Dentistry Based on Evidence vs' Evidencebased Dentistry

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Dentistry Based on Evidence vs. Evidence-based
Dentistry

• A. Isabel Garcia, DDS, MPH
• 2009 USPHS Scientific and Training Symposium
• Atlanta, GA

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Objectives

• Describe the basic elements evidence based
  dentistry
• Give examples of selected clinical procedures and
  their level of evidence
• Describe the role of PHS programs in promoting
  evidence-based approaches

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• Good and sound dental practice relies not upon
  bits and pieces of conveniently selected evidence
  (dentistry based on evidence), but rather upon
  the collection of the best available research
  evidence (evidence-based dentistry)
• Chiappelli F et al. J Den Res 82(1) 2003

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• The repertoire of the dentist may be based upon
  expert knowledge and skills, but experience can
  lead to comfort that ignores evidence for change
• Donoff, Evidence-Based Dentistry (2000) 2,1-2

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• Its not so much what we dont know that gets
  us in trouble, but what we think we know that
  just isnt true
• Robert Anthony

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Management of Deep Carious Lesions
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Management of asymptomatic unerupted third molars
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Identifying and keeping up with new evidence is
challenging
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Typical Steps in the Cycle of a New Technology
Patenting
Research
Discovery
Development
Marketing
Adoption
Production
Adapted from David Zilberman, UC Berkeley
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Long Gestational Period

• There are major discrepancies between what is
  known and what is practiced
• Up to 20 years lag time between research
  findings and translation into care
• Lag time has a greater negative impact on people
  with the greatest needs

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Challenges to Diffusion of New Information into
Practice

• Changes in science and technology occurring at an
  extremely rapid pace
• More than 11,000 oral health scientific papers
  published in MEDLINE last year (2008)
• On average gt30 articles per day
• Diffusion tends to take place gradually, in a
  non-linear manner over time
• Diffusion is driven by early adopters who set
  the pace for everyone else
• Payers and financing system may not keep apace

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And more challenges..

• Discerning credible research vs junk science
• Judging the scientific quality of research
  studies (not taught consistently in pre-doctoral
  dental curriculum)
• Conflicting findings from research studies
  addressing same clinical question
• Balancing the evidence with patient preferences,
  circumstances, and clinical experience

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Evidence-Based Dentistry (EBD)

• 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, with the dentists
  clinical expertise and the patients treatment
  needs and preferences.
• American Dental Association

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Evidence-Based Dentistry

• Relies on the best available research evidence
• Recognizes that scientific evidence evolves over
  time
• Integrates the best evidence with clinical
  experience and the needs and wants of patients

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• Dentistry based on evidence
• Tends to include selected evidence of variable
  quality
• Evidence-based dentistry
• Relies on identifying all the available evidence
  and assessing its quality

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EBD Process

• Structured approach to identify and use the best
  information relevant to a clinical question
• Develop focused question (Patient, Intervention,
  Comparison treatment, Outcome)
• Conduct search for relevant research
• Critically assess the evidence
• Use the best evidence in patient care
• Evaluate the process
• Health Sciences Library, UNC Chapel Hill

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Systematic Reviews

• Identify what we know and dont know
• Account for divergent findings
• Place research into a balanced perspective
• Help formulate clinical guidelines

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Differences between Systematic and Narrative
Literature Reviews
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Causal Pathway for the Diagnosis, non-surgical
Management and Preventionof Carious Lesions

• Separate pathways for 1o teeth, coronal root
  surfaces of permanent teeth
• Methods radiographs, visual tactile, FOTI, EC,
  fluorescence, combination
• 3) Risks radiation exposure, inadvertent
  cavitation, site inoculation, FP, FN
• 4) Validity evaluated as sensitivity and
  specificity

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Systematic Reviews Do

• Identify and review published materials
• Use explicit and detailed methods
• Select the admissible evidence
• Summarize the relevant research
• Evaluate the quality of individual studies
• Rate the overall strength of the evidence

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Systematic Reviews Dont

• Provide a cookbook for clinical practice
• Specify a practice guideline or standard
• Create a scheme to undermine intuition, clinical
  judgment and experience

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Sources of Systematic Reviews

• Cochrane Collaboration (www.cochrane.org)
• International Organization that develops and
  maintains systematic reviews
• Created in 1992 by the British National Health
  Service
• Cochrane Library (electronic database of trials
  and systematic reviews)
• Cochrane Oral Health Group, University of
  Manchester

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Sources of Systematic Reviews

• Evidence Based Dentistry
• Supplement of the British Dental Journal
• Central Resource for EBD relevant issues and
  articles
• Aimed at general dental practitioners

http//www.nature.com/ebd/index.html
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Sources of Systematic Reviews

• The Journal of Evidence-Based Dental Practice
• original articles
• reviews of articles on the results and outcomes
  of clinical procedures and treatment
• http//www.elsevier.com

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ADA Website for EBD
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Sources of Systematic Reviews

• Centre for Evidence-based Dentistry
  http//www.cebd.org/
• NHS Evidence http//nice.org.uk/nhsevidence
• AHRQ- Evidence Reports http//www.ahcpr.gov/clinic
  
• Forsyth Center for Evidence-Based Dentistry
• http//www.forsyth.org/research/centers/evidence.h
  tml

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Other Sources of Information

