuses on solving clinical problems and involves two fundamental principles, as
follows:
1. Evidence alone is never sufficient to make a clinical decision.
2. Hierarchies of quality and applicability of evidence exist to guide clinical decision making.

5. A definition for evidence based dentistry?
▪ Evidence Based Dentistry According to the American Dental Association (ADA),
▪ Evidence-based dentistry (EBD) is an approach to oral health care that requires
the judicious integration of systematic assessments of clinically relevant
scientific evidence, relating to the patient’s oral and medical condition and
history, with the dentist’s clinical expertise and the patient’s treatment needs and
preferences.

6. According to Sacketts (2000), Evidence-based practice involves integrating individual clinical practice with
the best available external clinical evidence from systematic research.
Mosby’s Medical Dictionary has stated that evidence-based dentistry is “a systematic practice of dentistry
in which the dentist finds, assesses, and implements methods of diagnosis and treatment on the basis of the
best available current research, their clinical expertise, and the needs and preferences of the patient”

7. Skills and abilities needed to apply evidence
based decision – making process
▪ Convert information ,needs and problems into clinical questions so that they can be
answered
▪ Conduct a computerized search with maximum efficiency for finding the best external
evidence with which to answer question
▪ Critically appraise the evidence for its validity and usefulness
▪ Apply the results of appraisal or evidence in clinical practise
▪ Evaluate the process and your performance

8. What are the components of evidence based research?
COMPONENTS
OF EBD
EVIDENCE
PATIENT
PREFERENCES
AND NEEDS
CLINICAL
EXPERTISE

9. Principles of evidence based dentistry
▪ Getting the best information quickly
▪ Assessing its quality
▪ Deciding whether its relevant
▪ Best identified valid and relevant evidence used in patient care

10. ▪ Advantages of evidence-based approach compared with other assessment
methods
▪ The EBA is:
1. Objective.
2. Scientifically sound.
3. Patient-focused.
4. Incorporates clinical experience.
5. Stresses good judgement.
6. Is thorough and comprehensive
. 7. Uses transparent methodology.
Limitations for getting good evidence
1.Inadequate steps to control bias in a study.
2. Insufficient number of participants studied.
3. Ignoring questions and outcomes of interest to patients.
4. Lack of rigorous scientific data to support clinical practices.

11. Some of terminologies used in evidence based approach
Bias
Confounding:
Confidence
Interval
Odds ratio
Chance:
Naturalism
Interaction:
Process
Interpretation
Systematic
review

12. EVIDENCE BASED PERIODONTOLOGY
▪ Periodontology has a rich background of research and scholarship.
▪ The substantial and extensive periodontal information base, developed over the years,
has provided a rational basis for choosing the best treatment for patients.
▪ Appraisal of this information has being an on-going and continuous effort by the
American Academy of Periodontology (AAP) to ensure that the most accurate and
efficacious concepts and technologies are used to provide care and stimulate innovation

13. ▪ Aims to facilitate the efficient use of research data, accelerating the introduction of the best
research into patient care.
▪ Muir Gray 1997: "An approach to decision making in which the clinician uses the best
evidence available in consultation with the patient, to decide upon the options that suits that
patient best .
▪ Evidence based periodontology is an approach to patient-care and nothing more.

14. Goal of evidence based periodontology
▪ To help the periodontist provide the best care of their patient

15. The similarities between the two are:
High value of clinical skills and experience
Fundamental importance of integrating evidence with patient values

16. Components Of Evidence-Based Periodontology

17. Framing the answerable question –P I C O
Problem
Describes a particular
group of patients may
include primary problem,
disease or coexisting
conditions
Intervention
Includes main intervention
prognostic factor or exposure
Comparator
Describe the main
alternative
OUTCOME
What is being
accomplished ,improved
,measured

18. EXAMPLE
▪ IN PATIENTS WITH PERIODONTAL DISEASE ,WILL SHORT
TERM SYSTEMIC ANTIBIOTICS ,WHEN COMPAREDTO
SURGERY , REDUCE POCKET DEPTH?

19. ▪ The formality of using PICO to frame the question serves three key purposes, as follows:
▪ 1. PICO forces the clinician to focus on what he or she and the patient believe to be the most
important single issue and outcome.
▪ 2. PICO facilitates the next step in the process, the computerized search, by identifying key terms that
will be used in the search.
▪ 3. PICO directs the clinician to identify clearly the problem, the results, and the outcomes related to
the specific care provided to that patient.
▪ This in turn allows identification of the type of evidence and information required to solve the
problem, as well as considerations for measuring the effectiveness of the intervention and the
application of the EBDM process.

