Evidence based dentistry, public health , Prosthodontics and EBD, history of ebd steps, evidence based medicine,evidence based practise. steps in ebd. advantages ,disadvantages, limitations. prosthodontic considerations.

1. DR. Kumari Kalpana
PGT 1ST YEAR
DEPT. OF
PROSTHODONTICS,CROWN &
BRIDGE
1

2. 2

3. CONTENTS
INTRODUCTION
DEFINITIONS
HISTORY
EVIDENCE – BASED PRACTICE
EVIDENCE – BASED DENTISTRY
3

4. PROCESS OF EVIDENCE BASED DENTISTRY
EBD & PROSTHODONTICS
ADVANTAGES
DISADVANTAGES
4

5. LIMITATIONS OF EVIDENCE – BASED DENTISTRY
WHAT EBD IS NOT ?
WHO BENEFITS FROM EBD?
CONCLUSION
REFERENCES
5

6. 6
INTRODUCTION
1,2
1. Kotwal M, Hallikerimath RB, Shigli K, Gangadhar SA. Evidence-based dentistry: The clinical connection to
innovation. J Indian Prosthodont Soc 2007 Mar;7(1):2-4.
2. Somaraj V, Shenoy RP, Shenoy GP , Jodalli P, Sonde L .Evidence Based Dental Practice: A Review.JOADMS
2015;1(3):112-122.

7. Evidence based dentistry is
an invaluable tool for the
specialist practitioners
needing to maintain
awareness of new
approaches outside their
branch of dentistry.
7

8. Evidence-based Dentistry (EBD) is the integration and
interpretation of the best currently available research
evidence combined with personal experience which
allows dentists to make decisions that will improve clinical
practice and academic researchers to be acquainted with
new developments in the field of healthcare.
8

9. DEFINITIONS
9
Somaraj V, Shenoy RP, Shenoy GP , Jodalli P, Sonde L .Evidence Based Dental Practice: A Review. JOADMS
2015;1(3):112-122.
Need for evidence-based practice in prosthodontics Anderson, James D. Journal of Prosthetic Dentistry , Volume
83 , Issue 1 , 58 – 65

10. The American Dental Association defines EVIDENCE BASED
DENTISTRY 5 as “an approach to oral healthcare 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.”
10

11. 11
Evidence - The available body of facts or information
indicating whether a belief or proposition is true or valid.
Survey - An observational study that generally has a cross-
sectional design; a commonly used design to collect points.
Randomized clinical trial - An experimental study in which
subjects are randomly assigned to treatment groups.

12. 12
Bias - Any systematic error that results in an incorrect estimate
of the association between treatment or exposure and the
result. The error related to the way the targeted and sampled
populations differ; which threatens the validity of a study.
Meta-analysis - A method for combining the results from
several independent studies of the same outcome so
that an overall P value may be determined.

13. HISTORY4,5,6
13
Hutter, Jeffrey W The History of Evidence-Based Dentistry in the ADA, Journal of Evidence-Based Dental Practice , Volume 4
, Issue 1 , 8 - 11
Suttle, C.M., Jalbert, I. & Alnahedh, T. Examining the evidence base used by optometrists in Australia and New Zealand.
Clinical & experimental optometry: Journal of the Australian Optometrical Association 95, 28-36 (2012)
Sohail, Kanwal; Sabir, Sohail EVIDENCE BASED DENTISTRY - A REVIEW. Pak Armed Forces Med J 2014; 64(2): 360-3

14. The term "evidence-based medicine" was introduced by
Guyatt et al in 1992 to shift the emphasis in clinical
decision making from "intuition, unsystematic clinical
experience, and pathophysiologic rationale" to scientific,
clinically relevant research.
14

15. In 1996, Sackett et al explained evidence-based clinical
decision making as a combination of not only research
evidence but also clinical expertise, taking into account the
patient’s preferences.
15

16. The American Dental Association initiated an active role in EBD in
February 1999 when the ADA Board of Trustees (BOT) addressed
this new approach to clinical practice by adopting the following
resolution (B-18-1999):
Resolved, that a task force be convened to determine the
Association’s role in EBD as it relates to patient care.
16

