EVIDENCE BASED DENTISTRY
Under the Supervision of;
Prof.S H Hashmi
Co-Supervised by;
Prof Geeta Rajpoot
Presented by Md. Zavir khan
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Introduction
Dentistry is both an art &
science It is a science because our fundamental understandings or building blocks of knowledge are founded on the scientific process of research.This includes basic,applied & clinical research.
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It is an art in that it draws on
experience & personal observation,because science cant account for the complexity of all variables in each situation.the synthesis of scientific understanding & clinical observation provides the basis for meaningful dental care. Evidence based dentistry is an attempt to synthesize both these aspects of dentistry.
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WHAT IS EVIDENCE-BASED DENTISTRY?
The foundation for Evidence
based practise was laid by David Sackett Who has defined it as integrating individual clinical expertise with the best available external clinical evidence from systematic research.
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It allows dentists, as well as academic researchers, to keep abreast of new developments and to make decisions that should improve their clinical practice.
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ADA DEFINATION OF 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, together with the dentists clinical expertise and the patients treatment needs and preferences.
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SOME IMPORTANT TERMS
Randomized controlled trial: RCTs are quantitative, comparative, controlled experiments in which investigators study two or more interventions in a series of individuals who receive them in random order.
The RCT is one of the simplest and
most powerful tools in clinical research
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The principal of evidence
based dentistry are finding the best information quickly when it is needed,assessing its quality and deciding whether it is relevent Will help practitioner to use research evidence in making everyday clinical decisions.
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META ANALYSIS : In statistics, a meta-analysis combines the results of several studies that address a set of related research hypotheses.
Meta-analyses are often, but
not always, important components of a systematic review procedure
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Systematic review :
is a literature review focused on a
single question that tries to identify, appraise, select and synthesize all high quality research evidence relevant to that question.
Systematic reviews of high-quality
randomized controlled trials are crucial to evidence-based medicine.
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Cochrane Library : is a collection of databases in medicine and other healthcare specialties provided by the Cochrane Collaboration and other organisations. At its core is the collection of Cochrane Reviews, a database of systematic reviews and meta-analyses which summarize and interpret the results of medical research. The Cochrane Library aims to make the results of well-conducted controlled trials readily available and is a key resource in evidence-based medicine
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CONTD..
The Cochrane Library consists of the following databases: The Cochrane Database of Systematic Reviews (Cochrane Reviews) The Database of Abstracts of Reviews of Effects (DARE) The Cochrane Central Register of Controlled Trials (CENTRAL) The Cochrane Database of Methodology Reviews (Methodology Reviews) The Cochrane Methodology Register (Methodology Register) Health Technology Assessment Database (HTA) NHS Economic Evaluation Database (NHS EED)
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WHY DO WE NEED EVIDENCE-BASED DENTISTRY?
to improve the quality of health care
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CONTD
Demonstrate best use of limited
resources
Stay up to date Medical information changes
constantly
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How to practice?
Identify the clinical problem Formulate clear question Clarify the relevant problem Search for evidence Ignore irrelevant information; interpret the
relevant evidence available
Decide in appropriate action based on best evidence
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scenario
Acute ulcerative gingivitis can be treated
with the antibiotic metronidazole. Why is it that not every patient given metronidazole recovers from the disease? Why do some untreated patients recover? Given this, how can we say that metronidazole is an effective treatment? the above example illustrates that people are naturally variable in their responses to exposures or treatments. Different people respond to the same exposure or same treatment, in different ways.
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Clinical research allows us to
make decisions about causes of and treatments for disease, while allowing for the natural differences between people. Evidence-based dentistry is founded on clinical research.
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5 As
1.
Asking answerable questions (Asking) Searching for the best evidence (Acquiring) Critically appraising the evidence (Appraising) Applying the evidence (Applying) Evaluating the outcome (Assessing)
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2.
3.
4.
5.
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Asking answerable questions
A prudent question is one half of
wisdom - Francis Bacon
Turning the clinical problems into
a well-built clinical question is a key skill of evidence-based practice.