20. Source of evidence
Primary source
▪ Original research publications
that have not been filtered or
synthesized
▪ Available online electronic
journals
Secondary source
▪ Synthesized publication of the primary
literature
▪ Includes: systematic reviews
meta analysis
evidence based article review
Clinical practise guidelines protocols

21. Primary source of evidence
▪ The PICO question provides the foundation for the search terms used in the database.
▪ PubMed is designed to provide access to both primary and secondary research from
the biomedical literature
▪ PubMed provides access to MEDLINE, the National Library of Medicine’s premier
bibliographic database covering the fields of medicine, nursing, dentistry, veterinary
medicine, the health care system, and the preclinical sciences

22. Secondary
▪ These resources include summaries of SRs and individual research articles, as well as clinical
practice
▪ Summaries of Systematic Reviews and Research Articles.
▪ Evidence-based journals are an emerging resource designed specifically to assist clinicians.
▪ . A one- to two-page structured abstract, with an expert commentary highlighting the most
relevant and practical information, is generally provided.
▪ provide concise and easy-to-read summaries of original research articles and of systematic
reviews selected from the biomedical literature.

23. Databases for search
▪ MEDLINE (PUBMED)
▪ EMBASE
▪ HEALTH STAR
▪ CINALH
▪ The COCHRANE COLLABORATION LIBRARY

25. Levels of Evidence
▪ The highest level of evidence, or the “gold standard,” is the systematic review (SR) and
metanalyses using two or more randomized controlled trials (RCTs) of human subjects.
▪ Meta-analysis is a statistical process often used with SRs.
▪ It involves combining the statistical analyses of several individual studies into one
analysis.
▪ When data from these studies are pooled, the sample size and power usually increase.
▪ As a result, the combined effect can increase the precision of estimates of treatment
effects and exposure risks.

26. Systematic Reviews
▪ Systematic reviews are a research design termed research synthesis. That is, they use research
methodology to pool data from multiple studies that address a particular hypothesis.
▪ A systematic review can be defined as a review of a clearly formulated question that attempts
to minimize bias using systematic and explicit methods to identify, select, critically appraise
and summarize relevant research.

27. OBJECTIVES OF SYSTEMATIC REVIEW
▪ To provide a comprehensive and contemporary appraisal of research
using transparent methods while aiming to minimize the bias
▪ To aid in clinical decision making

28. What A High Quality Systematic Review Can Do:
1. Find and summarize all available studies.
2. Provide an objective assessment of the quality or research and in particular the degree of protection
from bias within the original studies.
3. Estimate research effects across multiple studies with meta-analysis.
a. Meta-analysis is valid only if studies are similar in their research question and design.
b. Meta-analysis can estimate uncertainty and precision of the effect.
c. Meta-analysis may generate hypotheses for differential effects across subgroups of the population
tested.
4. If the effect is consistent across multiple studies (with small differences in design), then it may more
readily possible to generalise the results to clinical practice than the results from a single study
5. Overcome limitations of underpowered studies in detecting a true difference if such a true difference
really exists.

29. What A High Quality Systematic Review Cannot Do:
1. It cannot be used in isolation to dictate clinical practice.
2. It is a synthesis of available research and must be used in context with clinical judgement and patient preference.
3. Produce strong conclusions if the research base is weak in quality.
4. Overcome limitations of narrowly designed clinical research.
5. Exclude relevant studies. Although the majority of hits from the search will be excluded, this is due to the deliberate
strategy of achieving high sensitivity (likelihood of finding all relevant studies) but low precision (likelihood of only finding
relevant studies). Therefore, it is common to find that more than 90% of the search records are totally irrelevant to the
question and must be excluded.
6. Be a miracle research design: All research has strengths and limitations/weaknesses. Systematic reviews are no different
from other research designs in this respect

30. Meta analysis
▪ A statistical analysis that combines or integrates the results of several
independent clinical trials considered by the analyst to be combinable
▪ Types of meta analysis : pooled or quantitative
methodologic or qualitative

31. Evidence-based approach (EBA) in periodontal
therapy will be dealt under the following topics
▪ EBA and mechanical nonsurgical pocket therapy
▪ Effect of smoking on Non-surgical pocket therapy (NST)
▪ EBA in periodontal regeneration
▪ EBA and mucogingival surgery
▪ EBP and open flap debridement

32. EBA and mechanical nonsurgical pocket
therapy
▪ A total of nine reviews were searched for the best evidence .
▪ NST was found to have a positive effect with the exception
of pockets <3 µm.
▪ Patient, environmental, and operator factors affect therapy
delivery.
▪ No difference was found between the effect of hand and
machine-driven instruments.
▪ Machine-driven instruments were faster than hand-driven
instruments.