17. 2000 – 1st centre for Evidence based dentistry in India
was set up at Davangere.
November 11, 2002, the ADA Evidence-Based Dentistry
Advisory Committee hosted the EBD workshop in
Chicago
17

18. In 2003, a statement on evidence-based practice was
prepared by the delegates of the Evidence-based Health
Care Teachers and Developers.
The conference was held in Sicily, and the statement is
known as the Sicily Statement (Dawes et al, 2005). It
helped to introduce the broader concept of evidence-based
decision making to health care generally.
18

19. The American Dental Education Association and the
American Association of Dental Research sponsored a
symposium entitled ‘‘Educating Tomorrow’s
Practitioners in Evidence-Based Dentistry’’ at the 2004
American Dental Education Association Annual Session.
19

20. In 2009, Satterfield et al developed a trans disciplinary
model for evidence-based practice. This model depicts the
three core components of EBP (best available research
evidence, clinical expertise and patient’s preferences)
within the broader clinical or organizational context.
20

21. 21

22.  Evidence based practice evolved from clinical
epidemiology (the application of research undertaken
on populations to inform individual clinical decision
making) and critical appraisal to involve ‘explicit
decision making within clinicians' daily practice’.
 EBP was required to be based on best available,
current valid and relevant evidence
22

23.  By applying EBP to the delivery of a population
health care approach, health services should
deliver the Right treatment to the Right patient
on Right time by the Right person in the most
appropriate Right setting with Right patient
experience.
23

24. 24

25. 25

26. Evidence-based dentistry (EBD) is a new paradigm in
medicine, meaning that a therapy should be based on
evidence gathered from scientific studies, preferentially
based on randomized clinical trials involving a substantial
number of patients.
26

27. 27

28. How to use EBD?
1. Create an answerable question (ASK)
2. Track down the best evidence to answer the question
(ACCESS)
3. Critically appraise the information (APPRAISE)
4. Apply the results to one’s patients(APPLY)
5. Evaluate one’s performance.(ASSESS)
28

29. 29

30.  Asking the right question is perhaps the hardest skill
to learn— and yet it is the first and most fundamental
step to the Evidence Based Decision Making (EBDM)
process.
STEP – 1 ASKING ANSWERABLE QUESTION
30

31. There are two main types of questions that will determine an
efficient and relevant search strategy:
31

32. Background questions
Background questions are aimed at eliciting descriptive
information concerning clinical conditions, diagnostic tests
or treatments.
32

33. Foreground questions are targeted questions about therapy and
prevention, diagnosis, etiology and prognosis that directly inform clinical
decision making.
Examples of foreground questions are “Are antibiotics effective as an
adjunctive therapy for treating patients with chronic periodontitis?” or
“What is the diagnostic accuracy of the laser caries detection system?”
33

34. Besides the type of questions, we must identify the main
components of the question.
All types of questions typically have four main
components, which vary depending on the nature of the
question.
34

35. P…I…C…O…3,11
A “well-built” question should include 4 parts that
identify the patient
35

36. (P) problem or population (patient relevant to question)
(I) intervention or indicator(prevention strategy),
(C) comparison or control(the management strategy used as
reference against which to compare the intervention), and
(O) Outcomes (the consequences of intervention), referred to
as PICO.
A practical approach to evidence-based dentistry Brignardello-Petersen, Romina et al. The Journal of the American
Dental Association , Volume 145 , Issue 12 , 1262 - 1267
36

37. – The formality of using PICO to frame the question serves 3 key
purposes:
 First, it forces the questioner to focus on what the patient/client
believes to be the single most important issue and outcome.
 Second, it facilitates the next step in the process, the
computerized search, by selecting language or key terms that
will be used in the search.
37

38.  Third, it directs one to clearly identify the problem, results,
and outcomes related to the specific care provided to that
patient.
38

39. 39

40. Finally, we must identify the best type of primary study design to
answer the clinical question. Depending on the nature of the
question, EBD proposes a hierarchy of study designs, starting
with those that minimize the risk of bias, which we should seek
first to inform our clinical practice.
40

