Introduction
The purpose of this study was to evaluate the attitudes, awareness, and barriers toward evidence-based practice.
Methods
A survey consisting of 35 questions pertaining to the use of scientific evidence in orthodontics was sent to 4771 members of the American Association of Orthodontists in the United States. Each respondent’s age, attainment of a master’s degree, and whether he or she was currently involved with teaching were ascertained. To minimize bias, the survey questions were phrased as an examination of the use of scientific literature in orthodontics.
Results
A total of 1517 surveys were received (response rate, 32%). Most respondents had positive attitudes toward, but a poor understanding of, evidence-based practice. The major barrier identified was ambiguous and conflicting research. Younger orthodontists were more aware, had a greater understanding, and perceived more barriers than did older orthodontists. Orthodontists involved in teaching were more aware, had a greater understanding, and reported fewer barriers than those not involved with teaching. Those with master’s degrees had a greater understanding of evidence-based practice than those without degrees.
Conclusions
Educational initiatives are needed to increase the understanding and use of evidence-based practice in orthodontics.
Evidence-based practice is an approach that emphasizes finding and using the best current research evidence to help make health-care decisions. The goal of evidence-based practice is to give patients up-to-date treatment that research has shown to be safe, effective, and efficient. Ultimately, the goal of evidence-based practice is to continuously improve patient care based on new research developments.
Evidence-based practice is well established in medicine. The Institute of Medicine has designated evidence-based practice as a key feature of high-quality medicine. There is a wealth of information regarding evidence-based medicine, including evidence-based medical journals, evidence-based summaries, and evidence-based practice guidelines. The Agency for Healthcare Research has 12 evidence-based practice centers located in universities in the United States and Canada that conduct evidence-based medical research. In dentistry, evidence-based practice is less developed but is quickly gaining momentum. The American Dental Association has made a concerted effort to incorporate evidence-based practice into the dental field in the United States; its Web site has an entire section devoted to evidence-based dentistry. The Web site is an important resource that contains a comprehensive collection of systematic reviews in all areas of dentistry. Dental schools are introducing evidence-based courses into their curriculums, journals have focused on evidence-based dentistry, 2 centers for evidence-based dentistry have been established, and the Cochrane Collaboration ( http://www.cochrane.org ) has included an oral-health database. In orthodontics, evidence-based practice is still in its infancy.
Studies on evidence-based practice in medicine have found that most doctors welcome evidence-based practice and believe that it improves patient care. Barriers to evidence-based practice include lack of time, overwhelming amount of literature, and difficulties incorporating evidence into practice. Physicians thought that the best way to increase evidence-based practice was by using evidence-based guidelines developed by colleagues. Dentists have also expressed positive attitudes and awareness of evidence-based practice. However, their understanding of evidence-based concepts was poor. The major barriers dentists reported were lack of time, lack of knowledge about evidence-based practice, and financial constraints. Dentists believed that the development of practical guidelines, journal clubs, and peer-review sessions would help increase evidence-based practice in dentistry. There is currently no information about the attitudes and awareness, perceptions, and barriers to evidence-based practice in orthodontics.
The purpose of this study was to determine the attitudes and awareness of evidence-based practice in orthodontics. The term evidence-based practice was purposefully not used during data collection. To determine the initiatives that might be needed, barriers to using scientific evidence were also examined. We hoped that this study would identify obstacles and solutions to incorporating scientific literature into orthodontic practice.
Material and methods
A survey was designed to examine the perceptions of orthodontists toward evidence-based practice in orthodontics. To minimize bias among participants, the term evidence-based practice was not used in the survey. Instead, the questions were phrased as inquiries regarding the use of scientific literature in orthodontics. Each participant was asked to respond to a set of demographic questions, followed by a set of questions pertaining to scientific literature in clinical orthodontics. Most survey questions were derived from similar studies conducted in the medical field. The questions were divided into 5 categories: attitudes, awareness and current practices, barriers, understanding of terms, and statements to evaluate the participants’ awareness of the literature regarding major orthodontic controversies and sources for guiding clinical practice. Institutional review board approval was granted before starting the research project.
The respondent sample was grouped according to age, whether they were currently involved in teaching at a university, and whether they had attained a master’s degree. The age grouping included those 40 years of age or younger, those between 41 and 60 years, and those 61 years of age and older.
A pilot survey consisting of 45 questions was administered to 7 faculty orthodontists at the Saint Louis University Center for Advanced Dental Education. The survey was discussed with each orthodontist to ensure that the questions were unambiguous and valid. The survey questions were modified and improved based on their feedback.
