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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 11  |  Issue : 4  |  Page : 180-184

Evidence-based dentistry: Effectual tool in decision-making


1 Department of Periodontology and Implantology, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Periodontics, Babu Banarasi Das College of Dental Sciences, Lucknow, Uttar Pradesh, India
3 Department of Periodontist, Private Practitioner, Lucknow, Uttar Pradesh, India

Date of Submission30-May-2019
Date of Decision08-Jul-2019
Date of Acceptance08-Jul-2019
Date of Web Publication1-Oct-2019

Correspondence Address:
Charu Tandon
Tandon Clinic, Main Market, Barabanki, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_59_19

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  Abstract 


The goal of evidence-based dentistry (EBD) is to help practitioners provide their patients with optimal care. The practice-related element in EBD is the clinician's integration of the resulting knowledge with clinical expertise, and patient preferences to determine the treatment to be recommended to individual patients. Periodontology has a rich history and a strong passion for science. Evidence-based periodontology is the application of evidence-based health care to periodontology. The substantial and extensive periodontal information base, developed over the years, has provided a rational basis for choosing the best treatment for patients. Various components of evidence-based periodontology include the production of the best available evidence, the critical appraisal and interpretation of the evidence, the communication and discussion of the evidence to individuals seeking care, and the integration of the evidence with clinical skills and patient values. Evidenced-based approach offers a bridge from science to clinical practice.

Keywords: Evidence, evidence based dentistry, evidence based periodontology


How to cite this article:
Tandon C, Singh PK, Singh I, Verma SC. Evidence-based dentistry: Effectual tool in decision-making. Indian J Dent Sci 2019;11:180-4

How to cite this URL:
Tandon C, Singh PK, Singh I, Verma SC. Evidence-based dentistry: Effectual tool in decision-making. Indian J Dent Sci [serial online] 2019 [cited 2019 Nov 19];11:180-4. Available from: http://www.ijds.in/text.asp?2019/11/4/180/268420




  Introduction Top


The two important fields of health care to be considered are the knowledge or science and the application of this knowledge to different specialties and clinical application to practice evidence-based dentistry (EBD). It relates the science to the clinical practice through the use of scientific methods in order to reach the best treatment for a specific clinical situation of the patient.[1]

The principles of evidence-based health care provide the structure and guidance to facilitate the highest levels of patient care. EBD is founded on clinical research.

A major push to integrate the principles of the evidence-based approach into the mainstream of clinical practice has come from the fact that there is great variation on both clinical decision-making and results of therapy.[2]

To incorporate an evidence-based approach in dental practice, the practitioner's experience is primary since it is his/her responsibility to consider clinically relevant evidence and informed patient's preferences while defining the best course of treatment.[3],[4]

The foundation for EBD was laid by Sackett who has defined it as “integrating individual clinical expertise with the best available external clinical evidence from systematic research.” 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.[5]

EBD has been derived from the term “Evidence-Based Medicine” which is defined as “the integration of the best research evidence with clinical expertise and patient values.”[6] The term was coined by the clinical epidemiology group at McMaster University in Canada. American Dental Association has defined EBD as: “an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patients oral and medical condition and history, together with the dentist's clinical expertise and the patient's treatment needs and preferences.”[7]

Evidence-based periodontology aims to facilitate the efficient use of research data, accelerating the introduction of the best research into patient care. A useful definition of evidence-based health care has been proposed by Muir Gray: “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 suit that patient best.”[8] It is a tool to support decision-making and integrating the best evidence available with clinical practice and is composed of various levels, which starts with the recognition of a knowledge gap. From this knowledge gap we can derive a focused question which will help in searching the relevant information from the literature.

Among the available hierarchy of evidence, systematic reviews and meta-analysis take the top position and contribute to the highest level of evidence, followed by randomized clinical trials (RCTs). These are followed by non-RCTs, cohort studies, case–control studies, cross-over studies, cross-sectional studies, case studies, and expert opinions.[9] Guidelines for EBD are applicable to peer-reviewed literature and also to publications and lectures that provide a case report or, at best a case series done under conditions that may not be similar to those seen in average dental office. By the knowledge of EBD, the clinician can readily evaluate the mass of data and choose, in an educated manner, what to use and what to discard.[10] Hence, it supplies guidelines to help the clinician make an intelligent decision.