41. 41

42. Bidra AS. Evidence-based Prosthodontics. Den Clin N Am. 2014;58:1-17
“HIERACHY OF
EVIDENCE.”
42

43. SYSTEMATIC REVIEWS AND METAANALYSIS
– Research evidence can be reviewed by either informal or systematic approaches.
– Systematic reviews try to overcome the limitations of narrative reviews and be as
objective and transparent as possible.
– For a systematic review to be scientifically sound, reviewers must clearly describe
the research question, the criteria for inclusion or exclusion of the primary studies,
the techniques to assess the methodologic quality of the studies included, and the
methods used to extract and synthesize the results of the primary trials on which the
conclusions are based.
43

44. 44
 Systematic reviews summarize and synthesize the available
evidence related to diagnosis, therapy, prognosis, and harm
for clinicians, and decision makers.
 Systematic reviews are the cornerstone of EBD.

45.  Meta-analysis combine & summarize the results of multiple
studies & describe the true clinical effects of interventions
more accurately than do small individual studies.
45

46. 46 RANDOMIZED CONTROL TRIAL
 RCTs are considered the “gold standard” for evaluating a given
therapy and its causal impact on an outcome.
 In an RCT, study subjects are randomly assigned to one of two
groups: the treatment arm, which receives the therapy, or the control
arm, which receives a placebo or no treatment.
 Both study arms are subsequently followed in an identical manner
and analyzed for differences in outcomes.

47. Another form of allocation that is not truly random is
quasirandomization.
This entails allocation based on a patient’s medical record number
or date of birth or by simply allocating every alternate person. Such
methods of allocation are easy to manipulate, leading to a selection
bias.
Bidra AS. Evidence-based Prosthodontics. Den Clin N Am. 2014;58:1-17
47

48. 48
In Harwood’s extensive analysis of 44,338 prosthodontics publications between 1966 and
2005, only 955 articles (2%) were RCTs.
In another study by Dumbrigue and colleagues in 1999 only 1.7% of articles published in
prosthodontic journals met the minimum criteria to be included in central register of RCTs.
A recent study by Pandis and colleagues in 2010 compared and ranked the quality of RCTs
published in top journals across 6 different specialties of dentistry. Their results showed that
RCTs published in prosthodontics ranked the lowest among all specialties

49. 49
– Advantages
– Ability to minimize confounding factors through
randomization.
– By reducing biases, causality of an intervention on
a defined outcome can be most effectively
determined.
– Disadvantages
– They are typically more expensive and tedious to
perform.

50. COHORT STUDY
 Investigators select a group of people who share a common
characteristic or exposure, but do not have the disease or
outcome of interest.
50

51. • Meaningful clinical impact,
• large sample sizes and,
• A long follow-up period
51

52. Some examples of cohort studies with long-term follow-up, which
have had a significant impact on prosthodontics, include
• Tallgren’s 25-year follow-up study on reduction of the residual
alveolar ridges in complete denture wearers.
• A 20-year follow-up study by Douglass and colleagues on
cephalometric evaluation of vertical dimension changes in
patients wearing complete dentures.
52

53. Advantages
 Multiple variables may be assessed concurrently and disease
risk factors may be identified.
 Findings may be more generalizable.
 Study the relationship between certain outcomes and
exposures that could not otherwise be ethically administered
to subjects .
53

54. Disadvantages
Costly and time-consuming, as well as vulnerable to subject
attrition or loss to follow-up during the course of the study.
 Not ideal for studying rare diseases.
 No randomization, so are more prone to bias and
confounding than are RCTs .
54

55. CASE-CONTROL
 In this, those affected by a disease (cases) are compared to
disease-free controls from within the population.
 This type of study aims to identify an association between a
disease and potential risk factors.
55

56.  These studies may be performed through interviews or
patient chart review.
 This allows investigators to determine prior exposure to a
potential risk factor and the weight of its impact on disease
development.
56

57. Advantages
Require less time and cost than the mentioned studies.
Ideal design for researching rare diseases.
Although it is difficult to show causality, associations may be observed that
can be studied further using a more rigorous method.
57

