Introduction

Health information is rapidly generated and communicated through nontraditional avenues in contemporary society. Patients are invested in their health care, seek information, and, at times, question their providers. The clinician versed in evidence-based practice (EBP) skills is best equipped to address patients’ queries and maintain a cutting-edge practice. EBP is defined as the integration of the best available scientific evidence, clinician expertise, and patient values and preferences during the clinical decision-making process.¹ EBP is often confused with the academic practice of critiquing science; however, EBP involves more than just a critical appraisal of the literature. It is equally inclusive of clinician expertise and patient values and preferences.

Dental organizations have recognized the importance of EBP in dentistry (known as evidence-based dentistry, or EBD) and made concerted efforts to educate clinicians through workshops, resource centers, and publications.^1,2,3 Concurrently, the importance of providing dental students with the skill set needed to practice EBD has been noted by the American Dental Education Association (ADEA), the Commission on Dental Accreditation (CODA), and the American Dental Association (ADA). Accreditation Standard 2-21 of CODA’s Accreditation Standards for Dental Education Programs states, “Graduates must be competent to access, critically appraise, apply, and communicate scientific and lay literature as it relates to providing evidence-based patient care.”³ EBD instruction provides dental students with the skill sets they need to independently identify the best science and integrate that evidence with their expertise and patient values and preferences during clinical decision-making. EBP requires critical thinking skills and, combined with competency in EBD, provides future dental practitioners with the tools to make better-informed treatment decisions and become lifelong learners.

Although EBD is considered an important component of dental education and continuing education (CE) for clinicians, few resources are available to guide dental faculty, CE providers, or journal club leaders on how to educate their respective learners in EBD. The objective of this chapter is to identify curricular content and approaches for teaching EBD to dental learners in a variety of educational environments.

EBD hinges on the following five-step process:

This chapter addresses the first three steps of this process and includes three different approaches to EBD training, each of which addresses the objectives of the ADA CODA requirements for EBD.

Curricular Outcomes

The first step in designing a curriculum or educational program is to identify the desired curricular outcomes: what do you want the learner to gain from the experience? Although the desired overall outcome might be for the learner to practice EBD, it is important to identify specific knowledge and skills that you hope a learner will gain by the end of their instruction. Such identification helps to facilitate curricular development and outcome measurement. The learner audience, the time allotted for instruction, and the educational environment should also be considered when identifying outcomes. Examples of curricular outcomes for EBD might include the following:

Upon course completion, the learner will be able to:

Curricular Content

After identification of curricular outcomes, the content necessary to achieve those outcomes is defined. This content can be categorized into knowledge, scientific evidence, and behavior.

Knowledge

To practice EBD, learners must be able to define EBD and identify the components of its five-step process. To ask a question (that is, the first step of the five-step process), learners must be able to identify gaps in their knowledge and both describe and identify a PICO (population, intervention, comparison, outcomes) question (see Chapter 2). To search for the best evidence (the second step of the five-step process), learners must be able to identify appropriate resources (for example, critical summaries, clinical practice guidelines, and primary and secondary resources) and describe steps to obtain those resources (see Chapter 2). To appraise a resource (step three), the learner must be able to identify research study designs, describe the EBP evidence hierarchy, identify expected research study components, assess the validity of the research methodology used, identify potential sources of bias, and interpret the results (see Chapters 12, 13, and 14). Once the learner masters components of the appraisal process, the learner is then able to critique the quality of the science in question and assess applicability.

Foundational knowledge can be taught through lecture, problem-based learning, or online activities. In an ideal situation, foundational knowledge acquisition occurs prior to or during clinical experiences, given that predoctoral students must be prepared to apply this knowledge once they initiate clinical activities. The context for EBD may be premature during early didactic (that is, preclinical) instruction because of a lack of clinical maturity in the learners involved. For such instances, case-based instruction is useful to communicate relevance.

Scientific Evidence

EBP relies on the integration of high-quality contemporary scientific evidence into clinical decision-making. As such, curricular approaches for instruction in EBP must first equip learners with a knowledge of research study design and the evidence hierarchy, including an introduction to quantitative and qualitative primary and secondary research.

Foundational knowledge of scientific evidence includes the ability to identify the appropriate type of evidence to seek for the PICO question being asked. Learners must be trained in search strategies to efficiently and effectively identify key scientific evidence to address clinical questions. Training in the identification of scientific evidence should include the presentation and differentiation of the resources available to the learner in their current and future practice settings to assist in the acquisition of the highest level of evidence (see Chapter 2).

