1. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 1 Evidence-based Dental Practice

2. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 2 Outline Definition of evidence-based dentistry The process for EBD Systematic reviews Limitation of EBD

3. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 3 What is Evidence?

4. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 4 Sources of Evidence People (colleagues, specialists, experts) Textbooks Clinical journals Non-systematic reviews Systematic reviews

5. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 5 Types of Clinical Questions Therapy –Works? Harm –Side effects? Diagnosis –Accurate? Etiology –Without doubt?

6. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 6 Types of Clinical Questions Therapy –Randomized controlled trials Harm –Randomized controlled trials Diagnosis –Cohort studies Etiology –Cohort studies

7. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 7 Bias Bias is systematic or consistent errors that are caused by explicit or implicit factors or conditions in the study: –Explicit We know that we are biased –Implicit Hidden or un-detected

8. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 8 Bias and Healthcare Newsletters –MI Paste: A revolution in mineralization Expert opinion Continuing education One patient (case studies) “In my experience”

9. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 9

10. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 10 Hierarchy of Evidence Systematic reviews of randomized controlled trials Randomized controlled trials Experimental studies without randomization Cohort studies Case-control studies Observational studies Qualitative designs Audit of records Conference reports, consensus conferences, or expert opinion

11. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 11 ADA Definition of Evidence-Based Dentistry “…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.” ADA, 2002

12. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 12 Evidence-based Dental Practice

13. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 13 Evidence-based Dentistry Questions PICO Clinical problem Decision Evaluation Appraisal Synthesis Selection Search

14. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 14 Parachute Paradox Parachutes reduce the risk of injury after gravitational challenge, but their effectiveness has not been proved with randomized controlled trials. BMJ 2003;327:20-27.

15. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 15 Risks of EBD Clinicians do not deal with homogenous averages Fundamentalist EBDers Dissemination does not guarantee assimilation Abuse by third parties Legal liability

16. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 16 Example of a Systematic Review Home-based chemically-induced whitening of teeth in adults. Hasson H, Ismail AI, Neiva G Cochrane Database of Systematic Reviews, 2006

17. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 17 Clinical Questions What is the effectiveness or relative effectiveness of tooth whitening products with chemical, bleaching action, that are available for use at home (dispensed by a dentist or over the counter (OTC))? What are the harms reported in randomized controlled trials?

18. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 18 Methods Type of studies Randomized controlled trials Quasi-randomized controlled trials Placebo or other comparable products Human subjects Full reports Duration? –Majority presented data after 2 weeks

19. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 19 Methods Types of participants Adults 18 years or older Teeth tested should be free of stains due to use of tetracycline, fluoride products, or other systemic diseases or developmental conditions

20. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 20 Methods Search Methods 416 reports 162 duplicates 253 non-duplicates 193 did not meet the inclusion criteria 60 full reports were reviewed 2 reviewers

21. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 21 Methods Types of interventions Any tooth whitening product, for use at home, that has a chemical bleaching action rather than an abrasive action. Dentist-dispensed or OTC Gels applied in trays, paint-on films, whitening strips

22. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 22 Methods Search Methods All studies published between January 1966 and September 2005 Cochrane Center Register of Controlled Trials (182) MEDLINE (230) EMBASE Hand-searching (4) Letters to researchers and companies

23. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 23 Methods Search Methods 60 full reports 35 reports were excluded (lack of data on outcomes after 2 weeks of application; data were not comparable; statistics were incomplete). 25 studies (trials) were included in the review 17 trials used the Chroma Meter system 9 trials (11 reports) used the shade guide

24. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 24 Results Description 786 adult participants in the 17 studies that used the Chroma Meter. Age range was between 18 and 73 years. 766 participants in the 11 studies that used the shade guides. Age range was between 18 and 80 years.

25. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 25 Results Types of outcome measures Digital readings of ‘whiteness” obtained using a digital imaging device/colorimeter (Minolta CR- 221 or Chroma Meter), either from digital images or directly from facial tooth surfaces. Ordinal scales (Vita Shade Guide or equivalent) (16 tooth tabs)

26. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 26 Results Quality 21 trials were classified with high risk of bias 4 were rated with moderate risk of bias Quality assessment: –Concealment of allocation –Blinding of examiners –Training of examiners –Withdrawals

27. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 27 Results

28. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 28 Results

29. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 29 Results

30. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 30 Results

31. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 31 Results

32. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 32 Results

33. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 33 Results Funding 17 studies – 9 by P&G – 4 Ultradent and Discus Dental – 3 Colgate Palmolive –1 Pfizer 11 studies –2 Dentsply –4 Colgate Palmolive –2 Ultradent and Discus Dental –2 P&G –1 Pfizer 3 studies used shade guide and Chroma Meter.

34. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 34 Conclusions There is evidence that whitening products work when compared with placebo/no treatment. There are differences in efficacy between the products, mainly due to the levels of active ingredients, hydrogen peroxide and carbamide peroxide. All trials were however short term and the majority of the studies were judged to be at high risk of bias and were either sponsored or conducted by the manufacturers. There is a need for pragmatic long-term and independent clinical studies that include participants representing diverse populations. There is also a need to evaluate long-term harms. Several studies reported (when measured) the common side effects of tooth sensitivity and gingival irritation, and people should be informed of this.

35. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 35 The ADA Evidence-Based Dentistry Database

36. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 36 ADA-EBD Database

37. TEMPLE UNIVERSITY KORNBERG SCHOOL OF DENTISTRY 37 Evidence-based Dentistry EBD is comprehensive synthesis of scientific evidence to answer a clinically relevant question. EBD is a useful tool for life-long learning. EBD cannot provide answers to the question on how treat a patient; but rather provide the dentist with information to make the most appropriate decision with a patient. Abuse of EBD can only be prevented by a learned profession.