LSUHSC School of Dentistry Library

What is Evidence-Based Dentistry?

According to the American Dental Association, 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. EBD is based on three important domains:

·               The best available scientific evidence
         A dentist's clinical skill and judgment
·         Each individual patient's needs and preferences.

Only when all three are given due consideration in individual patient care is EBD actually being practiced.¹

When using EBD to solve clinical problems, it is important to remember that evidence alone is never sufficient to make a clinical decision; a hierarchy of evidence should guide clinical decision-making. EBD does not replace clinical experience or patient input, but provides an additional dimension to the decision-making process.

EBD is a five-step process:

1.       Formulation of an answerable clinical question (PICO)
    Searching for the best evidence
    Appraisal of the evidence for validity and usefulness
    Application of the evidence in clinical practice
    Evaluation of the process and performance

Formulation of an answerable clinical question:
Conversion of the information need into an answerable question is a vital part of the practice of EBD. The PICO process is a means to convert information needs into answerable clinical questions – Population or Patient (P), Intervention (I), Comparison (C), and Outcome (O). Asking the right question is one of the hardest skills to learn, but it is of vital importance. Using a PICO question will enable the practitioner to focus on the patient; identify the important terms for a literature search; and identify the problem, results, and outcomes for the specific case.

A properly formed PICO question contains four elements:

·         Patient/Problem (P): Identify the patient or problem. How would you describe the patient or problem to a colleague?
    Intervention (I): Identify what you intend to do for the patient
    Comparison (C): Compare the main intervention to an alternative intervention
    Outcome (O): What do you intend to accomplish, improve, or affect?²

Searching for the best evidence:
Scientific evidence is the product of well-designed and well-controlled investigation that minimizes bias. It is the synthesis of all valid research studies. A single study does not constitute evidence but instead contributes to it.

Some sources of good evidence:

American Dental Association (ADA): center for Evidence-Based Dentistry

Evidence-based Endodontics Literature Database

EviDents Search Engine for Evidence-Based Dentistry

National Guideline Clearinghouse

National Health Service (NHS) Evidence: Oral Health (As of 3/2011, no longer being updated)

Oral Health Group (Cochrane Library)

TRIP Database: Turning Research into Practice

Evidence Based Dentistry (nature)

Cochrane Library

PubMed Clinical Queries

Dynamed (not much dentistry)

GIDEON

Natural Standard

Databases for locating individual studies:

EMBASE

CINAHLPlus with full text

PubMed (MEDLINE)

TRIP Database: Turning Research into Practice

Web of Knowledge^{3, 4}

Appraisal of the evidence for validity and usefulness
In order to appraise the evidence for validity and usefulness, one must consider where the evidence falls on the Hierarchy of Evidence:

The best evidence to use in EBD is systematic reviews. Systematic reviews of the literature are rigorous and explicit methods for searching and critically appraising a body of clinical research on a specific topic. Following systematic reviews in the hierarchy of evidence are randomized controlled trials (RCT). RCTs provide good cause-and-effect evidence on a study group. Of less importance when analyzing evidence are cohort studies, case control studies, case series/case reports, and ideas, editorials, or opinions.

Application of the evidence in clinical practice
All studies should be appraised by the EBD practitioner before applying the evidence to patient care.

Some things to consider are:
·         Relevance; Is the clinical question relevant to your clinical question?
·         Validity; What were the results of the study?
·         Usefulness; Can you apply this evidence to your patient?

Examine the methodology of the study.
·         Aims; Are the aims of the study clearly stated?
·         Sample; Is the sample large enough to allow statistical conclusions to be drawn? Is the sample biased in any way?
·         Outcome Assessment; Have the authors made a fair and objective assessment of the outcomes? Were there any underlying factors that may have affected the outcome?
·         Statistics; Were the statistics clearly described and appropriate for the study?
·         Unforeseen losses; Did the study run into problems that may have affected the data?

Examine the interpretation of the study.
· Meaning of the findings and conclusions; Did the authors draw the right conclusions from the data? Use the findings to draw your own conclusions.
· Comparability with other literature; Interpret the results in the context of other published literature.⁵

Based upon a thorough examination of the evidence, the clinical skills and practical knowledge already in place, and the needs of the patient, a practitioner can use the evidence to determine a course of treatment for a patient.

Evaluation of the process
The final step in practicing evidence based dentistry is to evaluate the process. Practitioners should evaluate the success of the process based on the effectiveness of the treatment, satisfaction of the patient, and development of EBD skills. The skills necessary to practice EBD are not difficult to master but take time and practice nonetheless, and practitioners should not be discouraged while still acquiring them.²

More information available in the Dental Library:

Journals
Evidence-Based Dentistry
Journal of Evidence-Based Dental Practice

Books
Clarkson J. Evidence based dentistry for effective practice. London: Martin Dunitz; 2003. (WU 100 C56e 2003)

Forrest, Jane L. Evidence-based decision making: a translational guide for dental professionals. Philadelphia, PA: Wolters Kluwer; 2009. (WU 29 F77 2009)

Guyatt G. Users’ guides to the medical literature: a manual for evidence-based clinical practice. Chicago: AMA Press; 2002. (WB 100 G99u 2002)

Hackshaw, A. Evidence-based dentistry: an introduction. Oxford: Blackwell Munksgaard; 2006. (WU 20.5 H11e 2006)

Proceedings of the International Conference on Evidence Based Practice in Dentistry. (WU 100 In80 2001)

Richards D. Evidence-based dentistry: managing information for better practice. Chicago: Quintessence; 2008. (WU 100 Qu4 v. 41)

References

1. 1. ADA Center for Evidence-Based Dentistry. About EBD. http://ebd-ada.org/about.aspx

2. 2. Forest JL, Miller SA, Overman PR, Newman MG. Evidence-based decision making: a translational guide for dental professionals. Philadelphia, PA: Wolters Kluwer; 2009.

3. 3. LSUHSC Libraries Resource Guide – Evidence Based Practice. Louisiana State University Health Sciences Center. Libraries. http://www.lsuhsc.edu/no/library/resources/guides/EBM.html Updated September, 2010. Accessed September, 2010.

4. 4. Bushhousen E. Internet resources: Evidence-based dentistry. MLA News 2010 Jun/Jul; 50(6):10.

5. 5. Davis JPL, Crombie IK. The why and how of critical appraisal. In: Clarkson J, Harrison JE, Ismail AI, Needleman I, Worthington H. Editors. Evidence based dentistry for effective practice. London: Martin Dunitz; 2003. p. 43-57.

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This page is maintained by Elizabeth Strother. Last updated July 2011
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