33. Effect of smoking on nonsurgical therapy
▪ Systematic review of the effect of smoking on NST was conducted by Labriola et al.
▪ Search strategy included Medline, Embase and Central. Study design was controlled
clinical trial.
▪ The outcomes were:
▪ There was reduced pocket depth reduction in smokers, compared with non-smokers.
▪ There was no significant difference in the change
▪ Clinical Attachment Level (CAL) between smokers and non-smokers.
▪ The reason could be that the increased vasoconstriction in peripheral blood vessels of
smokers leads to decrease in bleeding and edema. Also, smokers would have less
potential for resolution of inflammation and edema within the marginal tissues and
therefore less potential for gingival recession.

34. Evidence-based approach in periodontal
regeneration
▪ Guided Tissue Regeneration
▪ The study population included chronic periodontitis patients in
subjects 21 years or older.
▪ The outcomes assessed were:
▪ Short-term clinical outcomes It included soft tissue changes such as
increased CAL and decreased PPD.
▪ Long-term clinical outcomes It included disease recurrence and tooth
loss.
▪ Patient-centered outcomes It included various factors such as ease of
maintenance, change in esthetics, p/o complications, cost/benefit ratio,
and patient well-being.

35. ▪ The meta-analysis done by Needleman et al and Murphy et al , revealed
that:.
▪ When compared with open flap debridement (OFD), guided tissue
regeneration (GTR) showed increase in CAL, decrease in PPD, and defect
fill.
▪ When GTR with bone substitutes was compared with GTR alone, the results
were similar.
▪ No evidence was found for difference in use of ePTFE versus bioabsorbable
membranes.
▪ Long-term clinical outcomes/patient centered outcomes could not be
determined due to lack of available data. Heterogeneity was large and bias
could not be eliminated

36. Evidence on mucogingival therapy
▪ Carlo Clauser in his meta-analysis found that:
▪ All the surgical procedures allow complete root coverage.
▪ Connective tissue grafting achieves complete root coverage more
frequently than does GTR.
▪ The probability of complete root coverage is high if the initial
recession is shallow, irrespective of the surgical procedure employed.
▪ The probability of achieving complete root coverage decreases
dramatically as the initial recession depth increases.

37. Evidence-based approach and open flap
debridement
▪ Systematic reviews were conducted by Heitz Mayfield et al and Antczak et al
▪ Clinical implications of the whole review regarding open flap debridement
▪ If pocket depth reduction is the main aim, surgical treatment is the treatment of
choice.
▪ If increase in clinical attachment level gain is the main aim, nonsurgical therapy is
of more benefit for shallow and moderate pockets and surgical therapy is the
treatment of choice for deep pockets.
▪ Predictability of treatment outcome at sites with furcation involvement or angular
defect is unclear.

38. Theprinciplesof evidence-basedhealthcareprovidestructureandguidanceto facilitatethehighestlevelsof patientcare.
Therearenumerouscomponentsto evidence-basedperiodontologyincludingtheproductionof bestavailableevidence,thecriticalappraisaland
interpretationof the evidence, thecommunicationanddiscussionof theevidenceto individualsseekingcareandtheintegrationof theevidencewithclinical
skillsandpatientvalues.
Hencegenerationof bestevidencealone,is notenoughto practiseevidence-basedhealthcare.
However,an understandingof theprinciplesshouldhelpto underpinthelatteraspects.
Evidence-basedhealthcareisnot aneasierapproachto patientmanagement,butshouldprovidebothcliniciansandpatientswithgreaterconfidenceand
trustintheirmutualrelationship.
CONCLUSION

39. REFERENCES
▪ Evidence-based Dentistry: Future Aspects Kanika Mahindra, Ashutosh Nirola
▪ Evidence - Based Periodontology - A Review of Dental Sciences Indian Journal E ISSN NO.
2231-2293 P ISSN NO. 0976-40031 Vishal Anand , Minkle Gulati , Bhargavi Anand
▪ Jeffcoat MK, McGuire M, Newman MG. Evidence based periodontal treatment: Highlights
from the 1996 World Workshop in Periodontics. J Am Dent Assoc 1997; 128:713-23
▪ Carranza 10th edition