Strategies to identify evidence aim to first identify secondary preappraised sources of evidence (see Chapters 6 and 7) in order to minimize the time needed for critical appraisal as well as to overcome learners’ lack of statistical knowledge and/or confidence in the critical appraisal process. If secondary resources are not available to address the question posed, then high-quality primary science should be sought. Critical appraisal checklists can be used to appraise research studies. Guided completion of critical appraisal checklists facilitates development of prioritization and interpretation skills in a structured process.

Behavior

Application

EBP behavior includes the assimilation of evidence-based principles and their application to patient care. Learners must possess the skills necessary to determine the relevance of scientific evidence for patient care, the feasibility of treatment, and the balance between benefits and harms while articulating explicit patient-centered outcomes.

Professionalism

Throughout the process of EBP instruction, learners develop the qualities of professionalism as they discover the value of practicing EBD, develop the skills needed for lifelong learning, and observe the modeling of professional behavior in an environment that mirrors current or future practice.

Communication

EBP is observed when learners use patients’ values, preferences, and circumstances to effectively communicate evidence to patients and integrate evidence in the clinical decision-making process. Ongoing observation of learners’ evidence-based communication with patients and colleagues, followed by structured feedback, helps guide the development of learners’ skills and proficiency in EBP.

Instructional Methods

EBD can be taught using various methods of didactic learning, application, and clinical activity.

Didactic Learning

The rationale for didactic or preclinical instruction is to equip learners with the knowledge and skills needed to practice EBP while, at the same time, supporting the growth of the fundamental behaviors needed to one day apply didactic concepts to clinic experiences.

Didactic content lays the foundation so that learners can effectively practice EBP in the future. Foundational knowledge can be delivered through lectures, readings, online tutorials, self-directed learning, problem-based learning, flipped classrooms, and/or Process Oriented Guided Inquiry Learning (POGIL). Writing assignments for groups and individuals, combined with guiding questions and structured reflections, provide insight into how learning is progressing. Scaffolding content and experiences enables students to acquire the knowledge and skills essential for competence in EBP.

Application

EBP is a behavior requiring repetition and application. Application of EBD’s five-step process begins with the didactic presentation of scenarios, followed by instruction through preclinical or clinical interactions, and, finally, the integration in real time of evidence to patient care. Instructional strategies for the integration of EBP center on diagnosis, treatment planning, patient education, and outcome assessment. The use of guiding questions during the presentation of information, patient cases, student reports, team presentations, formal case presentations, and reflection activities supports the advancement and application of desired EBP skills.

Clinical Activity

EBP clinical instruction integrates an authentic environment while refining EBD’s five-step approach and skills through real-world experiences. Clinical instruction guides the integration of scientific evidence with clinician expertise and patient values and preferences. The learning process evolves from an instructor-guided treatment planning process to a learner-initiated process where learners defend their treatment rationale by using the best available evidence and assessing outcomes of evidence-based interventions. Self-assessment and formative and summative feedback are integral pieces of clinical instruction in EBP.

Real-World Examples

Here we present three contemporary examples of programs in academic institutions that have successfully implemented EBP into their dental curriculums.

Virginia Commonwealth University School of Dentistry

The EBD program at the Virginia Commonwealth University (VCU) School of Dentistry provides students with the skills necessary to practice EBD upon graduation. EBD instruction is layered over three semesters, beginning in the second semester. The courses are strategically positioned to allow seamless integration of EBD in year 3 (D3) and year 4 (D4) treatment planning clinical courses.

In the first course, students are introduced to the concepts of EBP in a large classroom setting. Using interactive role-playing sessions, students are presented with real-life examples of how “good” scientific information can be misreported by public media (for example, TV, newspapers, and internet outlets) and/or how “bad” science can be published in reputable professional journals. Students learn to challenge assumptions, verify study validity, and question conclusions. Students acquire the skills needed to navigate the scientific literature in a hands-on workshop taught by the School of Dentistry’s library liaison. Additionally, students learn the basic concepts of biostatistics, the evidence pyramid, and study designs and how to frame clinical questions using the PICO format. Student performance is evaluated using a digital response system in class and written midterm and final exams.

