Evidence-Based

Dentistry
Dent 524- Lecture 3

Dr. Dua’a Almegbil, BDs, MSc,

PhD
The Evolution of Evidence-Based
Medicine
• In the last 40 years, the needs of and demands for
health care worldwide have increased dramatically.
These increases are related to the population ageing, the
development of new technologies and knowledge, rising
patient expectations, and associated increases in
professional expectations about the possibilities and
potential of health care
• Health care resources are finite and must be shared
equitably.
• The use of high-quality research evidence and guidelines
to inform individual patient care and population health
care have become central to this process.
• In the mid-1970s, various writers began to question the
effectiveness of medicine and the increasingly wider
influence exerted by the medical profession on society.
Thomas McKeown (1912–1988)
• McKeown ( 1976 ) mapped mortality rates for the
main killer airborne diseases (tuberculosis, whooping
cough, scarlet fever, diptheria, and smallpox)
against contemporary advances in medicine from
the mid-19th century to the early 1970s. He found
that the declines in the incidence and prevalence of
communicable diseases had occurred before their
microbial cause had been identified and before an
effective clinical intervention had been developed.
• McKeown concluded that the declines in mortality
rates were not attributable to immunisation and
therapy and suggested the declines could more
reasonably be attributed to better nutrition and
improved housing conditions which had occurred
over the period.
Archie Cochrane (1909-1988)
• Allied to McKeown’s historical analysis was the
work of Archie Cochrane who evaluated
contemporary clinical practice in the 1970s.
• Cochrane ( 1972 ) showed that many medical
treatments provided in the NHS were
ineffective, inefficient, and founded on medical
opinion rather than on a rigorous assessment
of efficacy and effectiveness. He proposed the
randomised controlled trial (RCT) as the best
way to assess the effectiveness of therapeutic
interventions.
• While the RCT has been lauded as the preferred ‘gold standard’ for assessing the
efficiency of therapeutic interventions, it is not an appropriate research design for all
research questions, particularly complex ones such as the primary prevention of
disease or the secondary prevention of adverse progression for an established disease.
• The pivotal decision for high-quality research is the selection of a research design that
is appropriate to the research question.
The Evolution of Evidence-Based
Medicine
• What was needed now was a way of evaluating and using this
research to inform clinicians, clinical practice, and the public.
• The introduction of a problem-based learning approach to
clinical education, first developed in the 1990s at McMaster
Medical School in Canada, stimulated new thinking about the
best way to evaluate and use research to inform individual
patient care. It was in Canada that the phrase evidence-
based medicine (EBM) was coined.
• The evidence-based movement spread rapidly throughout
Canada, North America, the UK, and Europe, largely due
to the extensive research funding available in these regions
and the location of the pioneers of EBM in Canada and the UK.
• These developments together created the conditions for the
emergence of EBM.
What is evidence-based
medicine (EBM)?
• Definitions of EBM combined clinical
experience and intuition with the
appraisal of research evidence as the
‘conscientious, explicit and judicious use
of current best evidence’ and the
integration of this best research evidence
from systematic research ‘with clinical
expertise and patient values’.
• EBM is then a task-oriented approach.
What is evidence-based practice
(EBP)?
• ‘Explicit decision making within the clinicians’ daily
practice’ (Dawes et al . 2005 , p. 3).
• EBP was required to be ‘based on the best available,
current, valid and relevant evidence’ (Dawes et al .
2005 , p. 1).
• Health services should deliver the ‘right’ treatment to the
‘right’ patient at the ‘right’ time using the ‘right’ person
in the most appropriate ‘right’ setting with the ‘right’
patient experience (i.e. patient choice, dignity,
satisfaction, and participation in clinical decision-
making).
What is evidence-based
dentistry?
• Richards and Lawrence introduced the concept to
dentistry by defining evidence-based dentistry
(EBD) as a ‘process that restructures how we think
about clinical problems’ and which was
characterised by ‘making decisions based on known
evidence’.
• There has, however, been an increase in the
reporting of studies that compare the outcomes of
different forms of treatment.
• For example, studies demonstrating the benefits of
amalgam versus composite restorative materials,
implant retained versus mandibular retained
dentures, and topical fluorides and gels for the
prevention of dental caries.
The process of evidence-based
practice (EBP)—the five steps
Step 1: Ask a clear answerable question