The ultimate beneficiaries of EBD are members of the public, who will gather the reward of better care. The internet allows patients, as well as professionals, access to health-care information. The public, however, does not have the tools to evaluate the data adequately and must rely on their educated dentists to help sort facts from fiction. Patients will be more educated, more involved in their treatment decisions, and more appreciative of quality care. Dentists will also be benefitted from EBD. Instead of conducting free product testing for dental product manufacturers, practitioners will have at their disposal more valid research on which to predicate their clinical decisions. Researchers will benefit by being called upon to do the clinical testing necessary before new products are placed on the market.

EBD consists of five steps:[10]

  1. Convert the need for clinical information into an answerable question
  2. Find and rank the best evidence with which to answer the question
  3. Critically appraise the evidence for validity, impact, and applicability
  4. Integrate this evidence with clinical expertise and the patient's unique circumstances and preferences
  5. Evaluate effectiveness and efficiency in executing steps 1 through 4.



  Need of Evidence-Based Dentistry Top


In the current era, clinicians are expected to keep up with the advancements in dental therapies, materials, research, and clinical recommendations. There is an abundance of research-based and even anecdotal evidence supporting various aspects of dentistry. Both clinicians and patients have ready access to all kinds of online information using web browsers from the comfort of their offices or homes. It is therefore common for doctors and patients to use online resources for a quick search and to prepare for the upcoming medical/dental visit. Although online information is a great resource, it is often difficult for the clinicians and more so for the patients to evaluate the extensive literature available in terms of validity, quality of data, and reliability of information.[11]

It is important, especially with regard to patient safety, for dentists to be able to keep up to date with developments in diagnosis, prevention, and treatment of oral disease and newly discovered causes of disease. Advances in dentistry are usually first reported in dental journals, and in order to keep up with new research, health-care professionals need to feel confident that they can read and evaluate dental papers.

When examining the causes and treatment of diseases, we always see variation between people in whether they are affected by an exposure or treatment. We need to be able to judge whether any differences observed are due entirely too natural variation or an effect that is above and beyond that of natural variation. For example, to determine whether smoking is a cause of periodontitis or not, we could observe how many smokers develop the disease, but we need to ask, “How many nonsmoker would develop periodontitis?”

Clinical research allows us to make decisions about causes of and treatments for disease, while allowing for the natural differences between people. EBD is founded on clinical research.[5]


  Method of Practicing Evidence-Based Dentistry Top


EBD is built upon asking questions. These would arise in several ways, those instigated by the management of a single patient, a patient would like some information from you about some aspect of dentistry, operator may be interested in a particular topic which you have discussed with a colleague or you have read about in journals and other media.[12]

The main steps in practicing EBD are:

Define the question

Formulating the question will help to focus not only on the literature search but also on the interpretation of the information found, Sackett et al. suggest that a searcher might want to obtain either background information or foreground information. Background information related to a general understanding of a disorder, test, treatment, products, and other matter. These questions usually have two components. They start with who, what, where, when, why, or how and a verb that connects them to the item of interest.

Foreground questions, on the other hand, are more specific and relate to the management of the patient. These questions usually have four components:

  1. The patient problem or population (P)
  2. An intervention (I)
  3. The comparison (C)
  4. An outcome (O), referred to as PICO.


The question focuses the search terms and expedites the identification of strongest evidence that directly addressed the patient's problem from among the found titles. It provides dentist with good (but not compelling) evidence to support an answer to the patient. It also provides the dentist with a new piece of information to use next time the problem arises.[12]

Search for the information

There are many sources of information on dental treatments and on causes of oral diseases. Published articles in medical and dental journals are now easy to search online, using electronic databases such as Medline. Organizations such as the National Institute for Clinical Excellence produce summaries of the evidence on particular therapies and guidelines about their use.

Interpret the evidence

This is the most time-consuming step and is often seen as the most difficult aspect of reading research papers. Three aspects that are fundamental to interpreting research results are:

  1. The size of the effect of a treatment (or exposure). Is the effect large enough to be clinically important?
  2. Do the observed results represent a real effect, or are they likely to be a chance finding?
  3. Research results are always based on a sample of people (or objects), would we see similar results if we took another sample?