58. EBD &
PROSTHODONTICS12
58

59. Although the 5 hierarchical levels of evidence and the
pyramidal representation may be popular in medicine, the
applicability of this paradigm to prosthodontics is
questionable because few articles in prosthodontics
comprise RCTs and large cohort studies, implying that most
current clinical practices in prosthodontics are all based on
“weak evidence”.
59

60. Additionally, 2 critical elements of importance to prosthodontics
that are omitted from the evidence-based pyramid are sample
size and duration of a study.
These 2 elements can significantly affect the way evidence
has an impact on clinical practices.
60

61. For example, results from a cohort or a case-control study with
a very large sample size and/or a long-term follow-up on all-
ceramic crowns can have a better impact on clinical decisions
compared with results from an RCT with a small sample and a
short-term follow-up. In this scenario, in spite of RCT regarded
as the “strongest evidence,” it would fail to be used by
clinicians for confident decision making.
61

62. STEP – II ACQUIRE EVIDENCE2
The evidence is available from a wide range of sources:
1. Colleagues:
The first option for most as most healthcare professionals remember learning
to carry out various procedures from senior colleagues or from a peer who
has had experience of the procedure.
63

63. 2. Books:
A good source of comprehensively established information
in which the information is laid out in well-defined sections
with an index of terms making them useful as quick
references for basic background information.
64

64. 3. Journals:
One method of keeping track of the latest advances in the field of interest as
they have more up-to-date information than books because articles are
generally published within months of submission.
4.Internet:
A revolutionized way through which most people work as they can access
information from any number of sources electronically.
65

65. Electronic Databases
MEDLINE:
This is the US National Library of Medicine’s (NLM) premier
bibliographic database that contains over 11 million references
to journal articles and can be accessed free of charge.
66

66.  The MEDLINE database belongs to a larger family of more
than 40 NLM databases called MEDLARS (Medical Literature
Analysis and Retrieval System), which includes specialized
databases such as Cancerlit, AIDSLINE & TOXLINE.
 MEDLINE plus provides consumer health information and
encourages consumers to discuss search results with their
health care professional.
67

67. 68

68. PubMed system:
Developed by the National Library of Medicine, located
at the National Institutes of Health (NIH), and through
the National Centre for Biotechnology Information
(NCBI), serves as an search tool for accessing dental,
medical, and biomedical literature citations and
provides links to full-text journals at the web sites of
participating publishers.
69

69. 70

70. 71

71. 72

72. 73

73. Cochrane Collaboration:
An international non-profit, independent organization
dedicated to making up-to-date, accurate information about
the effects of healthcare readily available worldwide. It
produces and disseminates systematic reviews of healthcare
interventions and promotes the search for evidence in the form
of clinical trials and other studies of interventions.
74

74. 75

75. 76

76. Guidelines for reporting
evidence10
77
 With the burgeoning publication growth in prosthodontics, it is
necessary for investigators to comply with certain guidelines
for reporting scientific evidence. Several consensus groups and
task forces in medicine have suggested various guidelines.
 The common goal of all guidelines is to improve scientific
reporting and ensure standardization so that they allow an
accurate assessment of the presented evidence.
 Popular guidelines are described further.

77. 78 CONSORT
TREND
PRISMA
MOOSE
SORT
AMSTAR

78. – CONSORT
– Consolidated Standards of Reporting Trials (CONSORT) is a
popular guideline for
– reporting RCTs. A group of scientists and editors in 1996
developed this statement
– to improve the quality of reporting of RCTs. The objective of
CONSORT is to provide
– guidance to investigators about how to improve the reporting of
their trials and to be
– clear, complete, and transparent.
79

79. –TREND
– Transparent Reporting of Evaluations with Nonrandomized
Design (TREND) was created in 2003. In contrast to
CONSORT, the objective of TREND is to provide guidance to
investigators to standardize and improve the reporting of
studies with nonrandomized designs (cohort and case-control
studies).
80

80. – PRISMA
– The objective of Preferred Reporting Items for Systematic
Reviews and Meta- Analyses (PRISMA) is to provide guidance
to investigators to standardize the reporting of SRs and meta-
analyses. Initially, a group of scientists and editors in 1996
initiated a document called Quality of Reporting of Meta-
analyses (QUOROM), and, in July 2007, QUOROM was
changed to PRISMA.
81

