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Evidence Based Dentistry.pptx
- 1. Dr. VAIBHAV BANSAL Dept.of Public Health Dentistry EVIDENCE BASED DENTISTRY
- 2. EBD 2 “Facts are stubbornthings and whatever may be our wishes, our inclinations, or the dictates of our passions, they cannot alter the state of facts and evidence.”- John Adams
- 3. Contents Terminology Introduction What is EvidenceBased Dentistry Traditional Vs Evidence Based Dentistry How to do EBD Advantages & limitations Applications Summary & Conclusion References
- 4. Terminology Evidence isanything used to determine or demonstrate the truth of an assertion. Scientific evidence is evidence which serves to either support or counter a scientific theory or hypothesis. In scientific research evidence is accumulated through observations of phenomena occur in the natural world, or created as experiments in a laboratory
- 5. ‘Level ofevidence’: The extent to which one can be confident that an estimate of effect or association is correct (unbiased). Best research evidence : clinically relevant, unbiased, reproducible & patient centered research Critical appraisal: a systematic process used to identify the strengths and weaknesses of a research article.
- 6. Introduction Science + art= Quality dental care Deterioration of expertise and effectiveness Dilemma of decision making.
- 7. Introduction Undergraduate dentistry Source ofinformation; Teachers, textbooks and occasionally journal articles. Rare literature search Difficulty in effective clinical practice “The slippery slope of clinical competence”
- 8. Knowledge Gap Time tomeet information needs decreasing Amount of Information is rising Knowledge Gap
- 9. Evolution of theDental Knowledge Base Era Knowledge Creation Knowledge Synthesis Knowledge Dissemination Age of the Expert Experiential Experimental Apprenticeship Age of Professionalization Experiential limited observational Shared Experimental Texts, societies, journals, schools Age of Science Experiential Traditional literature review Texts, journals, schools, Age of Evidence Experiential Systematic review Texts, journals, schools, Systematic review
- 11. Definition “An approach tooral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences”. ADA 2000
- 12. Process that restructuresthe way in which we think about clinical problems” and is characterized by; “making decisions based on known evidence” (Richard and Lawrence 1995)
- 13. EBD - Whatis it? Clinical Expertise Research Evidence Patient Preferences EBD
- 14.
- 15. EBP vs. TraditionalPractice Similarities 1. Clinical skills & experience 2. Integrating evidence with patient values
- 16. EBP vs Traditionalpractice Differences EBP traditional practice Uses best evidence available Unclear basis of evidence Systematic appraisal of quality of evidence Unclear or absent appraisal of quality of evidence More objective ,transparent & less biased More subjective, opaque & biased Greater acceptance of uncertainty Greater tendency to black & white conclusion
- 17. Steps of EBD Ask Acquire Appraise Apply Analyze &Adjust Patient Assessment Evaluation, Disseminat ion& Follow up 5 STEPS OF EBD
- 18. Patient{B urden of illness Complaint s Ask an answerable question Searchfor best evidence Critical appraisal Apply to the patient Treatment decision
- 19. How to doEBD (Sackett and Strauss 2000) IDENTIFYING THE CLINICAL PROBLEM LOCATING THE EVIDENCE HIERARCHY OF EVIDENCE MAKING SENSE OF EVIDENCE ACTING ON THE EVIDENCE
- 20. 1. Identifying theClinical Problem Ask a clear question about the problem. Background Questions{Why, how, when} Foreground Questions{Specific} 2 type of Questions can be asked
- 21. Asking Good Questions:the PICO process P{Problem} I{Intervention} O{Outcome} C{Comparison} PICO
- 22. Mr. X, revealsthat he is at risk for infective endocarditits and is allergic to penicillin. Typically amoxicillin is used. Knowing that erythromycin and clindamycin may be alternatives, a search is conducted to determine the antibiotic and regime most appropriate to prescribe before scaling and rootplaning.
- 23. PICO Format forClinical Questions Question Element Example Patient or problem Infective endocarditis & penicillin allergy Intervention Clindamycin Comparison Erythromycin Outcome Provide effective antibiotic prophylaxis in terms of safety, better absorption, and more sustained serum levels.
- 24. The question isstructured as --- “For a patient at risk for infective endocarditis and a penicillin allergy, does clindamycin as compared to erythromycin provide more effective antibiotic prophylaxis in terms of safety, better absorption, and more sustained serum levels?”
- 25. Key terms canbe identified to use in conducting the search infective’ or ‘endocarditis ‘penicillin allergy’, ‘clindamycin’, ‘erythromycin’ and ‘antibiotic prophylaxis’.
- 26. 2.Locating the Evidence: Fourbasic routes to find an evidence Expert Textbook Database Journal Article
- 27. Searching for Evidence Google Pub med Allow at least 30 minutes for first time search. With practice, a shorter search time will be possible.
- 28. 3. Hierarchy ofEvidence SRs& MAs RCTs Cohort Studies Case –Control Studies Case Series, Case Reports Editorials, Expert Opinion Sackett DL et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000 SRs- systematic reviews, MA- meta-analyses RCTs- Randomized controlled trials
- 33. Systematic Review Combined Results Study 1 Study2 Study 3 Study 4
- 35. Meta-Analysis “Conducting researchabout research.” It is often of value when several RCTs have been performed ,which individually, lack the power to detect statistically significant differences between interventions, but are capable of doing so in the aggregate.