Reliability was assessed by administering the survey to 20 orthodontic residents on 2 separate occasions, 2 weeks apart. The reliability analysis was used to identify and eliminate problematic questions. The final survey ( Appendix ) consisted of 35 questions, including 6 pertaining to attitudes, awareness, and current practices; 10 pertaining to barriers; 10 pertaining to the understanding of terms; 7 statements on orthodontic issues; and 2 questions on solving clinical problems.
The final version of the survey was submitted to and approved by the Board of Directors of the American Association of Orthodontists (AAO). The board agreed to send the survey to all orthodontists and residents in the United States with valid e-mail addresses. To maintain the anonymity and privacy of the respondents, the AAO forwarded the link by e-mail. A reminder e-mail was sent a week later. Results of the survey were recorded and maintained anonymously on the Survey Monkey server ( Surveymonkey.com ; Portland, Ore).
Statistical analysis
The survey data were analyzed by using SPSS software (version 14.0, SPSS, Chicago, Ill). Nonparametric statistics were used to evaluate group differences because the response variables were ordinal. The Mann-Whitney U test was used to test for differences between the dichotomous groupings, and the Kruskal-Wallis H test was used to compare the 3 age groups. The sources for guiding clinical practice were nominal and evaluated with chi-square tests. A P value of <0.05 was considered significant.
Results
The survey was sent to 8455 orthodontists, it was opened by 4771, and 1517 participated in the study. The response rate was 32%. The modal age group of the sample was 41 to 60 years, there were 79% men and 21% women, and the modal number of years in practice group was 16 to 20 years ( Table I ). Twenty-eight percent of the respondents were involved in teaching; 59% of the respondents had master’s degrees.
| This study | Survey of Keim et al | AAO, April 2010 | |
|---|---|---|---|
| Age (y) | 41–50 (modal value) | 52 (median value) | 57 |
| Men (%) | 79 | 85 | 80 |
| Women (%) | 21 | 15 | 20 |
| Time in practice (y) | 16–20 (modal value) | 21 (median value) | 24 |
| Masters degree (%) | 59 | NA | 51 |
Attitudes, awareness, and current practices
The orthodontists were generally positive toward the incorporation of scientific evidence into their practices ( Table II ). Most agreed that research influenced their daily work (80%) and that peer-reviewed journals are the best source of evidence (82%). The majority also expressed interest in more clinical guidelines (75%) and indicated that they read scientific journals at least monthly (91%). The majority of respondents were completely unaware of the Cochrane database (55%), and only a slight majority of respondents had used PubMed during the past year (52%).
| Percentages of respondents | Group differences | |||||
|---|---|---|---|---|---|---|
| Strongly disagree or disagree | Neutral | Agree or strongly agree | Age | Involved in teaching | Master’s degree | |
| Research influences daily work | 5% | 15% | 80% | NS ( P = 0.130) | Yes >no ( P <0.001) | Yes >no ( P <0.013) |
| Journals are the best source of evidence | 3% | 15% | 82% | NS ( P = 0.496) | Yes >no ( P <0.001) | Yes >no ( P <0.001) |
| Interested in more guidelines | 6% | 19% | 75% | 1 >2 = 3 ( P <0.001) | NS ( P = 0.110) | NS ( P = 0.385) |
| Daily | Weekly | Monthly | Rarely | ||||
|---|---|---|---|---|---|---|---|
| Frequency of reading journals | 5% | 33% | 53% | 9% | 3 >1 = 3 ( P <0.022) | Yes >no ( P <0.001) | NS ( P = 0.960) |
| Unaware | Some awareness | Fully aware | ||||
|---|---|---|---|---|---|---|
| Awareness of Cochrane | 55% | 20% | 25% | 1 >2 = 3 ( P <0.001) | Yes >no ( P <0.001) | NS ( P = 0.095) |
| No | Yes | Uncertain | ||||
|---|---|---|---|---|---|---|
| Used Pub/Med in past year | 47% | 52% | 1% | 1 >2 = 3 ( P <0.001) | Yes >no ( P <0.001) | NS ( P = 0.552) |
Those 40 years of age or younger were significantly ( P <0.05) more likely to be interested in guidelines, were more aware of Cochrane, and had used PubMed in the past year to a greater extent than those over 40 years of age. Those 61 years of age and older were significantly more likely to report reading journals than their younger colleagues. Orthodontists involved in teaching were significantly more likely than their nonteaching colleagues to have positive attitudes, awareness, and current practice toward the use of scientific literature in clinical practice. Orthodontists with master’s degrees reported that research influenced their daily work significantly more frequently than those without master’s degrees.