81. – MOOSE
– Meta-analysis of Observational Studies in Epidemiology
(MOOSE) was created in 1997. The objective of MOOSE is to
provide guidance to investigators to standardize the reporting
of meta-analyses from nonrandomized studies. The MOOSE
checklist includes 35 items, ranging from background to
funding source.
82

82. –SORT
Strength of Recommendation Taxonomy (SORT) has emerging
popularity in dentistry. It was developed by a group of family
physicians in 2004 to classify the level of evidence for a study
and provide recommendations. The objective of SORT is to
provide a patient-oriented guidance to assess the quality,
quantity, and consistency of evidence and allows investigators
to rate individual studies or bodies of evidence.
83

83. –AMSTAR
– Assessment of Multiple Systematic Reviews (AMSTAR) was
developed in 2007 as an instrument to assess the
methodological quality of SRs. It consists of 11 questions to
analyze the quality of an SR, such as “Was a comprehensive
literature search performed?” and “Was a list of studies
(included and excluded) provided?” Each of these questions
has 4 possible answers for the investigator: “Yes,” No,” Can’t
Answer,” and “Not applicable.” This helps investigators
critically analyze the quality of a published SR.
84

84. STEP – III APPRAISE EVIDENCE10
Analyzing the validity, importance and usefulness of the evidence is
called critical Appraisal.
Critical appraisal is a way of rapidly assessing published papers in
order to sort out the relevant or valid papers from poor quality or
irrelevant ones..
85

85. The methodological conduct of the study is key to determining
the reliability of the study particularly the elimination of bias.
Bias is the ‘systemic deviation of the results from the truth
because of the way it has been conducted analyzed and
reported’.
86

86. A study that has minimized bias sufficiently is said to have internal validity.
Control of the bias is a major determinant of the strength of a design.
87

87. 1. Selection bias
2. Performance bias
3. Detection bias
4. Attrition bias
5. Selective reporting bias
Types of bias
88

88.  Many papers have minor, and some may have major, faults.
 The objective of critical appraisal is not to make spurious
criticism; it is to decide whether a flaw is serious enough to
compromise the methodology and therefore the results obtained,
the generalizability of the paper, and applicability to clinical
practice.
89

89. STEP – IV APPLY EVIDENCE6
After gathering the information obtained from assessing the
evidence, one should be able to take decision to act.
However, the decision to act should be based on the
evidence, the willingness of the patient to receive the
treatment, and the practitioner’s ability to provide the
treatment.
90

90. 5.Assessing 3
 Having identified evidence that is both valid and relevant,
clinicians can either implement it directly in a patients care or
use it to develop team protocols or even hospital guidelines
 They can also use evidence to revolutionize continuing
medical and dental education programs or audit.
91

91.  In experience, implementing the evidence is best learned
through group discussions or in other meetings of the clinical
team in which members explore ways of incorporating the
evidence into a patients clinical management.
92

92. 93

93.  For individuals –
 Enables clinicians to upgrade their knowledge base
routinely.
 Improves clinicians understanding of research
methods and makes them more critical in using data.
 Improves computer literacy and data searching
techniques.
 Improves reading habits.
94

94.  For clinical teams-
 Gives team a framework for group problem solving and for
teaching.
 Enables juniors to contribute usefully to team.
 For patients –
 More effective use of resources
 Better communication with dentists about the rationale
behind management decisions
95

95. 96

96. 1. It takes time both to learn and to practice
2. Establishing the infrastructure for practicing evidence
based dentistry costs money.
3. Evidence based dentistry exposes gaps in the evidence.
4. Medline and the other electronic databases used for
finding relevant evidence are not comprehensive and are
not always well indexed.
97

97. LIMITATIONS OF EVIDENCE-BASED
PROSTHODONTICS5
1.Applicability of research to a specific patient population,
publication biases, paucity of current data, cost, and ethics.
2.The information gained from clinical research may not
directly answer the principal clinical question of what is best
for a specific patient.
98
Bidra AS. Evidence-based Prosthodontics. Den Clin N Am. 2014;58:1-17