- 36. Clinical Decision Support System(CDSS) Link the patient’s electronic health record to current best-evidence based on the individual patient’s clinical circumstances. There are few such systems currently available E.g.. Dental practice based research network Pearl
- 37. Type of Evidence TYPE I: At least one good systematic review (including at least one RCT) TYPE II: At least one good RCT TYPE III: Well designed intervention studies without randomization TYPE IV: Well designed observational studies TYPE V: Expert opinion, influential reports and studies NHS Wales (1998). Oral health. Cardiff, Health Evidence Bulletins
- 38. Strength of Evidence ClassificationStrength of recommendations A Directly based on category I evidence B Directly based on category II evidence or extrapolated recommendation from category I C Directly based on category III evidence or extrapolated recommendation from category I or II D Directly based on category IV evidence or extrapolated recommendation from category I, II or III
- 39. 4. Making Senseof the Evidence To evaluate or appraise the evidence for its validity and clinical usefulness. DARE COCHRANE CASP
- 40. DARE( Database ofabstracts of reviews of effectiveness)includes structured abstracts which have been critically appraised by the NHS Centre for reviews and Dissemination. Cochrane collaboration oral health group: Database of relevance to oral health
- 41. Critical Appraisal Skills Program(CASP) Independentevaluation of strength of evidence Studies include RCTs, cohort, case controls &case reports CASP tool starts with some screening questions
- 42. For RCTs importantquestions for appraisal involves Type of population group, intervention Inclusion & exclusion criteria Random allocation Blinding Precision of the results Outcomes
- 43. 5. Acting onthe Evidence Apply the evidence on your patient’s situation or problem. Individual practitioners judgment is key. Evidence based practice therefore seeks to inform clinical decisions, not to impose them
- 44.
- 45. Barriers in Transmission& Dissemination of Evidence Limited access to scientific information Lack of time Information Overload
- 47. Timing of evidencediscussion with patients During patient education as part of hygiene appointments. At fees and payment arrangements with patients. Dedicated treatment planning appointments.
- 48. Advantages 1. It helpus updating our knowledge continuously instead of reading lots of irrelevancy & unreliable literature, so time saving. 2. It helps policy makers through development of clinical guidelines', providing them with enough documents & evidence.
- 49. 3. Instead ofteaching students current standard treatment method, it teach them how to find the best current therapy for their disease. 4. EBD promote evidence instead of persons authority. 5. It decreases medical errors.
- 50. What are theLimitations of EBD? First, the need to develop new skills in searching and critical appraisal can be daunting. Second, busy clinicians have limited time to master and apply these new skills, and the resources required for instant access to evidence are often woefully inadequate in clinical setting.
- 51. Applications Concept of harm: 1.Situations of adverse outcomes in pregnancy by any intervention 2. Treatment decisions on medically compromised patients 3. Any drug causing probable serious harm
- 52. Q. Is thereany association between periodontitis and adverse pregnancy outcomes? What should be the answer????
- 53. We donot have enough data to say with certainty that periodontal disease causes health problems in the newborn. There is evidence that nonsurgical periodontal treatment is safe during pregnancy. However, without treatment, your gum disease may become worse, which will likely result in loss of bone and perhaps teeth. There is no evidence that such treatment is harmful to the unborn child.
- 54. Day to DayTreatment Decisions Does single-visit root canal treatment without calcium hydroxide dressing, compared to multiple- visit treatment with calcium hydroxide dressing for 1 week or more, result in a lower healing (success) rate.
- 55. Effectiveness ofsingle- versus multiple-visit endodontic treatment of teeth with apical periodontitis: a systematic review and meta- analysis.(Sathorn C, Parashos P, Messer H H) CONCLUSION: Single-visit root canal treatment did not significantly increase healing(success) in comparison with multiple visits. There was a lack of evidence of a difference between single and multiple visits for root canal treatment.
- 56. Summary & Conclusion IdentifyClinical Problem Search for evidence Make sense of evidence Act on evidence Discard Store Update evidence
- 57. EBD involvesthe 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 both the individual & community level.
- 58. References Daly B.Evidence based dentistry. In Daly B, Watt GR, Batchelor P, Treasure TE. Essential dental public health. New York, Oxford University Press Inc.,2002;107-17. Thomas VM. Evidence Based Dentistry. Dental Clinics of North America;2009:53(1). Richards D, Lawrence A. Evidence Based Dentistry. BDJ 1995;7:270-3. Available from www.ada.org/definition of ebd.
- 59. Sackett DLet al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Churchill Livingstone; 2000 Available from-http://www.ebbp.org/steps.html. Anderson J. Need for evidence-based practice in prosthodontics. J Prosthet Dent 2000;83:58-65. Oxford Centre for Evidence Based Medicine. Levels of evidence and grades of recommendation. Available from http://www.cebm.net/levels _of_evidence.asp