Teaching Evidence-Based Dentistry: Some Applications to Orofacial Pain

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Teaching Evidence-Based Dentistry Some
Applications to Orofacial Pain

• Alan G. Glaros, Ph.D.
• University of Missouri - Kansas City

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Evidence-Based Dentistry

• An approach to clinical practice that involves
  the ability to locate, critique, summarize and
  apply best available information to patients
• Best available external evidence
• Individual clinical expertise

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Sources of Information

• Manufacturers claims
• Personal clinical experience
• CE programs, study clubs
• Published papers and research reports

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How Trouble Begins

• A relationship is established between mercury
  ingestion and health
• There is mercury in dental amalgam
• I dont feel well and I have dental amalgams
• Therefore, my symptoms are due to mercury in
  dental amalgams

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How Trouble Begins

• Dentist removes amalgam restorations
• I feel better
• Patient and dentist increasingly convinced that
  removal of amalgams produced improvements

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Why EBD?

• New evidence constantly being generated which
  will significantly change the way we care for
  patients, but most clinicians usually fail to get
  it
• Therefore, both our up-to-date knowledge and our
  clinical performance deteriorate with time

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Evidence on TMD

• Glass, Glaros, McGlynn (1993)
• 47 of general dentists and 46 of dental
  specialists recommend irreversible procedures for
  TMD patients
• Glaros et al. (2001)
• 61.6 of Internet sites on TMD recommended
  irreversible procedures

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Why EBD? (2)

• Trying to overcome clinical entropy through
  traditional CE programs doesnt improve clinical
  performance
• EBD approaches to clinical learning may keep
  practitioners up-to-date

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Four Tasks

• Ask a well-built clinical question
• Search for the best evidence
• Critically appraise the evidence
• Apply the results and evaluate

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Four Elements

• Who is the patient? What is the problem?
• What intervention? What cause? What prognostic
  factor?
• Comparison intervention
• Outcome(s)

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A Well-Built Clinical Question

• In a sixty-eight year old woman complaining of
  TM joint pain, would fabricating a splint or the
  use of non-steroidal anti-inflammatories provide
  sufficient relief from pain without causing
  significant side effects?

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Teaching The Asking of Answerable Questions

• UMKC requires all first year students to take
  course in research design and methodology
• 15-20 of in-class time devoted to EBD
• Students practice elements of EBD in 4 of 5 brief
  reviews of assigned literature
• Students prepare EBD final project

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Teaching The Asking of Answerable Questions

• In class, practice with prompted examples from
  instructors
• Ask students to formulate their own questions on
  items that interest them
• Bleaching
• Medications for treating aphthous ulcers
• Anti-virals for oral herpes lesions

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Teaching The Asking of Answerable Questions

• In clinic, instructors prompt students to ask
  questions

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Four Tasks

• Ask a well-built clinical question
• Search for the best evidence
• Critically appraise the evidence
• Apply the results and evaluate

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Search for Best Evidence

• Select resource
• Design search strategy

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Sources of Evidence

• Database (Medline)
• Journals and reference libraries
• CD-ROM
• Internet
• Journal clubs
• Colleagues

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Teaching Skills on How to Search

• Explicit instruction on how to use search
  software and how to in design search strategy
• At UMKC, one hour instruction
• Structure of information source
• Available search terms
• How to operate searching software
• Grateful Med

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Teaching Tips

• Searching specific terms better than broad, vague
  terms
• Students familiar with Internet searches
• Unstructured searches fun, but not suitable to
  clinical environment
• Students given EBD question and asked to search
  on their own, then asked to use specific search
  strategy

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Teaching Tips

• Hands-on practice better than demonstration
• Be prepared!
• Computer lab
• Use librarians
• Follow-up in clinic

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Four Tasks

• Ask a well-built clinical question
• Search for the best evidence
• Critically appraise the evidence
• Apply the results and evaluate

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Critical Appraisal

• Is the evidence valid?
• Is the evidence useful?

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Evaluating Evidence From Clinical Research

• Single trial
• Multiple trials

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Potential Additional Topics

• Prognosis
• Meta-analysis
• Economic analysis
• Clinical decision analysis
• Test characteristics
• Numerical measures of effect

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Teaching Critical Appraisal

• Grand rounds
• Lectures/coursework
• Workshops on EBD

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Teaching Critical Appraisal

• Clinical patient presentation
• Small groups
• EBD journal clubs

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Is the Evidence Useful?

• Apply critical appraisal to individual patient
• Intervention appropriate for patient?
• Intervention consistent with patient
  circumstances and attitudes?
• Are costs, both financial and clinical,
  acceptable to patient and clinician?

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Nihilism

• No study is perfect, so what good is the
  literature?

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Avoiding Nihilism

• Select good articles
• Separate innocent problems from fatal flaws
• Separate statistical significance from clinical
  significance
• Emphasize methodology, not box scores

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Avoiding Nihilism

• Describe editorial and publication process
• Place articles in context
• How would the reader design a better study?

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Changing the Culture

• Cluster EBD teachers/practitioners
• Encourage and value student input
• Problem-based learning

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Four Tasks

• Ask a well-built clinical question
• Search for the best evidence
• Critically appraise the evidence
• Apply the results and evaluate

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Outcomes Assessment

• Emphasize collection of outcome data
• Quantification of outcomes, including side
  effects
• Chart audits/quality assurance

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EBD

• Conscientious, explicit and judicious use of
  current best evidence in making decisions about
  the care of individual patients
• Best available external evidence
• Individual clinical expertise

Sackett et al., 1998
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Cautions

• EBD may not provide answer applicable to patient
• EBD must be tempered with clinical expertise
  related to patient assessment, characteristics,
  and preferences

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Useful Web Sites

• www.cochrane.org
• www.cche.net
• www.ihs.ox.ac.uk/cebd/index.html