1. Evidence-Based Dentistry
Hope Saltmarsh
Jane Gillette
Julie Frantsve-Hawley
Introduction. Hope will present slides 1-17.
Hello everyone. I am here today to talk to you about Evidence-Based Dentistry

2. What does EBD mean? Script:
I’d like to start this presentation by understanding your perceptions and thoughts when someone uses the term Evidence-Based Dentistry? What does EBD mean to you? << Please open up the topic for discussion>>
Note to Presenter: By posing this question and asking for comments, you can shed light on attendees’ varied opinions and preconceptions before proceeding. Once a few people respond please summarize what you heard.

3. What is EVIDENCE-BASED DENTISTRY?
According to the ADA…
Evidence-based dentistry (EBD) is an approach to oral 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.
Script:
Let’s take a look at what the ADA definition of EBD states.
According to the ADA, EBD is an approach to oral health care that requires the integration of systematically assessed evidence with the clinicians expertise and the patients needs and preferences.
By saying “relating to the patients oral and medical condition and history”, this definition takes a patient-centered approach to treatment decisions

4. Three Components of EBD
Is an approach to oral health care
Is a method to acquire, understand and apply the most current science
Clinical expertise
Patient preferences & needs
Evidence
EBD
Script:
If we think about Evidence, Clinical Judgment and Patient Needs and Preferences as three circles then EBD is right in the center where all the three circles overlap 
It is important for us to understand that EBD is an approach to practice, an approach to making clinical decisions and is just one component used to arrive at best treatment decision.
EBD is a method to stay up to date on the current science.

5. Evidence-Based Dentistry Is NOT….
Cookbook dentistry
A standard of care
A mandate of what must be done
A substitute for clinical judgment
Script:
We often hear the term EBD being used on several occasions by several different people. Some believe that it takes away the dentist’s ability to provide individualized patient care, that is cookbook dentistry, that there is a path that is mandated from diagnosis to treatment that everyone should or must follow and that it is a substitute for clinical judgment
In fact, this is not the case.
One example that comes to mind immediately is the placement of sealants over early carious lesions. We all have placed sealants and all of us tell our patients, “Keep your follow-up appointments, I will see you soon” and at the next appointment you would check it and make sure everything is ok. Now if you have a patient that is not regular and does not maintain oral hygiene well enough you might consider a restoration to begin with.”
Sealants need to be monitored and restored and if a sealant is lost, the tooth is at no higher risk of decay than if the sealant was never placed.
So EBD is actually about providing personalized dental care based on the most current scientific knowledge.

6. The Value of Evidence-Based Practice
Note to presenter: A short story on why you became interested in EBD would help the audience associate with this presentation. You may also use an example of a clinical situation when you used evidence to manage a patient.
Some talking points include:
As a practitioner you gain…
Improved clinical decision-making capability
Greater self-confidence in treatment planning
Satisfaction derived from creating customized treatment plans
Greater respect from improved communication with patients.
Your Patients gain…
More trust and confidence in you and your practice
Greater incentive to invest in quality oral health care
Increased pride from being a patient of a community thought leader and a distinctive practice
Your Dental Team and Practice gain…
Increased staff confidence, pride, trust and personal satisfaction.
Enhanced recognition in the community and with peers
Greater opportunity to conserve practice financial resources by enabling wiser decisions in product, equipment and therapeutic selections.

7. What is evidence? Script:
Now, Let’s move on to understanding “evidence”
The dictionaries define evidence as “an outward sign” or “something that furnishes proof”.
For a moment lets all go to court!
Now in a court of law evidence we often hear the words “circumstantial evidence” or “hear-say evidence.”
So there are different types of evidence, some of which serve as better proof than the others.
Coming back to health care, we also have different levels of evidence.

8. What are the levels of evidence?
Strong
Systematic Reviews
RCT’s
Cohort study
Case control study
Case series
Case report
Expert opinion
Animal research
Bench-top research
Script
The highest level of evidence is a systematic review. In a systematic review, the authors try to identify all evidence on a particular topic and analyze the data cumulatively. The advantage of this type of document, and the reason why it is at the top of the pyramid, is that it is based on multiple studies, not just one, it follows a systematic process, and it provides a big picture of what ALL the evidence on a topic points to.
Below a systematic review is a randomized controlled trial or an RCT. This is a highest level of a clinical study
There are other types of clinical studies like the cohort studies, case control, case series and case reports.
Right under the clinical studies are the expert opinions especially those developed through consensus panels followed by animal research and bench-top research
So in an IDEAL world we would have RCT’s and systematic reviews to answer all our questions
Weak

9. How much is enough? Do we need an RCT to answer this question:
Will using a parachute save lives?
Group 1: Jump with parachutes
Group 2: Jump without parachutes?
Script:
Well then, Why can’t we only use RCT’s for evidence? The simple answer of course is because our world is not ideal!
But specifically because
One, it may not be available. RCTs have not been conducted to address all clinical questions.
Two, it may not be applicable. There are circumstances where an RCT is either unnecessary or unethical to answer a clinical question. A typical example is that there is no need to do an RCT to determine if using a parachute will save lives when jumping from an airplane. We know the answer to this without doing an RCT.
Sometimes after a systematic assessment of the literature if we find that expert opinion is THE ONLY evidence available it is graded as a weak level of evidence. In such a situation we accept the levels of uncertainty and use our judgment to determine how strongly we might recommend this approach to our patients. We understand that further research is needed in this case and that results may very likely change the way we might approach a similar situation in the future.