During the second semester, students apply their acquired critical appraisal knowledge when evaluating peer-reviewed scientific manuscripts. Small groups present their critical appraisal of a systematic review or a primary study article addressing a PICO question. The students frame questions that stimulate critical thinking among their peers in the audience and are assessed by the quality of questions and in-class presentation. Student performance is evaluated based on the presentation, written quizzes, and a written final exam.

Knowledge and application of EBD are assessed using a modified POGIL group project in addition to an individual paper during the third course. POGIL is based on the philosophy that teaching is enabling, knowledge is understanding, and learning is active construction of subject matter.⁴ POGIL activities encourage a deeper understanding of core concepts while developing higher-order process skills including critical thinking, problem-solving, and communication through cooperation and reflection. Additionally, POGIL improves self-assessment and helps students identify areas of limited understanding.

At VCU, each class is divided into 12 groups of approximately eight students, and each group facilitates one POGIL session. The presenting group is given a clinical scenario one week in advance, and the members work together to develop a worksheet. After constructive feedback from faculty on the draft worksheet, the students refine the content. Prior to the session, the presenting group and faculty finalize the questions and responses. To ensure the success of the POGIL session, the presenting group is instructed not to divulge the contents of the worksheet to their peers.

At the beginning of the POGIL session, the case scenario is revealed and the class divides into small groups for discussion. Each group is assigned a student facilitator to guide discussion as the team addresses the worksheet questions. The groups have the freedom to work on the questions at their own pace; however, if the conversation stalls or deviates greatly from the topic, the student facilitator redirects attention to the topic. The student facilitator uses the completed template to guide discussion. At the end of the session, individual groups turn in their worksheets and the student facilitators meet to reflect on their experience and prepare a two-page summary of the experience.

The worksheets are the foundation of the modified POGIL activity and require hours of preparation. An effective worksheet (1) starts with a realistic clinical scenario with sufficient background information on the topic of interest, (2) contains open-ended questions to encourage problem-solving during student deliberation and discussion, and (3) is based on students’ prior knowledge. Although it is important to challenge students, questions should be within reach.

University of Texas Health Science Center San Antonio School of Dentistry

Foundations

At the University of Texas Health Science Center San Antonio (UTHSCSA) School of Dentistry, the EBP program is designed to educate students on the traditional EBD approach with an emphasis on “just in time” learning.^5,6 This approach was developed in response to the need for clinicians to stay up-to-date over the course of their careers while faced with a constant flood of new biomedical information and products.

In the just-in-time model, when faced with a clinical treatment or care dilemma, students are taught to (1) formulate a focused clinical question and then quickly (2) search the biomedical research literature (for example, via PubMed or the Trip Database) for the most recent and highest level of evidence, (3) critically evaluate that evidence, and (4) make a clinical judgment about the applicability of that evidence for their patient. These techniques and the skills required for execution are taught to predoctoral dental students in graded didactic courses during the first two years of training.

Critically Appraised Topics (CATs)

After didactic training, students apply these just-in-time skills when preparing a concise one-page Critically Appraised Topic (CAT)^5,7 on a focused clinical question under the guidance of a faculty mentor. The student and faculty mentor work together to refine the CAT, and the faculty mentor is listed as coauthor of the CAT.

A separate faculty member serves as the CAT’s editor, providing a secondary level of editing and peer review. Both the CAT’s editor and faculty mentor are ultimately responsible for the quality and accuracy of the CAT. A key component of the UTHSCSA School of Dentistry EBP/CAT initiative has been a formal faculty development program on EBD, with an emphasis on the skills needed to prepare CATs and mentor their student authors.

Completed CATs are published in a searchable online CAT library.8 The content and structure of a CAT mirrors EBD’s five-step process. For students in the preclinical stage of learning, a CAT’s focused clinical question is usually formulated based on the student’s area of interest or a classroom encounter, rather than an actual patient encounter. Once students progress to the clinical phase of their training and are faced with a clinical dilemma, they are encouraged to apply the CAT protocol to locate, evaluate, and identify the strongest evidence relevant to a patient’s problem.

Evidence-Based Case Presentations

To achieve the goal of integrating EBP skills into all levels of the curriculum and especially into direct patient care, skills are further reinforced in the context of formal case presentations during the final two years of clinical training. A student’s general practice group provides the forum for these presentations, which document the comprehensive care of a patient, including the peer-reviewed evidence base for treatment.