All research studies involve measuring outcome. If our aim is to determine whether to use a new treatment or not, it is the effect of treatment on a specified outcome measure that is examined. Hence, we always need to consider whether the measure used in a particular study is both meaningful and appropriate for addressing for original question that prompted us to search for the information.[12]

Outcomes can be described as true or surrogate endpoints. True endpoints are those that have a clear and direct clinical relevance to patients. For example, in dentistry, true endpoints are pain, tooth loss, esthetics, and quality of life related to oral health, all of which are tangible to the patient. Surrogate endpoints are measures that do not have an obvious impact that patients can identify easily. For example, periodontitis can be assessed in several ways, including measuring pocket depth or attachment level. Although simple to measure and objective, such surrogate outcomes are not always tangible to the patient. A surrogate outcome is usually assumed to be a precursor to true outcome.[13]

The evidence for routine scaling and polishing is an example in dentistry where a mixture of true and surrogate outcome measures have been used to determine whether this procedure is effective or not. Plaque, calculus, pocket depth, attachment change, and bacteriological assessments are easily defined surrogates but are relevant only if they relate closely to outcomes that matter to the patient, such as tooth loss or bleeding. These outcomes are more clinically relevant, but the evidence on how much they are affected by routine scaling and polishing is scanty. Since most research in this area has used surrogate outcomes, no conclusions, at present, can be made about the effectiveness of scaling and polishing.[14]

Act on the evidence

The information obtained from assessing the evidence should then be considered in relation to the question that prompted the dentist to undertake the search.[15]


  The Development of Evidence-Based Periodontology Top


Evidence-based periodontology is built upon developments in clinical research design throughout the 18th, 19th, and 20th centuries. Evidence-based medicine has only been known for just over a decade one of the earliest to take up the challenge in periodontology (in fact in oral health research overall) was Alexia Antczak Bouckoms in Boston, USA. She and her colleagues challenged the methods and quality of periodontal clinical research in the mid-1980s and setup an oral health group as part of the Cochrane Collaboration in 1994. The editorial base of the oral health group subsequently moved to Manchester University in 1997 with Bill Shaw and Helen Worthington as coordinating editors. The first Cochrane systematic review in periodontology was published in 2001 and researched the effect of guided tissue regeneration for infrabony defects.[16]

Periodontology held by the American Academy of Periodontology included elements of evidence-based health care, supported by Michael Newman at UCLA. The 2002 European Workshop on Periodontology became the first international workshop to use rigorous systematic reviews to inform the consensus. The workshop was organized by the European Academy of Periodontology for the European Federation of Periodontology, under the chairmanship of Professor Klaus Lang. Most recently, the International Center for Evidence-Based Oral Health was launched in 2003 (http://www.eastman.ucl.ac.uk/iceboh) to produce high-quality evidence-based research with an emphasis on, but not limited to, periodontology and implants and to provide generic training in systematic reviews and research methods.


  Evidence-Based Periodontology Versus Traditional Periodontology Top


Evidence-based periodontology uses a more transparent approach to acknowledge both the strengths and limitations of the evidence. An appreciation of the level of uncertainty or imprecision of the data is essential in order to offer choices to the patient regarding treatment options. Evidence-based periodontology also attempts to gather all available data and to minimize bias in summarizing the data. Furthermore, evidence-based periodontology acknowledges explicitly the type or level of research on which conclusions are drawn. However, one aspect that influences the reliability of the data is the control of bias, which is a collective term for factors that systematically distort the results of research away from the truth. Different research designs offer different possibilities for the control of bias and therefore vary in their reliability. The comparison between evidence-based periodontology and traditional periodontology is shown in [Table 1].
Table 1: Comparison of evidence-based versus traditional periodontology

Click here to view


The similarities between the two are:

  • High value of clinical skills and experience
  • Fundamental importance of integrating evidence with patient values.[17]



  The Components of Evidence-Based Periodontology Top


Evidence-based periodontology starts with the recognition of a knowledge gap. From the knowledge gap comes a focused question that leads on to a search for relevant information. Once the relevant information is located, the validity of the research needs to be considered in two broad areas. First, is the science good (internal validity)? Internal validity focuses on the methodology of research. Second, can the findings be generalized outside of the study (external validity)? External validity might be affected by the way treatment was performed.