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Pico analysis
P:Patient (or Problem) I:Intervention (or Cause,
Prognosis) C:Comparison (or Control) O: Outcome(s)
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scenario
for an arthritic patient does
using electric toothbrush provide more effective oral hygiene maintenance than by using manual toothbrush??
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P:(problem)
arthritic patient I:(intervention) C:(comparison) O:(outcome) electric toothbrush
manual toothbrush
oral hygiene
Commonly referred to as PICO .
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Finding evidence
Traditional sources of
information
Modern sources- electronic
databases. The most widely available database is Medline which can be accessed via the Pub Med interface.
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All clinical research studies are
encompassed under the broad heading of epidemiologic studies. These studies can be further subdevided Descriptive , Analytical & interventional studies
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A new type of studies has
emerged after the advent of EB research I.E. integrative studies Integrative studies include Systematic reviews & Meta analysis.
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The quality of various research designs
can be placed in a research design hierarchy. Position of each research design within the hierarchy is a function of the strengths & weakness of features within each design. The higher the study design ranks in the research hierarchy,the better the study design minimizes bias & distributes random variation equally between the study groups.
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Sources of evidence
Sources of evidence
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Levels of evidence
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Drilling for the Best Information
Cochrane Library Clinical Evidence Clinical Inquiries
Specialty-specific
journals
Usefulness
ACP Journal Club Textbooks, Up-toDate, 5-Minute Clinical Consult Journals/ Medline PubMed
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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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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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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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Appraising the evidence
The important thing is not to stop
questioning. Curiosity has its own reason for existing Albert Einstein
Once the evidence is collected it
must be screened for validity(closeness to the truth)
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Contd.
Impact (size of the effect) and
applicability (usefulness in clinical practice). The users guide are designed to test an article on these 3 parameters. These guides are basically a set of questions whose answers should be provided to the reader by the article in order to obtain best clinical evidence for the ques in focus.
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Acting on the evidence
"Remember, people will judge you by your
actions, not your intentions. You may have a
heart of gold -- but so does a hard-boiled egg." - Anon.
There are a number of well documented
delays between clinical practice and the available research evidence.
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Integrate the critical
appraisal with clinical expertise and with the patients unique biology,values & circumstances.
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Evaluating your performance
"I hear and I forget. I see and I
remember. I do and I understand." Confucius Finally,evaluate performance in terms of effectiveness & efficiency by questioning the ability to complete steps 1-4 successfully & seek ways to improve performance in future.
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Advantage of evidence based approach compared with other assessment method
Is objective Is scientifically sound Is patient focused Incorporates clinical experience Stresses good judgment Is thorough and comprehensive Uses transparent methodology
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Dentistry based on evidence
Dentistry based on evidence and evidence based dentistry . Are they same??????????
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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Barriers to implementing EBD
Lack of time Lack of appropriate skills for
formulating clear questions,executing efficient electronic searches & evaluating the literature. Keeping up to date
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Perhaps the greatest
impediments to the EBD are the fear & mistrust on the part of practitioners that the evidence will be misused by decision makers,particularly 3rd party funders & regulatory bodies & that the individual anatomy of dentists ,in caring for their patients ,will be threatened.
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Problems of introducing EBD
Amount of evidence Quality of evidence Dissemination of evidence Practice based on authority rather than evidence
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Advantages
Improved patient,staff & dentist
satisfaction Greater pride among patients,staff & dentist in high quality care Improved clinical decision making capability Greater confidence in T/t planing More opportunity to provide T/t choices selected for minimizing risk of harm & maximizing T/t safety.
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Greater satisfaction Reduced overhead & improved
production by saving time & money. Higher T/t acceptance Enhanced patient trust & rapport Improved practice building opportunities as patients share with others their trust,confidence & pride in their EBD practicing dentist.
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Conclusion
Evidence based care is a global
movement in all the health science disciplines It represents a philosophical shift in the approach to practice-a shift that emphasizes evidence over opinion & at that same time judgement over blind adherence to rules This approach provides a bridge between research & everyday patient care.
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In near term future for EB
practice is likely to be characterised by continuation of current trends in dissemination of EB info to clinicians. The primary means for dissemination will consists of evidence summaries & EB T/t recommendations & guidelines.
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THANK YOU
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