Graduate-Level EBD Training Strategy

The same EBP/CAT skills are taught in the majority of the school’s residency programs. Each resident is required to write a CAT as part of their course or residency requirements. Graduate-level students may choose to write their CAT based on their area of research or on a clinical encounter. As with the undergraduate students, these CATs are coauthored by a faculty mentor and formally reviewed by the CATs editor.

FAST CATs Program: Academic Detailing

The FAST CATs (Faculty, Alumni, Student, Team: Critically Appraised Topics) Program provided dental students the opportunity to serve as academic detailers.⁶ In academic detailing, a trained “detailer” meets face-to-face with a practitioner in the practitioner’s office and provides evidence-based information about patient care topics. In the FAST CATs Program, dental students served as the detailers.

After a two-and-a-half-day workshop, students visited general dentists and presented CATs in person during the students’ summer breaks. Students received credit for this selective course, and the dentist received one hour of CE credit. This program was designed to reinforce the EBP teaching program, to facilitate the flow of information from scientific literature to dental practitioners, and to obtain the opinion of experienced practitioners on the practicality of new interventions in real-world settings. Students reported that their participation in the project reinforced their commitment to EBP, and the detailing was well received by the dentists involved.⁹ FAST CATs was a pilot program funded by a National Institutes of Health (NIH) Education Grant (R25) for several years.

Impact of the UTHSCSA School of Dentistry EBD/CATs Program

The impact of the EBD/CATs program on students, residents, and faculty was evaluated using the Knowledge, Attitudes, Access, and Confidence Evaluation (KACE) questionnaire.¹⁰ The KACE questionnaire assessed individuals’ understanding of EBP, attitudes toward EBP, evidence-searching methods, and comfort with critical appraisal. Scores across these four dimensions were compared before and after EBP/CATs courses. Among students and residents, all scores, except resident attitudes toward EBP, increased significantly. What’s more, post-training EBD knowledge scores for dental students and residents equaled or surpassed those of faculty.

Challenges

Full implementation and integration of an evidence-based teaching program is not without its challenges. The CATs were piloted with an ADA Foundation grant, subsequently developed and supported by an NIH R25 grant, and then supported in part by a U.S. Health Resources and Services Administration grant. Grants are, of course, a self-limited source of funding. Moreover, the success of a fully implemented EBD program depends on faculty who serve as not only mentors but also as valued collaborators for evidence-based care in the clinic. Investigating clinical problems, locating and appraising the evidence base for treatment, and reporting back to the general practice group requires a time commitment on the part of faculty, which takes time away from patient treatment. State budget cuts—and therefore dental school budget cuts—have added to the challenge of full clinical integration of EBD.

University of Iowa College of Dentistry

Overview

The University of Iowa College of Dentistry (UI COD) EBD instructional track is designed to prepare graduates with the skills and experience necessary to independently apply EBD principles to clinical practice.¹¹ The instructional track includes educational content within EBD, professionalism, and lifelong learning domains, while the types of learning include knowledge (for example, facts and concepts) and behavior (for example, application, practice, and assimilation).¹² The curriculum is designed to bring consistency to EBD across departments and throughout the four predoctoral years so as to help manage student expectations.

Assessment

Each curricular component incorporates a learning guide that serves as the foundation for assessment. Outcome assessment is both formative, to guide students during the learning process, and summative, to document outcome achievement. Assessment of knowledge is relatively straightforward; however, assessment of behavior is difficult. Better or worse responses in the context of differing environments with differing confounders necessitate a subjective assessment process. Assessment confounders (including the student’s knowledge base, clinical maturity, technical skills, ethical maturity, and faculty guidance) result in students acquiring skills at different points in their clinical training. Formative feedback is individualized to support each student’s growth at the time of evaluation.

Year 1 (D1)

Students are introduced to primary literature with an emphasis on study design, statistical principles, and critical appraisal. Fundamental knowledge is presented didactically; students apply their new knowledge when appraising primary literature in small groups. Knowledge (for example, statistical facts and concepts) is assessed summatively through written exams, while application (for example, appraisal) is assessed formatively through group presentations.

Year 2 (D2)

Students are introduced to EBD concepts, principles, and professionalism. Students complete short online assignments designed to introduce or reinforce EBD knowledge and write arguments in response to EBD-related editorials and perspectives. The short assignments are considered low stakes; formative feedback is designed to guide students’ thought process.