• The key to EBP is the construction of a clear

answerable question derived from a clinical
issue or problem. using the participant,
intervention, comparator, and outcome
(PICO) format.
PICO Format
• An excellent way to aid the refinement of the question is to use the PICO format. PICO
enables the question to be translated into a format that is searchable in medical
databases and is more likely to give answers that are precise and relevant.
 P: The participants’ characteristics (e.g. age, gender, social class, all of which might be
important to the question).
 I: The definition of the intervention or indicator is critical as it will determine the type of
study searched for, e.g. is the question about therapy, a diagnostic test, or prognosis?
 C: The comparator denotes the alternative intervention; this could be another
intervention or no intervention.
 O: The outcome of interest, e.g. leading to lower mortality, decrease in bleeding on
probing
Choice of appropriate research
design to answer the question

• Randomised controlled trial

• Cohort study
• Case control studies
• Cross-sectional survey
Levels of evidence (the hierarchy of
evidence)

• The relative weight of different primary and

secondary studies when making decisions
about a clinical intervention.
• Top of the hierarchy of evidence is the
systematic review.
Step 2: Access the literature and
locate the
best evidence available
• Richards and Lawrence ( 1995 ) suggest that there are four basic routes to
finding the evidence: ask an expert, read a textbook, find the relevant article in
your reprint file, or search a database such as MEDLINE.
Asking an expert is a Finding the relevant Searching a
Reading a textbook
good starting point, article in your reprint database would
seems like a good idea,
but they may not be file also sounds a appear to be the
but there is evidence
completely aware of good idea, but you best way to
that they rapidly go out
all the up-to-date may not have a gather the
of date, even when
evidence, and often relevant reprint and evidence, as it will
new (Altman 1991 ).
hold quite subjective even if you do you be the most up-to-
opinions about never get around to date and quite
particular issues. reading it properly. comprehensive.

Accessing the literature has become much easier

given the development in search engines, electronic
medical databases, and the sheer volume of
Step 3: Appraise the literature
• Many papers published in medical journals have serious flaws (Greenhalgh 2006 ) and
it is important to be able to identify a good article and know whether you can trust the
results or whether you need to use some discretion with applying the findings.
• You cannot assume that an article appearing in a respected, peer-reviewed medical
journal contains reliable information (Altman 2000).
• Critical appraisal is the process of ‘carefully and systematically examining research to
judge its trustworthiness, and its value and relevance in a particular context’ (Burlls
2009 , p. 2).
Step 4: Apply and act on the
evidence
• It is widely acknowledged that getting evidence into clinical practice is often
slow and lags behind the publication of authoritative treatment guidelines.

• The implementation of guidelines in practice is influenced by:

1. Where and how the guideline was produced
2. How it is brought to the attention of clinicians
3. How clinicians are prompted and supported to implement the guidelines
4. The way in which guidelines are presented to the clinician
Step 5: Assessing and evaluating
performance
• These include self-assessment on skills to ask an answerable question; find
the best external evidence; appraise evidence for validity and potential
usefulness; integrate critical appraisal with clinical expertise; apply in clinical
practice; teach EBP to colleagues; and continue professional development.
Evidence-based public health
and guidelines
• Recommendations are developed informed by
evidence but are set within a framework
acknowledging a range of social values, taking
account of theories of public health and behaviour
change.
• They should also reflect the views and experiences of
those being advised to take action and the people
who may be affected by that action (NICE 2009 ).
• NICE guidance of relevance to the practice of
dentistry includes guidance on extraction of wisdom
teeth, antibiotic prophylaxis for the prevention of
infective carditis, dental radiographs, and dental
recalls.
The limitations of EBP
• EBP does not give due recognition to clinical expertise, ignores patients’ views,
and could be used as a cost-cutting tool.

• Many of the guidelines on a clinical topic are not implemented widely and go
out-of-date quickly
• EBP itself displays three of the shortcomings of medical sciences:
1. A shortage of coherent and consistent evidence;
2. Difficulties in applying global evidence to an individual patient;
3. and barriers to the practice of high quality clinical care
The limitations of EBP
• There are three further limitations particular to EBP
itself:
[Link] need to possess searching and critical appraisal
skills;
[Link] limited time clinicians have to develop and practise
these skills; and
[Link] resources to allow immediate access to information
in clinical settings are few
Conclusion

• EBP involves the systematic collection and incorporation of

research evidence into clinical practice, to improve the
quality and effectiveness of interventions for consumers
and providers of health care.
• It has implications for the delivery of health care at the
individual, community, and population levels.
• Evidence-based practice involves the integration of best
research evidence with clinical expertise and patient
values.
• Clinical practice should therefore be evidence-informed
rather than evidence-driven.
Thank You!