Simple Approaches for Establishing an Evidence-Based Dental Practice

Constructing an evidence-based dental practice requires leadership, commitment, technology support, and time, as well as skill practice in searching, appraising, and organizing evidence. In mastering the skills of evidence-based dentistry, clinicians can implement high-quality science into practice through a variety of opportunities including the development of clinical care guidelines, procedural technique protocols, and electronic dental record auto-note templates, as well as treatment planning, care prioritization, and case presentation. The benefits of building an evidence-based dental practice are many, including improvements in patient care and satisfaction, increased treatment predictability and confidence in care approaches, as well as potential cost savings.

Key points

  • The benefits of an evidence-based dental practice are improvements in patient care and satisfaction, increased treatment predictability and confidence in care approaches, as well as potential cost savings.

  • All dental team members, including nonclinical staff, can play a significant role in establishing an evidence-based dental practice.

  • Clinicians can efficiently search and appraise evidence by focusing on evidence-based clinical practice guidelines, Cochrane Reviews, and systematic reviews and primary studies with evidence synopses.

  • There are many opportunities for integrating science into practice, including the development of clinical care guidelines, procedural technique protocols, and electronic dental record auto-note templates, as well as treatment planning, care prioritization, and case presentation.

Introduction

Adopting a commitment to the use of the current best evidence in care delivery is central to ensuring high-quality care and optimal patient outcomes. As with all of medicine, dentistry relies on scientific discovery to advance patient care. In a review of US health care, the Institute of Medicine (IOM) concluded that there were large gaps between the care people should receive and the care they actually receive. The problem they identified was based on the fact that the translation of new scientific discoveries into routine patient care was a long process fraught with barriers that often lead to imperfect application of new knowledge at the point of patient care. The IOM characterized results of this imperfect process in 3 ways. First, they found an overuse of treatments known not to provide patient health benefits. They also found an underuse of treatments known to provide patient health benefits. Finally, they reported routine misuse of treatments such that they failed to deliver their full benefit to patients. They described this problem as the “know-do” gap, meaning that there is frequently a gap between what clinicians know to be best for patients and what care is actually delivered to patients.

Because new knowledge generated from high-quality clinical research often fails to find its way into clinical practice, frontline (dental) health care providers are the focus of much of the efforts of those who create new clinical evidence, as it is frontline providers who ultimately decide whether to adopt and use the science to guide their treatment decisions. The study of the uptake of science into clinical practice is called translational research.

The field of translational research was developed out of the IOM report and similar research documenting the widespread failure across all of health care to consistently apply appropriate new knowledge to improve patient outcomes. The aim of translational research is to address these failures in care delivery by systematically identifying and removing the barriers that prevent new scientific knowledge from being adopted into routine clinical practice. The process of bringing new scientific knowledge to clinical practice is often depicted as a pipeline beginning with basic scientific discoveries and ending with routine patient care, and often referred to as moving knowledge from “bench to bedside” (or in dentistry’s case, bench to chairside) ( Fig. 1 ).

Fig. 1
Translation of research findings from benchtop to chairside. RCTs, randomized controlled trials.

The focus of this article is the last step in the translational pipeline: the implementation of best available evidence into clinical practice. Specifically, the focus is on the steps needed for a typical dental office to ensure the delivery of optimal oral health care. This process includes the deliberate and systematic selection and application of current best evidence regarding what is known to work and what is known to not work. We call this type of care “best practices.” Importantly, the approaches for developing an evidence-based practice, described as follows, empowers the dentists and the office staff to be their own new knowledge producers. This means that the dentist no longer must rely on continuing education courses from “experts” to determine optimal treatment plans. It means that dentists can confidently discuss with patients the benefits and harms of any treatment. It also means that a dentist will be confident that they are selected approaches to care that will lead to the best possible outcome for each patient.

