1. The Necessity of an Evidencebased Approach to Diagnosis and Treatment

Chapter 1

The Necessity of an Evidence-based Approach to Diagnosis and Treatment

Today, the concept of evidence-based health care surrounding our clinical practice of dentistry is discussed more than ever. However, many times this term has been used to define anything but “evidence-based dentistry” (EBD).

The term “evidence-based” has evolved through certain iterations through the years. It was first used in 1992 when a paper was published by a clinical epidemiology group at McMaster University in Canada (Evidence Based Medicine working group 1992). Their article described their challenge to adopt an “evidence-based practice” (EBP) approach since it “de-emphasizes intuition, unsystematic clinical experience and pathophysiological rationale as sufficient grounds for clinical decision making.” The paper was written with the clear intent of placing a greater emphasis on a systematic appraisal of the evidence.

The first use of the term “evidence-based” in the UK was in a 1996 British Medical Journal article by David Sackett et al. and was defined as the “… conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. …”

The term “current best evidence” is the operative word here because it implies that our best available evidence should by definition change as we progress through more research findings, to the point that what was true as the best available evidence even as recently as ten years ago in dentistry in some respects is not even true today. Many examples come to mind, such as the new adhesive systems, a newer generation of composites, more non-surgical periodontal therapy, more procedure-specific use of biomaterials due to better-applied research results, and so on.

The American Dental Association (ADA) has defined the concept of EBD as:

“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.”

EBD has five components. This premise is simply based on the notion that to perform a scientific search for the current best evidence, one must be able to interpret the clinical scenario, translate it into searchable terminology, and then find the best evidence by critically assessing the quality and the appropriateness of the published evidence to address the identified clinical scenario. The five components are:

1. Translate a clinical problem into a question. For example: A new patient who is pregnant comes to see you with a chief complaint that she wants a second opinion on her need for periodontal surgery. She has heard periodontal disease may cause low-birth-weight babies and asks, “Do I really need surgery or could I just have dental cleanings (scalings) to prevent a low-birth-weight baby?” An easy method to translate a clinical scenario into a searchable format is by using the PICO structure. PICO is an acronym for Problem, Intervention (or Index, i.e., a category or condition), Comparison, and Outcome. So, by using PICO, one would devise the following structured format for the example described above:
How would I describe the dental Problem or population?
“In pregnant patients …”
Which main Intervention or index am I considering?
“With periodontal disease …”
What is the main Comparison or alternative?
“Compared to pregnant people (patients) without periodontal disease …”
What is the Outcome to be studied?
“Is there a greater risk of low-birth-weight babies?”
2. Effectively search for the best evidence. For this component, one must determine which databases to search and then use the appropriate databases and search filters to find the best evidence. The most common database is Medline (accessible via many free Internet portals such as www.pubmed.gov); however, there are many highly specialized databases such as Psychlit for behavioral research, Cancerlit for cancer literature, and NHSEED for economic evaluation research (UK) (see Chapter 4). As a source of high-level study designs, the Cochrane Oral Health Group (OHG), which originated in New England in 1994 and moved to Manchester (UK) in 1996, now has a registry of 83 reviews, 53 protocols, and 26 titles in dentistry (Clarkson et al. 2003). OHG specifically reviews a particular type of study design, randomized controlled trials (RCT), which are suitable study designs for treatment-based clinical decisions. Summaries of the reviews are listed on the OHG website (www.ohg.cochrane.org/).
The term “filter” refers to the strategy for condensing thousands of articles into a more refined or limited set of relevant data. Filtration could be based on “human”/>

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Jan 14, 2015 | Posted by in Periodontics | Comments Off on 1. The Necessity of an Evidencebased Approach to Diagnosis and Treatment
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