After locating and appraising the research, the results then need to be applied clinically or at least included in a range of options. Finally, the results in clinical practice need to be evaluated to reveal whether the adopted technique achieved the expected outcome.[16]

For rigorous systematic reviews, independent reviewers usually undertake quality appraisal in duplicate and checklists are frequently employed for this purpose.[18]


  Clinical Relevance Top


Even though we may have the best evidence obtained from well-done systematic reviews and meta-analysis in certain areas of dentistry, it is often tedious for the practitioners to read through the elaborate reviews and extract relevant information out of them. For this purpose, it is of paramount importance to create clinical recommendations/guidelines and critical summaries that can be useful to all.[19]

Simultaneously, it is important to recognize that there are several barriers to the implementation of EBD. The information overflow from so many websites and journals can often overwhelm a clinician. Sometimes, due to the lack of data, the systematic reviews may be insufficient to produce relevant clinical guidelines. Another barrier could be related to patient needs and preferences, which may cause everything else to take a backseat. Finally, the clinician's experience and lack of motivation to change what may have worked well for the practice for years can present to be a challenge.[20]


  Use of Diagnostic Data In Clinical Practice Top


According to Beck, dentistry, in contrast to medicine, has deemphasized diagnostic activities and merged them with treatment-planning activities. Nevertheless, the aim of a medical or dental clinician is to arrive at a diagnosis that may direct a subsequent course of management. The diagnostic process is initiated by the patient history and symptoms and is followed by the clinical examination, during which the clinician perceives signs that are manifestations of the disorders. The clinician may also use assays or measurements that are traditionally referred to as diagnostic tests or tools. In reality, symptoms, signs, and assays may all be considered diagnostic tools, because all are sources of information used to generate a diagnosis.[21]

Sacket et al. explain that patients, clinicians, and researchers generally agree that the presence of disease indicates a derangement in anatomy, biochemistry, physiology, or psychology. They less often agree, however, on the exact criteria that define the condition that is the target of the diagnostic process.[22]

The essentialistic view is closely related to a modern principle of disease termed biochemical fundamentalism. This view is based on the idea that disease can be described in terms of biochemistry and molecular biology. Diseases are assumed to follow regular patterns, and once the underlying biochemical events are understood, the course of the disease can theoretically be predicted. Hence, disease classification becomes a matter of biotechnology, and the need for defining a normal state is avoided by relying upon statistical terms to define the disease state. This statistical approach forms the basis for using biomarkers as diagnostic or screening tests. Overall, the nominalistic approach may offer a more realistic strategy for coping successfully with the varying manifestations of conditions such as coronary heart disease and temporomandibular disorders that can be defined in both essentialistic and nominalistic terms.[23]


  Discussion Top


The purpose of EBD is to support dental practitioner for treatment of dental problems. Evidence-based periodontology is more objective, more transparent, and less biased process than traditional periodontology.[14] However, EBD has several problems such as quality, quantity, and dissemination of evidence.[24],[25] In addition, a lot of clinicians do not have enough time to learn and apply EBD and do not know access to evidence usage with resources.[11],[26] With the help of developing technology, that is - Internet, dentists can easily access to evidence provided on the American Dental Association's website.[27]

Periodontitis is a disease affecting to large population of all in the world. There is a relationship between periodontitis and gene polymorphism and the ethnic differences effect host responses to bacterial dental plaque.[28],[29] For example, in Turkish population, localize aggressive periodontitis is seen more often.[30] Together with evidence-based periodontology, the most effective treatment options are chosen easily under the disease risk population.

By means of the researches which have been made in the 21st century and the easy information obtaining, evidence-based periodontology notion needs to be used more. In our world where the quality in every field increases, doctors must turn the evidence-based periodontology into an education philosophy, and they must perform on any of their patients in order to present more quality and treatment opportunities in periodontology field. The consideration capacity of young clinicians should be increased by giving evidence-based periodontology education before and after graduation in the universities. Through the training of database usage, the better usage of databases such as Medline or PubMed for dentistry students or new doctor can be made easier. In the fast changing word, it should not be forgotten that from diagnosis methods to treatment choices are changing fast as well. A complicated treatment applied previously can be applied with easier way. Legal problems of the doctors will also decrease with the developing in medical diagnostic tests and reducing in the diagnosis faults. By means of the correct diagnosis and optimal treatment with the reduced needless process and drug usage, treatment costs will be reduced, and therefore, it contributes to effective source usage and national economy. Scientific data and happy patients will be obtained owing to the evidence-based periodontology.


  Conclusion Top


EBD is very important for both the clinicians and the patient population. However, its acceptance into dental practice has been a relatively slow process. The importance of providing a balanced mix of science, clinical expertise, and patient needs to optimize patient care in a practice cannot be underestimated.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Hackshaw AK, Paul EA, Davenport ES, editors. Evidence-based dentistry: What is it and how to practice it. In: Evidence-Based Dentistry – An Introduction. Oxford: Blackwell Munksgaard; 2006. p. 1-9.  Back to cited text no. 1
    
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[PUBMED]  [Full text]  
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