CRITICAL APPRAISAL ON
DIAGNOSIS
Fitri Yuniawati, drg; Wulan Geraldine, drg; Diani
Sulistyawati, drg; Shoimah Alfa, drg
Program Studi IKGK
2016
Clinical Scenario
• Kasus:
Pasien laki-laki usia 30 tahun dengan
keluhan sakit saat mengunyah.
Pemeriksaan obyektif didapatkan gigi vital
dan tes perkusi +.
Diperlukan pemeriksaan penunjang untuk
menegakkan diagnosis final.
08/24/21 Presentation of Critical Appraisal 2
of Prognosis
Clinical Question
PICO
Patient and Intervention: Comparison: Outcome of
the problem: interest:
Pasien CBCT Radiografi Gambaran
dengan Perioapikal lesi
periodotitis Periodontitis
apikalis apikalis
08/24/21 Presentation of Critical Appraisal 4
of Prognosis
Clinical question
• Apakah Cone Beam Computed
Tomography (CBCT) lebih akurat dalam
mendeteksi periodontitis apikalis
dibandingkan Radiografi Periapikal?
08/24/21 Presentation of Critical Appraisal 5
of Prognosis
Steps in Practicing EBM
1. Convert the need for information into an answerable
question.
2. Track down the best evidence with which to answer
that question.
3. Critically appraise the evidence for its validity, impact,
and applicability.
4. Integrate the evidence with our clinical expertise and
our patient’s characteristics and values.
5. Evaluating our effectiveness and efficiency in
executing steps 1–4 and seeking ways to improve
them both for next time.
Citation:
Kanagasingam, S., Lim, C.X.,Yong, C.P.,
Mannocci, F., Patel, S., Diagnostic Accuracy
of Periapical Radiography and Cone Beam
Computed Tomography in Detecting Apical
Periodontitis Using Histopathological
Findings as a Reference Standard,
International Endodontic Journal, 2016; 1-10
08/24/21 Presentation of Critical Appraisal 9
of Prognosis
Steps in Practicing EBM
1. Convert the need for information into an
answerable question.
2. Track down the best evidence with which to
answer that question.
3. Critically appraise the evidence for its validity,
impact, and applicability.
4. Integrate the evidence with our clinical expertise
and our patient’s characteristics and values.
5. Evaluating our effectiveness and efficiency
in executing steps 1–4 and seeking ways to
improve them both for next time.
I. Are the results of this diagnostic
studies valid? (Primary Guides)
1. Was there an independent blind comparison
with a reference (“gold”) standard of
diagnosis?
• Ya. Pada penelitian ini semua spesimen dilakukan
uji PR dan CBCT oleh blinded experienced
endodontics, dan divalidasi oleh blinded oral
pathologist dengan menggunakan pemeriksaan
histopatologist sebagai standar referensi.
08/24/21 Presentation of Critical Appraisal 11
of Prognosis
I. Are the results of this diagnostic
studies valid? (Primary Guides)
2. Was the diagnostic test evaluated in an
appropriate spectrum of patients (like those in
whom it would be used in practice)?
• Ya. Digunakan 9 jenazah yang tidak
teridentifikasi, yang meninggal tidak lebih dari
14 hari dan disimpan dalam suhu 2-4⁰ C.
spesimen rahang tidak dibedakan antara
maksila dan mandibula, dengan mengeklusi gigi
yang rusak saat pemotongan.
08/24/21 Presentation of Critical Appraisal 12
of Prognosis
I. Are the results of this diagnostic
studies valid? (Secondary Guides)
3. Was the reference standard applied regardless
of the diagnostic test result?
• Ya. Standar referensi yang dipakai merupakan
pemeriksaan yang obyektif untuk membuktikan
adanya lesi periapikal, namun secara etis
pemeriksaan tersebut tidak dapat dilakukan
pada pasien klinis.
08/24/21 Presentation of Critical Appraisal 13
of Prognosis
I. Are the results of this diagnostic
studies valid? (Secondary Guides)
4. Was the test (or cluster of tests) validated in a
second, independent group of patients?
• Tidak . Uji diagnostik dilakukan satu kali pada
tiap spesimen, namun interpretasi hasil
dilakukan oleh 5 examiner yang telah
dilakukan kalibrasi terlebih dahulu.
08/24/21 Presentation of Critical Appraisal 14
of Prognosis
I. Are the results of this diagnostic
studies valid? (Secondary Guides)
5. Were the methods for performing the test
described in sufficient detail to permit replication?