Barriers
A large proportion, although not a majority of respondents, thought that the practical demands of work (46%) and insufficient clinical guidelines (44%) were barriers to using scientific evidence in clinical practice ( Table III ). Most respondents indicated that the literature is ambiguous and conflicting (59%).
| Percentages of respondents | Group differences | |||||
|---|---|---|---|---|---|---|
| Strongly disagree or disagree | Neutral | Agree or strongly agree | Age | Involved in teaching | Master’s degree | |
| Practical demands of work | 34% | 20% | 46% | 1 >2 >3 ( P <0.001) | No >yes ( P <0.001) | NS ( P = 0.228) |
| Insufficient clinical guidelines | 21% | 35% | 44% | 1 >2 = 3 ( P <0.001) | NS ( P = 0.436) | NS ( P = 0.419) |
| Literature is ambiguous/conflicting | 15% | 26% | 59% | 1 >2 = 3 ( P <0.001) | Yes >no ( P <0.019) | NS ( P = 0.105) |
| Satisfied with current knowledge | 45% | 25% | 30% | NS ( P = 0.300) | No >yes ( P = 0.006) | Yes >no ( P = 0.009) |
| No | Yes | Uncertain | ||||
|---|---|---|---|---|---|---|
| Skills to undertake a literature review | 6% | 79% | 15% | 1 >2 = 3 ( P <0.001) | Yes >no ( P <0.001) | NS ( P = 0.194) |
| Comfortable performing a literature review | 16% | 67% | 17% | 1>2 = 3 ( P <0.001) | Yes >no ( P <0.001) | NS ( P = 0.160) |
| I have access to published research papers | 5% | 85% | 10% | 1 >2 = 3 ( P <0.016) | Yes >no ( P <0.001) | NS ( P = 0.719) |
| No | Yes | ||||
|---|---|---|---|---|---|
| No access to the Internet | 87% | 13% | NS ( P = 0.317) | NS ( P = 0.924) | NS ( P = 0.742) |
| Access to the Internet at home | 9% | 91% | NS ( P = 0.999) | NS ( P = 0.999) | NS ( P = 0.999) |
| Access to the Internet at work | 3% | 97% | NS ( P = 0.922) | NS ( P = 0.139) | NS ( P = 0.670) |
Those who were less than 40 years of age cited practical demands of work, insufficient clinical guidelines, and ambiguous literature as barriers more often than did their older colleagues. Those between 41 and 60 years of age were significantly more likely to cite the practical demands of work as a barrier than those 61 years and older. Conversely, those 40 years or younger were significantly more likely than their older colleagues to express comfort with their skills to perform a literature review and were more likely to have access to research papers. Orthodontists involved in teaching felt more comfortable with their skills to perform a literature review than did those not involved in teaching. They were also more likely to have access to research papers, and stated that the research is ambiguous and conflicting more often than those not involved in teaching. Orthodontists with a master’s degree were more likely to be satisfied with their current knowledge than those without degrees.
Understanding of terms
Less than a third of the orthodontists understood or could explain the meaning of meta-analysis , odds ratio , sample power , confidence interval , and specificity ( Table IV ). Only 6% of the respondents understood and could explain the meaning of PICO . However, the vast majority (87%) of respondents had some understanding and wanted to learn more about these terms.
| Understand and could explain it to others | Some understanding | Don’t understand but would like to | Don’t understand and don’t want to | |
|---|---|---|---|---|
| Blinding | 52% | 28% | 16% | 4% |
| Systematic review | 50% | 43% | 5% | 2% |
| Meta-analysis | 32% | 36% | 24% | 8% |
| RCT | 75% | 23% | 1% | 1% |
| Strength of evidence | 49% | 43% | 7% | 1% |
| Odds ratio | 21% | 40% | 32% | 7% |
| Sample power | 31% | 40% | 24% | 6% |
| Confidence interval | 31% | 39% | 24% | 6% |
| Specificity | 30% | 44% | 21% | 5% |
| PICO questions | 6% | 15% | 66% | 13% |
Practitioners aged 40 years or less were significantly more likely than their older colleagues to understand all of the evidence-based terms ( Table V ). Those between 41 and 60 years of age were significantly more likely to understand blinding and confidence interval than those 61 years and older. Orthodontists currently involved in teaching were significantly more likely than those not involved in teaching to understand all terms. Those with a master’s degree were significantly more likely to understand all terms than those without a master’s degree.