Approach

Leadership and the Role of the Dental Team

Dentist leaders are uniquely positioned to promote science-based practice through the management of their dental offices and by inspiring and supporting staff in engaging in the evidenced-based dentistry (EBD) process. Organizational mission statements describe to the public the aims and values of a business. One of the largest systemwide impacts can be realized from the development of an organizational mission statement that establishes and defines the practice’s commitment to using current best evidence. From the foundation of an organizational commitment to EBD comes a series of systematic strategies and tactics for knitting science into the fabric of a practice. These approaches, which are discussed later, include activities such as the development of Clinical Care Guidelines, treatment planning and prioritization of care, and communicating treatment recommendation to patients. Last, dynamic leadership can motivate and encourage each dental team member to have an active role in cultivating an evidence-based dental practice.

In fact, all members of the dental team, even nonprofessional staff, can be taught a range of skills in EBD. Although advanced training in EBD usually focuses on skill building for dentists and dental hygienists, dental assistants and administrative staff should also have a basic understanding of why evidence-based health care is important, bias and research design, and how to find high-quality and reliable evidence, such as Cochrane Plain Language Summaries. Perfect for dental assistants and administrators, Cochrane US offers a free 6-module online course, Understanding Evidence-based Healthcare: A Foundation for Action . Understanding the rationale and framework for science-based care helps promote continuity of messaging to patients throughout the practice, communication of the science-basis for treatment recommendations, and, of course, buy-in related to constructing an EBD practice. This last point is important, as any change in a practice can initially result in more work for staff. Teaching the basics of EBD to support staff helps reinforce the importance of any “extra” work related to the practice change.

Evidence-Based Dentistry Training Resources

At the outset, clinicians may find that they are slower and less accurate in the searching, appraising, summarizing, and organizing of evidence than desired. As with other new skills in dentistry, such as mastering digital impressions, continuing education and repeated practice in EBD skills improves speed and performance. Fortunately, there are many learning opportunities available to practitioners, including in-person courses, online training, journals and books, and study clubs.

Some of the most effective learning happens in educational experiences that include peers, that are in small groups, and in-person. These types of interactions are effective because differing peer perspectives help challenge our own thought processes and beliefs, and peers commonly bring to light questions or topics that may not have been considered otherwise. Specific for dentistry, the American Dental Association (ADA) offers in-person single-day and multiday courses, sometimes in partnership with universities. These courses range from the basic philosophy of EBD, to how to actually conduct systematic reviews (SRs) and meta-analyses. Courses in EBD also can be found through specialty organizations, such as the American Academy of Pediatric Dentistry, and continuing education programs hosted by national dental organizations and state dental associations.

Looking outside of the profession of dentistry for learning opportunities, such as medicine and nursing, has significant benefits as well. Exposure to other health professions helps broaden and deepen knowledge, not just in terms of evidence-based health care, but working within an interdisciplinary team. For the truly ambitious, 2 universities, McMaster University and Oxford University, offer a range of more intensive options, such as workshops, short courses, and even graduate degrees in evidence-based health care. Basic skill-building workshops, offered at many regional university and public libraries are also useful. Frequently, these classes are no more than an hour long and build practical skills in the use of citation management software, Excel, and literature database searching.

There is a prolific variety of online options available to learners of evidence-based health care ( Box 1 ). Online learning, although not interactive, is appealing because of its low cost and convenience. The ADA’s Center for Evidence-based Dentistry offers videos and even podcasts specific to dentistry. Another organization, also named the Center for Evidence-based Dentistry but based in the United Kingdom, offers a comprehensive set of resources on question formulation, searching for evidence, and appraising evidence and implementing science into practice. Not specific to dentistry, but science-based practice in general, are numerous online resources, including those from the Center for Evidence-based Medicine (CEBM), Cochrane, and PubMed. The CEBM and Cochrane both have an expansive selection of resources on topics, including interpreting common statics found in SRs, which is usually an area of growth and learning for most clinicians.