10. Use your judgment How strongly should I recommend this to my patient?
What is the Level of evidence
What is the Quality of this evidence
Does this apply to my patient?
Script:
So while practicing EBD we look for the highest level of evidence that is applicable to a situation and that is available till date through a systematic assessment of the literature.
Once we find this evidence then we need to ask ourselves:
One, Is it reliable? What is the level of evidence that I have for this question? Or what types of studies support the conclusion?
Two, What is the quality of this evidence? Or are the results consistent? How large is the effect? Are there critical flaws in the study design?
Three, Does this study apply to my patient? Does the population and intervention apply to my situation?
Based on my experience and judgment, how strongly should I recommended this evidence as an option for treatment to my patient?
How do the patients needs and preferences influence this choice?

11. You and your patient make the final decision
Complaint
Signs
Symptoms
Patient
Treatment
decisions
Answerable
question
Can it apply to
the patient?
Search for
best evidence
Script:
In the end, You and your patient are in control starting from the chief complaint until a treatment decision is made. In EBD Evidence supports this process.
I often hear people tell me, “<Your Name> I already do this so what’s different?”
Critical appraisal
of evidence
Clinician

12. Is this different from what I am doing now?
When selecting dental products, how valuable do you find each of the sources of information below?
% indicate the “very valuable” only
2008 PPR Reader Survey
Script:
We all consider evidence in practice but.. Are we considering all the evidence? Are we systematically assessing this evidence? Are we aware of the level and quality of evidence?
The ADA recent conducted a survey for their professional product evaluation program and asked dentists how they rated the different sources of information when trying to purchase a product. The highest on this survey was expert opinion!
So when you hear a speaker on stage using the term “evidence-based”, ask yourself… is this information based on a systematic assessment of existing literature? What is the level of evidence being presented? Is this just the presenters’ own study conclusions?

13. How does EBD work?
Script:
So how does one implement EBD?

14. The EBD Process Ask answerable questions Access the best evidence
Appraise the evidence
Apply evidence to patient care
Note to presenter: This slide includes an animation which will work with each click of your mouse. Please try out.
Script:
The first step is to define a clinically relevant, focused question. In defining a question we must pay attention to four elements – what is the population (children/adults or smokers/non-smokers etc.), what is the intervention, what are we comparing it to and what is the outcome that we need?
The second step focuses on systematically searching for evidence published or unpublished, that may help to answer this question.
The third step of the EBD process is focused on appraising the validity and reliability of the evidence. Important questions to ask at this point – What is the level of evidence used to come the conclusion? Does this apply to my patient?
The fourth step of the EBD process involves using the evidence in treatment planning. Based on my clinical expertise and the patients needs and preferences how strongly should I recommend this to my patient
The final step involves assessing treatment outcomes for the patient.
Assess/evaluate treatment outcomes

15. Acknowledging the difference
Evidence-Based Practice
Uses best evidence
Systematic appraisal of quality of evidence
Objective, transparent, less biased
Acceptance of levels of uncertainty
Traditional Practice
Unknown basis of evidence
Limited/incomplete appraisal of quality of evidence
Subjective, opaque, potentially biased
Black and white conclusions
Script:
In traditional practice, we don’t actively look for emerging evidence, we depend on what we learned in school or what we hear speakers say. We never ask if the speaker is talking from his experiences and his study findings or if his presentation is based on a systematic assessment of all the evidence. We look for “Yes/No” answers.
In contrast, EBD is about using the best available evidence after a systematic assessment of the literature and accepting that sometimes we don’t have the answers and we should be ready to change when these answers are found.
Such a process is a change in perspective i.e. we need to begin to look at things in a different way
Note to presenter: Please try to use an example from your experience highlighting these differences

16. Let’s adapt -- It’s a paradigm shift!
A change of perspective on a subject
It’s true!
SCIENCE Changes!!
EBD is a way to keep up with this change
Script:
So EBD is a paradigm shift…. Questioning the answers we know and an effort to learn continuously.
As a science-based profession, we must acknowledge that what we knew yesterday may not be the same as what we know today, and probably will not be the same as what we will know tomorrow.
Science always provides new information, and new questions, and knowledge are always changing.
EBD is simply a way to keep up with the change in knowledge and apply it when treating patients.