• National Guideline Clearinghouse
  www.guideline.gov
• Comprehensive source for guidelines and materials
• Summary of guidelines, side by side comparisons
• Standard set of guideline attributes
• Type of evidence supporting the recommendations
• U. S. Preventive Services Task Force
  www.preventiveservices.ahrq.gov
• Recommendations based on reviews of the evidence
  of effectiveness of clinical preventive services

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Examples of Evidence Reviews/Clinical
Recommendations

• Dental recall interval between routine dental
  examinations (NICE)
• Preventing caries, oral cancer and sports-related
  craniofacial injuries (TFPS)
• Role of dental prophylaxis in pediatric dentistry
  (AAPD)
• Guided tissue regeneration for periodontal
  infra-bone defects (Cochrane)

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Examples of Evidence Reviews/Clinical
Recommendations

• Prevention of mucositis and candidiasis for
  patients receiving chemotherapy (Cochrane)
• Management of un-erupted and impacted third molar
  teeth (SIGN- Edinburgh)
• Guidelines for infection control in dental
  health-care settings (CDC)
• Efficacy and safety of water fluoridation (NHS
  CRD York)

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US Preventive Services Task Force Grade
Definitions
http//www.ahrq.gov/clinic/uspstf/grades.htm
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Levels of Evidence
Based on Oxford Centre for Evidence-based Medicine
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Levels of Evidence

• 1a Systematic Reviews of Randomized Controlled
  Trials
• 1b Individual Randomized Controlled Trial
• 2a Systematic Reviews of Cohort Studies
• 2b Individual Cohort Studies
• 3a Systematic Reviews of Case-Control Studies
• 3b Individual Case-Control Studies
• 4 Case series, poor quality case-control studies
  
• 5 Expert opinions without explicit critical
  appraisal
• Oxford Centre for Evidence-based Medicine, March
  2009

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Extent of Evidence forSelected Dental Preventive
Measures
for the prevention of dental caries
only. Adapted from Lewis and Ismail, Can Med
Assoc J, 1995
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Extent of Evidence forSelected Dental Preventive
Measures
NIDCR/AHRQ Evidence Report. CDC,
Recommended Infection Control Practices for
Dentistry, 2003.
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• 1950s Ipana toothpaste Ipana jingle
• PG Advertising Campaign during late 1960s

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• Fluoride gel is effective in preventing caries in
  school-aged children (Ia)
• Patients at low caries risk may not receive
  additional benefit from professional topical
  fluoride application (Ia)
• Data support caries reduction from gel treatments
  of 4 minutes or more (Ia) but no clinical data on
  effectiveness of 1-minue applications (IV)

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The practice of evidence based medicine, then
is a process of life-long, self-directed learning
in which caring for our own patients creates the
need for clinically-important information about
diagnosis, prognosis, therapy, decision
analysis, cost. Sackett, 1995
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Management of Deep Carious Lesions
Dental Deep Caries Study
Compliments PEARL Dental PBRN
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No difference in the incidence of damage or
disease of the nerve of the tooth (pulp)
irrespective of whether the removal of decay had
been minimal (ultraconservative) or complete .no
difference in the progression of decay and
longevity of restorations. However, the number
of included studies is small and differ
considerably. Partial caries removal is
therefore preferable to complete caries removal
in the deep lesion, in order to reduce the risk
of carious exposure. However, there is
insufficient evidence to know whether it is
necessary to re-enter and excavate further..
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Using Systematic ReviewsAsk yourself

• Does the review explicitly state methods?
• Are the studies of high scientific merit?
• Were results of the studies consistent?
• Do the patients/study settings resemble my own?
• Were all outcomes considered?

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No difference in the incidence of damage or
disease of the nerve of the tooth (pulp)
irrespective of whether the removal of decay had
been minimal (ultraconservative) or complete .no
difference in the progression of decay and
longevity of restorations. However, the number
of included studies is small and differ
considerably. Partial caries removal is
therefore preferable to complete caries removal
in the deep lesion, in order to reduce the risk
of carious exposure. However, there is
insufficient evidence to know whether it is
necessary to re-enter and excavate further..
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http//clinicaltrials.gov
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Complete vs. Partial Removal of Deep Caries A
PEARL membership survey  revealed that 80 remove
all caries from deep lesions. This study aims
to (1) compare the tooth vitality at 1 year
posttreatment of complete vs. partial caries
removal in deep Class I lesions (2) assess the
effects of deep caries treatment on patients
postoperative hypersensitivity and oral
healthrelated quality of life and (3)
evaluate the effectiveness of cavity lining and
bonding techniques.
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PRECEDENT Study of 3rd Molars
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Role of PHS Programs in Promoting Evidence-based
Dentistry
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Role of PHS programs in promoting EBD

• EHR adapted for longitudinal monitoring of
  status and treatment needs
• EBD can be integrated into existing performance
  standards and evaluations
• PHS programs and leaders are uniquely positioned
  to be innovators and early adopters for the
  entire profession

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Take home messages

• Dentistry based on evidence isnt the same as
  doing evidence-based dentistry
• Systematic reviews can offer credible, unbiased
  information and help keep up with the science
• Readily available on-line sources for systematic
  reviews and clinical guidelines exist
• PHS programs and leaders are uniquely positioned
  to be innovators and early adopters for the
  entire profession

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Thank You!