98. 3. EBD does not advocate absolute adoption of clinical evidence but
calls for an integration of the clinical evidence along with the
dentists’ clinical expertise and patient needs and preferences.
4. EBD does not provide a cookbook that dentists must follow nor
does it establish a standard of care.
5. According to the ADA, the EBD process must not be used to
interfere in the dentist/patient relationship.
99

99.  Evidence based dentistry does not take the clinical decisions
out of clinician's hands and put them into the hands of the
literature.
 Evidence based dentistry does not mean that third parties will
control dental practices.
 Evidence based dentistry does not mean the clinician need
not study basic and dental material sciences.
 Evidence based dentistry does not mean clinicians abandon
everything they learned in dental school.
What EBD is Not…12100

100. Who Benefits From EBD ?? 12101
The ultimate beneficiaries of EBD are members of the public,
who will reap the rewards of better care. The internet allows
patients, as well as professionals, access to health care
information. The public, however, does not have the tools to
evaluate the data adequately and must rely on their educated
dentists to help sort fact from fiction.

101. Dentists, who will also benefit from EBD.
Researchers, who will benefit by being called upon to do
the clinical testing necessary before new products are
placed on the market.
102

102. A Iqbal, AM Glenny General dental practitioners' knowledge of and attitudes towards evidence-based practice -
British dental journal, 2002
To assess general dental practitioners’ understanding of, and
attitudes towards, evidence-based practice (EBP).
29 %
60 %
81 %
Sales
1st Qtr 2nd Qtr 3rd Qtr
103

103. 104

104. As a global movement in all the disciplines of health sciences,
evidence-based care represents a shift in the practice – judgment
based on scientific evidence overpowering blind adherence to
rules. EBD approach empowers clinicians to question and
consider the use of current best evidence in decision-making on
the management of individual patients. It offers many benefits,
ranging from more efficient and effective healthcare delivery to
improve treatment standards and outcomes.
105

105. REFERENCES
106

106. 107
1. Kotwal M, Hallikerimath RB, Shigli K, Gangadhar SA. Evidence-based dentistry: The clinical
connection to innovation. J Indian Prosthodont Soc 2007 Mar;7(1):2-4.
2. Somaraj V, Shenoy RP, Shenoy GP , Jodalli P, Sonde L .Evidence Based Dental Practice: A
Review.JOADMS 2015;1(3):112-122.
3. Need for evidence-based practice in prosthodontics Anderson, James D. Journal of Prosthetic
Dentistry , Volume 83 , Issue 1 , 58 – 65.
4. Hutter, Jeffrey W The History of Evidence-Based Dentistry in the ADA, Journal of Evidence-Based
Dental Practice , Volume 4 , Issue 1 , 8 - 11
5. Suttle, C.M., Jalbert, I. & Alnahedh, T. Examining the evidence base used by optometrists in
Australia and New Zealand. Clinical & experimental optometry: Journal of the Australian
Optometrical Association 95, 28-36 (2012)
6. Sohail, Kanwal; Sabir, Sohail EVIDENCE BASED DENTISTRY - A REVIEW. Pak Armed Forces Med
J 2014; 64(2): 360-3
7. Daly B, Batchelor P, Treasure ET, Watt RG. Essential dental public health. 2nd ed. Oxford(UK);
Oxford; 2013. p. 79-96.

107. 108
8. Anderson JD. Need for evidnce-based practice in prosthodontics . J Pros Dent. 2000
Jan;83(1):58-65.
9. Santosh HN, Nagaraj T, Bose A, Sinha P, Mahalaksmi IP. Evidence-based dentistry: A
new dimension in oral health. J Adv Clin Res Insights 2014;3:114-119
10. A Iqbal, AM Glenny General dental practitioners' knowledge of and attitudes towards
evidence-based practice - British dental journal, 2002
11. A practical approach to evidence-based dentistry Brignardello-Petersen, Romina et
al. The Journal of the American Dental Association , Volume 145 , Issue 12 , 1262 1267
12.Bidra AS. Evidence-based Prosthodontics. Den Clin N Am. 2014;58:1-17
13. .Goldstein G. What is evidence based dentistry. Den Clin N Am. 2002;46(1):19.

108. 109