Students apply EBD’s five-step process to four simulated and/or clinical scenarios (for example, exercises); expectations for the steps of asking an answerable question, searching for the best evidence, and critically appraising the evidence increase throughout the year. Assessment of the five-step exercises is considered high stakes; both formative and summative feedback are provided.

Year 3 (D3)

Students continue to be introduced to EBD principles and professionalism. Similar to the D2 year, students complete short, low-stakes online assignments designed to further develop their appraisal skills and/or introduce professionalism concepts. EBD content is integrated into clinical decision-making as part of patient care during the D3 year. Students apply EBD’s five-step process to patient cases during four different clerkship rotations (that is, high-stakes exercises), and EBD content is included in student case presentations. Assessment of five-step exercises is both formative and summative.

Although lifelong learning is emphasized by faculty during the D1 and D2 years, students gain a new appreciation for the importance of lifelong learning during the D3 year as they assimilate new knowledge, clinical expertise, patient values and preferences, and alternative viewpoints during clinical decision-making.

Year 4 (D4)

During the D4 year, students are expected to assimilate the EBD knowledge and skills acquired during their D1 through D3 years within EBP to further develop lifelong learning skills. Throughout didactic activities, students utilize EBD’s five-step process to support decision-making as they prepare for entry into independent practice. For example, students use EBD skills as a foundation for technology decision-making during group activities. In the clinical setting, students integrate EBD elements into comprehensive patient care in real time. Students formally present their application of EBD’s five-step process to support their clinical decisions in a capstone case presentation. Students reflect on their patient care experiences and the impact of these experiences on their professional growth as part of lifelong learning. Assessment throughout the D4 year is both formative and summative, with feedback designed to support ongoing growth.

Summary

UI COD’s EBD predoctoral curriculum is published and available for reference.¹¹ A companion manuscript describes the development and implementation of assessment strategies guiding student learning in EBD knowledge and behavior.¹² Although EBD competency is not universally defined, the UI COD team identified educational objectives for EBD’s five-step process using Benjamin Bloom’s knowledge and cognitive dimensions and Stuart and Hubert Dreyfus’s model of skill acquisition.¹³ UI COD student growth in EBD behavior has been evaluated utilizing this approach.¹⁴

Competency Assessment

Documentation of learner performance is an essential component of all educational programs. Currently, EBD competency does not have a clear definition, although several investigators have defined competency for research purposes.^12,14 Therefore, program faculty are charged with defining competency and designing assessment strategies for competency outcomes. Within a curriculum, educational activities must communicate the desired outcomes and impart the knowledge and behaviors necessary to achieve these outcomes. In general, documentation of competency includes identification of outcomes, design of assessment activities, and evaluation of student performance.¹⁵

For example, the objective of the UTHSCSA School of Dentistry EBD program is to provide students with lifelong learning skills that will enable them to provide the best patient care and remain up-to-date during their 30 to 40 years of dental practice. This approach entails learning the EBD skills needed to quickly find the latest scientific evidence related to a patient’s specific problem at the point of care. In this context, EBD competency is defined as the demonstrated ability to apply those skills in both preclinical and clinical settings.

Consider the field of fixed prosthodontics, where students are presented with didactic instruction on the preparation of teeth for full-coverage crowns. Students apply this knowledge at the preclinical stage through preparation of typodont teeth. When a minimum level of competency has been achieved, the students transfer their knowledge of crown preparations to patient care in the clinic. They demonstrate their mastery of these skills through traditional assessment methods (for example, multiple-choice testing) as well as through formal competency examinations at both the preclinical and clinical levels.

In a similar manner, in an EBD curriculum, students first learn key concepts and skills in a classroom setting as part of a graded course (Figure 15.1). At UTHSCSA School of Dentistry, students further demonstrate competency of their newly acquired EBD skills through writing a CAT.^5,7 In the preclinical setting, a CAT is the EBD equivalent of a typodont crown preparation—that is, an application of skills in preparation for future patient care. Once in the clinic, students transfer their EBD skills to patient encounters, investigating clinical problems and using an evidence-based approach to inform the clinical decision-making process. Evidence-based formal case presentations are used to confirm mastery of EBD skills at the clinical level.

Figure 15.1. A Comparison of Curricula for Fixed Prosthodontics and Evidence-Based Dentistry

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