Box 1
Online and printed evidence-based dentistry learning resources

  • Online Learning Resources

  • Printed Learning Resources

    • How to Read a Paper (book)

    • Critical Thinking: Understanding and Evaluating Dental Research (book)

    • Journal of the American Dental Association series on Evidence-based Dentistry (journal manuscripts)

    • Evidence-Based Decision Making: a Translational Guide for Dental Professionals (workbook)

    • Evidence-Based Dentistry for the Dental Hygienist (workbook)

    • Journal of Evidence-based Dental Practice (journal)

    • Evidence-based Dentistry (journal)

For those who prefer the feel of holding a book or a paper, there are many printed materials available, including books, journals, and workbooks (see Box 1 ). A classic book, with detailed, easy-to-understand explanations and examples, is Trisha Greenhalgh’s How to Read a Paper . This book should be on every EBD learner’s list to read. Also, on the must-read-list is the Journal of the American Dental Association series on Evidence-based Dentistry. This remarkable series, developed just for the dental profession, is arguably the first EBD learning engagement a clinician should consider. It covers a wide range of topics, including levels of evidence, basic statistics, and appraising and implementing evidence. The strength of this series, besides its comprehensive nature, is that it is written with the dental professional in mind and uses real-world examples and application in dentistry.

Accessing Evidence

Since published scientific evidence is the foundation of EBD, clinicians must have low-cost, easy access to scientific literature. Practitioners usually access low-cost or free health care research in 1 of 2 ways:

  • 1.

    Through a university medical library (alumni or regional)

  • 2.

    Through membership in an organization such as the ADA

As a member benefit, the ADA provides free access to a vast number of dental journals, including access to full Cochrane Reviews. Even without either of these 2 options, a significant amount of information is available for free, such as the ADA’s EBD Clinical Practice Guidelines and Cochrane Review abstracts, some select full Cochrane Reviews, as well critical summaries of primary and secondary literature such as those developed by the Dental Elf. Regardless of how evidence is accessed (library or organizational membership), most searching is conducted online; consequently, a solid Internet connection and laptop or computer are requirements.

Formulating a Question

The most fundamental step in investigating a clinical topic is formulating a focused clinical question. This is because the question formulated drives the search terms, and insufficient search terms lead to inadequate or misleading search results. A good clinical question typically follows the “PICO” format; that is, your question should define the P atient/Population, I ntervention, C omparison/Control, and I ntervention. For example, a sufficient clinical question would be “Do perioperative antibiotics reduce implant failure in adults?” A search strategy that included only the words “dental implants” would result in too many nonrelevant returned results. A search strategy that included the words “amoxicillin prescribed before dental implant placement in the disabled elderly” would be too narrow and not return enough results. Instead, better search terms on this topic would be “antibiotic prophylaxis AND dental implant failure” or “perioperative antibiotics AND dental implants.” These 2 approaches would likely capture an adequate number of relevant results.

Finding Evidence

Search approach 1: access evidence-based clinical practice guidelines and systematic reviews with evidence synopses

Because evidence can be stratified according to its level of objectivity and reliability, clinicians should always begin the search process by querying the highest level of evidence. Specifically, this means searching for “secondary” forms of evidence, such as evidence-based clinical practice guidelines (CPGs) and high-quality SRs with evidence synopses ( Table 1 ). We strongly advise practitioners attempt this approach first, as this method results in the highest-quality and most meaningful science in the shortest amount of time.

Table 1
EBD resources by evidence type
Name of Resource Type of Evidence
ADA Center for Evidence-based Dentistry ( EBD.ADA.org ) Evidence-based CPG
TRIP Database ( tripdatabase.com ) Evidence-based CPG
Evidence synopses
Systematic reviews
Primary studies
PubMed Clinical Queries ( ncbi.nlm.nih.gov/pubmed/clinical ) Systematic reviews
Dental Elf ( nationalelfservice.net/dentistry/ ) Evidence synopses
ADA Library and Archives ( ada.org/en/member-center/ada-library ) Full access to Cochrane Reviews and all dental journals, including Journal of Evidence-based Dental Practice and Evidence-based Dentistry (free to ADA members)
Journal of the American Dental Association : Clinical Scans ( jada.ada.org/clinicalscans ) Evidence synopses (free to ADA members)
Journal of Evidence-based Dental Practice Evidence synopses
Evidence-based Dentistry Evidence synopses
Cochrane Database of Systematic Reviews ( cochranelibrary.com/cochrane-database-of-systematic-reviews/ ) Systematic reviews

Abbreviations: ADA, American Dental Association; CPG, clinical practice guideline; EBD, evidence-based dentistry.
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Aug 9, 2020 | Posted by in General Dentistry | Comments Off on Simple Approaches for Establishing an Evidence-Based Dental Practice
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