| Age | Involved in teaching | Master’s degree | ||||
|---|---|---|---|---|---|---|
| Blinding | 1 >2 >3 | ( P <0.001) | Yes >no | ( P <0.001) | Yes >no | ( P = 0.037) |
| Systematic review | 1 >2 = 3 | ( P <0.001) | Yes >no | ( P <0.001) | Yes >no | ( P <0.001) |
| Meta-analysis | 1 >2 = 3 | ( P <0.001) | Yes >no | ( P <0.001) | Yes >no | ( P = 0.018) |
| RCT | 1 >2 = 3 | ( P <0.001) | Yes >no | ( P <0.001) | Yes >no | ( P <0.001) |
| Strength of evidence | 1 >2 = 3 | ( P <0.001) | Yes >no | ( P <0.001) | Yes >no | ( P <0.001) |
| Odds ratio | 1 >2 = 3 | ( P <0.001) | Yes >no | ( P <0.001) | Yes >no | ( P <0.001) |
| Sample power | 1 >2 = 3 | ( P <0.001) | Yes >no | ( P <0.001) | Yes >no | ( P <0.001) |
| Confidence interval | 1 >2 >3 | ( P <0.001) | Yes >no | ( P <0.001) | Yes >no | ( P <0.001) |
| Specificity | 1 >2 = 3 | ( P <0.001) | Yes >no | ( P <0.001) | Yes >no | ( P <0.001) |
| PICO questions | 1 >2 = 3 | ( P = 0.022) | Yes >no | ( P <0.001) | Yes >no | ( P = 0.036) |
Statements regarding orthodontic issues
Most respondents (>75%) were consistent with the best, current evidence regarding statements about orthodontic issues ( Table VI ). Those less than 61 years of age were significantly ( P <0.05) more likely than their older counterparts to agree with the current best evidence with regard to the statement “2-phase treatment of Class II Division 1 malocclusion is more efficient than 1-phase treatment in the permanent dentition.” Those less than 40 years of age were significantly ( P <0.05) more likely than their older colleagues to agree with the current best evidence with respect to the statement “third molars cause incisor crowding.” Orthodontists currently involved in teaching were significantly more likely to agree with the current best evidence on 4 of the 7 statements than those not involved in teaching. Those with a master’s degree were significantly more likely to agree with the current best evidence on the appropriate timing of a frenectomy than those without degrees.
| Strongly agree or agree | Neutral | Disagree or strongly disagree | Age | Involved in teaching | Master’s degree | |
|---|---|---|---|---|---|---|
| 2-phase tx more efficient than 1-phase tx | 12% | 11% | 77% | 3 >2 = 1 ( P = 0.027) | NS ( P = 0.206) | NS ( P = 0.314) |
| Occlusion causes TMD | 10% | 8% | 82% | NS ( P = 0.117) | No >yes ( P = 0.001) | NS ( P = 0.336) |
| Third molars cause incisor crowding | 4% | 10% | 86% | 3 = 2 >1 ( P <0.001) | NS ( P = 0.243) | NS ( P = 0.051) |
| Frenectomy performed before tx | 3% | 5% | 92% | NS ( P = 0.088) | NS ( P = 0.208) | No >yes ( P = 0.030) |
| Premolar extraction smiles are less esthetic | 9% | 10% | 81% | NS ( P = 0.219) | No >yes ( P = 0.001) | NS ( P = 0.645) |
| Extraction tx causes TMD | 1% | 2% | 97% | NS ( P = 0.273) | No >yes ( P = 0.022) | NS ( P = 0.483) |
| Casts should be mounted for diagnosis | 7% | 10% | 83% | NS ( P = 0.201) | No >yes ( P = 0.013) | NS ( P = 0.482) |
Primary reason for changing practice philosophy
Regardless of their involvement with teaching, number of years in practice, or whether they had a master’s degree, orthodontists were most likely to change their practice philosophy based on “expert advice” ( Table VII ). Expert advice was followed most closely by clinical journals.
| Age ∗ ( P <0.001) | Involved in teaching ∗ ( P <0.001) | Master’s degree ∗ ( P = 0.033) | |||||
|---|---|---|---|---|---|---|---|
| ≤40 y | 41–60 y | ≥61 y | No | Yes | No | Yes | |
| Colleague advice | 24% | 12% | 9% | 17% | 10% | 18% | 14% |
| Expert advice | 32% | 35% | 36% | 36% | 29% | 36% | 33% |
| Clinical journals | 15% | 26% | 29% | 22% | 25% | 21% | 23% |
| Literature reviews | 18% | 13% | 11% | 12% | 22% | 14% | 15% |
| Other | 11% | 14% | 15% | 13% | 14% | 11% | 15% |
| Total | 100% | 100% | 100% | 100% | 100% | 100% | 100% |
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