17. Is what we learned in school still true?
Past – Present - Future
Suggested original script:
Lets stop a minute and ask ourselves, how much of what we practice today was taught to us in Dental School? How much have we adapted science? What new evidence has emerged since we left school?
There have been several changes that we could talk about in Dentistry:
The notion that caries can be managed in non-surgical ways is new. Opportunities exist for management through re-mineralization or transitioning a lesion from an active to an inactive state. There are also researchers attempting to develop vaccines against caries.
The fact that caries is an infectious disease, is something that the general public is not aware of.
Is what we learned in school still true?

18. Medical Publishing Annually: 20,000 journals 17,000 new books MEDLINE:
6 million references
400,000 new entries yearly
Script:
Did you know that there are 20,000 journals with 400,000 new entries yearly?
One of the biggest challenges for a practitioners is the abundance of information being generated every day and the lack of time to make sense of any of it.

19. Barriers to change Time Access Complexity of information Script:
Understanding the changes and a willingness to move forward puts us face to face with the challenges that confront us.
But this needs time. I know I don’t have time. In the course of running a busy practice, it is difficult to find the time to conduct a literature search, read all identified articles, critically assess the articles, and come to some conclusion.
Even if I have time, the typical private practice or small practice nature of most dental offices does not provide access to a wide variety of journals.
Finally, many articles published in scientific formats are not user-friendly for chair-side application.
But these are just some walls we need to learn to climb. The ADA and many other agencies offer several resources to help apply evidence in practice. So our goal should be to find such sources and use this information.
If you have limited time consider the secondary sources of evidence such as summaries and systematic reviews, (Note that a list appears on Slides 32, 33 and 34)

20. …that fluoride varnish is effective in caries prevention?1
Did you know…
…that fluoride varnish is effective in caries prevention?1
… that sealants placed on a non-cavitated lesion reduce caries progression?2
ADA Council on Scientific Affairs, “Professionally applied topical fluoride evidence–based clinical recommendations, JADA 137, Aug 2006;
2. ADA Council on Scientific Affairs. Use of pit and fissure sealants: evidence-based clinical recommendations. JADA 2008;139(3):
Script
How many of you knew that….
(Note to presenter: Engage the audience by asking how many were aware of these changes)
The ADA through its Center for EBD has several different programs to help practitioners find the answers.

21. Try and you can climb that wall!
Formulate your question Search the secondary sources Search the primary sources Use it in your treatment decision
It’s a matter of finding the road in our busy practices. There are sources that make it easier to accomplish and keep up with Science. Such secondary sources of evidence, such as the summaries of systematic reviews, the systematic reviews themselves provides a quick read on the bottom line and reduce the amount of time that each one of us needs to spend appraising every clinical study.

22. Where can I find evidence?

23. - Providing the tools you need
Script:
The ADA established the Center for Evidence based Dentistry in 2007 to provide tools for practitioners to help implement the EBD approach.

24. Script:
The ADA Center for EBD has a two-fold vision.
The first part is helping practitioners implement EBD
The second part is disseminating the most current scientific information for members of the dental team

25. Script
The ADA Center for EBD has a dedicated website for current scientific information This website provides one-centralized location for scientific information.
It includes a searchable database of all systematic reviews, one –page synopsis, called a critical summaries systematic reviews, links to external sources of scientific information.
Additionally practitioners can give feedback to the ADA on important clinical ideas through this website,

31. Clinical Recommendations
ebd.ada.org
Systematic Review
Clinical Recommendations
The ADA publishes Clinical Recommendations in JADA.
Clinical recommendations are intended to translate systematically assessed information from multiple sources into practical applications.

32. ebd.ada.org
Script:
The ADA has published recommendations on topical fluoride, sealants and oral cancer, and is developing recommendations on fluoride supplements and fluoride in infant formula. These recommendations should be published in 2010.
Both of these documents are open access manuscripts in JADA.

33. ebd.ada.org

38. Supported by a grant from the NLM and the NIDCR
(Grant Number G08 LM008956)

39. TRANSITION TO JANE GILLETTE

41. EBD Champion

43. “Thank you for the privilege and honor to participate in this meeting, one of the best I’ve attended and one that I believe will produce a lot of fruit in academia, education, research, and practice.”
“I really enjoyed this experience and initiation into being a champion for EBD. There are high expectations for me to disseminate this information in my dental school, component societies and study clubs. I feel this has been a good preparation for me to go home and start working on this.”
“Excellent program. The passion in the presenters has to be contagious!”

44. ADA/Forsyth Evidence-Based Dentistry Course
5 days
Critical appraisal
Research Designs
Statistics
Advanced searching techniques
Certificate: in Evidence-Based Dentistry from the Forsyth Institute

45. ADA/Forsyth EBD Course

46. Other Educational Opportunities
nature.com/ebd/journal

47. THANK YOU! Visit ebd.ada.org ADA Contact: ebd@ada.org
Script:
I hope I provided you with enough information to interest you in EBD and help you apply this approach in your practice. Please feel free to contact the American Dental Association if you are interested in any of their programs.