•Ya. (lihat pada Bahan dan Metode)
08/24/21 Presentation of Critical Appraisal 15
08/24/21 Presentation of Critical Appraisal
of Prognosis 15
of Prognosis
II. Are the valid results of this diagnostic
study important?
HASIL PENELITIAN
08/24/21 Presentation of Critical Appraisal 16
of Prognosis
II. Are the valid results of this diagnostic
study important?
1. Does this valid evidence demonstrate an
important ability of this test to accurately
distinguish patients who do and don’t have a
specific disorder?
08/24/21 Presentation of Critical Appraisal 17
of Prognosis
Likelihood Ratio
• Likelihood ratio for positive test result
= sensitivity / (1-specificity)
= 0,89 / (1-1) = ∞
• Likelihood ratio for negative test result
= (1-specificity) / sensitivity
= (1-1) / 0,89 = 0
08/24/21 Presentation of Critical Appraisal 18
of Prognosis
III. Can you apply this valid, important evidence about a
diagnostic test in caring for your patient?
1. Is the diagnostic test available, affordable,
accurate, and precise in your setting?
• Pemeriksaan CBCT sudah tersedia, hasilnya
lebih akurat dalam mendeteksi lesi periapikal
dibanding PR, tetapi memerlukan biaya yang
lebih mahal.
08/24/21 Presentation of Critical Appraisal 19
of Prognosis
III. Can you apply this valid, important evidence about a
diagnostic test in caring for your patient?
2. Can you generate a clinically sensible estimate of your
patient’s pre-test probability (from personal
experience, prevalence statistics, practice databases,
or primary studies)?
• Are the study patients similar to your own?
• Is it unlikely that the disease possibilities or probabilities
have changed since the evidence was gathered?
• Hasil penelitian dapat digeneralisasikan terhadap pasien
klinis karena penelitian dilakukan pada spesies yang sama.
08/24/21 Presentation of Critical Appraisal 20
of Prognosis
III. Can you apply this valid, important evidence about a
diagnostic test in caring for your patient?
3. Will the resulting post-test probabilities affect your
management and help your patient?
• Could it move you across a test-treatment threshold?
• Would your patient be a willing partner in carrying it out?
• Untuk menjawab pertanyaan ini, ada 3 hal yang perlu dilakukan, yaitu
1) jangan di uji dan di terapi, 2) diuji dan di terapi berdasar hasil uji
dan 3) tidak di uji namun dilakukan terapi. Dari perlakuan tersebut
akan didapat batasan yang menyebabkan kita menghentikan uji
selanjutnya.
• Jika uji diagnostik negatif atau menghasilkan nilai RL rendah
mendekati 0,1, uji jangan dipakai. Karena nilai RL dalam hasil uji ini
1, maka dapat dilakukan sebagai alat uji diagnostik yang tepat.
08/24/21 Presentation of Critical Appraisal 21
of Prognosis
III. Can you apply this valid, important evidence about a
diagnostic test in caring for your patient?
3. Will the resulting post-test probabilities affect your
management and help your patient?
• Could it move you across a test-treatment threshold?
• Would your patient be a willing partner in carrying it out?
08/24/21 Presentation of Critical Appraisal 22
of Prognosis
Steps in Practicing EBM
1. Convert the need for information into an
answerable question.
2. Track down the best evidence with which to
answer that question.
3. Critically appraise the evidence for its validity,
impact, and applicability.
4. Integrate the evidence with our clinical expertise
and our patient’s characteristics and values.
5. Evaluating our effectiveness and efficiency
in executing steps 1–4 and seeking ways to
improve them both for next time.
08/24/21 Presentation of Critical Appraisal 23
of Prognosis
Resolution of the case
Hasil penelitian menunjukkan bahwa
penggunaan CBCT dan PR memiliki
spesifitas yang sama, namun CBCT
tingkat akurasi yang lebih tinggi dalam
mendeteksi apikal periodontitis
dibanding PR.
08/24/21 Presentation of Critical Appraisal 24
of Prognosis
Steps in Practicing EBM
1. Convert the need for information into an
answerable question.
2. Track down the best evidence with which to
answer that question.
3. Critically appraise the evidence for its validity,
impact, and applicability.
4. Integrate the evidence with our clinical expertise
and our patient’s characteristics and values.
5. Evaluating our effectiveness and efficiency in
executing steps 1–4 and seeking ways to
improve them both for next time.
08/24/21 Presentation of Critical Appraisal 25
of Prognosis
08/24/21 Presentation of Critical Appraisal 26
of Prognosis
