Dentistry over the last 100 years has been characterized by improved approaches to education and practice. Parallel to trends in the field of medicine as a whole, dentistry is moving toward evidence-based practices. The goal of evidence-based dentistry is the assurance, through reference to high-quality evidence, that care provided is optimal for the patient and that treatment options are presented in a manner that allows for fully informed consent. As we transition toward broad-based use of evidence-based dentistry approaches in clinical practice, many dental offices will benefit from a better understanding of how evidence-based dentistry can improve patient outcomes. This article lists the likely benefits evidence-based dentistry can provide to patients, staff, and dentists when routinely adopted in daily practice.
Dentistry, like other health care fields, is a science-based profession. As such, it is expected that research and technologies will continually evolve based on advances in the understanding of the science, and that the corresponding treatment decisions will evolve as well. Practitioners are continually challenged with the task of keeping current with the scientific literature. Given the sheer volume of scientific journal articles and the wide variations in methodology, meeting this challenge continues to be difficult for all health care professionals.
During the 1990s, a new process for incorporating the most current scientific literature into health care emerged. Known as evidence-based medicine (EBM), this process was developed as a systematic approach to identify and critically assess the evidence relevant to specific clinical questions. The ultimate purpose of EBM is to help health care providers implement the most current scientific information into patient care.
The term evidence-based medicine first appeared in the medical literature in 1992. In 1995, Dr. David Sackett founded the Oxford Centre for Evidence-Based Medicine and is often credited with early advances in the EBM movement. In a 1996 British Medical Journal article, Sackett provided the most commonly cited and used definition of evidence-based medicine ( Box 1 ). Sackett acknowledged that EBM requires the incorporation of three key items into the clinical decision-making process: the best evidence, clinical expertise, and patient values.
Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.
Data from Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: What it is and what it isn’t. BMJ 1996;312(7023):71–2.
These same three elements form the foundation for evidence-based approaches to health care by many professional groups, including dentistry. In the fall of 2001, the American Dental Association (ADA) adopted an evidence-based dentistry policy statement, which includes the same three elements—scientific evidence, clinical expertise, and the patient’s needs and preferences—in the definition of evidence-based dentistry (EBD) ( Box 2 ). By systematically incorporating the best available clinical evidence, the evidence-based approach aims to help dental professionals apply their professional judgment to make the best-informed clinical decisions. The policy statement also emphasizes that scientific evidence, by itself, cannot dictate patient care, but rather optimal oral health care must also incorporate the needs of the individual patient, as assessed by the attending dentist. More recently, the ADA established the Center for Evidence-Based Dentistry. The center’s primary goals are to disseminate critically appraised information of current scientific evidence related to oral health and help dentists implement EBD in their practices.
Evidence-based dentistry (EBD) is 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.
Data from American Dental Association, ADA policy on evidence-based dentistry. Available at: ada.org/prof/resources/positions/statements/evidencebased/asp . Accessed June 16, 2008.
It is well known that implementation of research evidence into clinical practice is an important component of any health care practice. However, research findings are often inadequately disseminated and translated to practitioners, and practitioners tend to resist applying new information. Numerous barriers stand in the way of translation and dissemination of evidence, two of which are limited access to scientific information and lack of time to identify, critically assess, and implement evidence.
Since the inception of EBM in the early 1990s, the rapid growth of the Internet has made it easier for practitioners to gain access to the most current evidence. Use of computer-based systems for information retrieval has had an important impact on health care. These kinds of advances in technology, because they offer the potential of delivering real-time information at the point of care, have a role helping to overcome the barriers of access to information and time constraints. Multiple online resources are available to dental professionals. These are cited elsewhere. Examples of such resources include Web sites with summaries of systematic reviews ( Table 1 ) and Web sites for identifying evidence-based clinical recommendations or guidelines ( Table 2 ).
|Database of Abstracts of Reviews of Effectiveness||www.crd.york.ac.uk/CRDWeb/|
|National Library for Health—Oral Health Specialist Library||www.library.nhs.uk/oralhealth/|
|Evidentista (Pan American Centers for Evidence-Based Dentistry)||us.evidentista.org/?o=1026|
|Bandolier : Dental and Oral Health||www.jr2.ox.ac.uk/bandolier/booth/booths/dental.html|
|Cochrane Oral Health Group||www.ohg.cochrane.org/reviews.html|
|Centre for Evidence-Based Dentistry||www.cebd.org/?o=1069|
|National Guideline Clearinghouse||www.guidelines.gov|
|ADA Evidence-Based Clinical Recommendations||www.ada.org/prof/resources/ebd/clinical.asp|
|PubMed Clinical Queries (National Library of Medicine)||www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml#reviews|
|National Institute for Health and Clinical Excellence||www.nice.org.uk/guidance/index.jsp?action=byTopic&o=7298&set=true|
As EBD continues to evolve, it is expected that implementation by practitioners will occur gradually as well. The diffusion of innovation theory describes the different stages of adopting new ideas, technologies, or methods. This theory proposes that a limited number of individuals—the innovators and early adopters—are the first to take hold of new concepts. These innovators and early adopters influence the remainder of the population. Anecdotal information suggests that this theory holds for EBD; groups of innovators and early adopters first implemented EBD and influenced other dentists.
In partnership with the Journal of Evidence-Based Dental Practice and supported by an educational grant from Procter & Gamble, the ADA established the EBD Champion program to leverage the knowledge, experience, and influence of those currently implementing EBD, the innovators and early adopters. This program will develop a network of oral health care workers who will assist their colleagues to implement evidence-based approaches to practice. As part of an ongoing program, practitioners throughout the United States are recruited to become EBD Champions. These individuals learn how to implement EBD using a number of resources currently available and to ultimately disseminate their learning and experience to colleagues. Thus, the EBD Champions serve as a resource to the practitioners in their communities.
It is clear that dentists, members of the dental team, and patients are the primary targets for the continued evolution of EBD. However, this evolution has also revealed many other stakeholders with integral roles in EBD. We have discussed above the role of professional associations, specifically the ADA, but other stakeholders include policy makers, third-party payers, the dental industry, and educators.
Evidence-based dentistry and dental education
Contemporary dental education in the United States is the result of several hundred years of educational evolution and innovation. The self-training and apprenticeship-training approaches, common up through the early 19th century, began to end with the opening of the first United States dental school, in Baltimore in 1840, and the first university-based dental department, at Harvard in 1867. Although change occurred slowly, an early watershed event in dental education was the release of the Gies Report in 1926, which resulted in the closing of many proprietary dental schools and the eventual mandate that all dental schools be university-based and operate under an accreditation process to ensure educational quality and consistency.
Once dental education became universally housed within universities, steady progress toward a science-based curriculum became evident. Concomitant with this was the development of the concept of professionalism and the perceived need for standards of practice and ethical guidelines. As a result, dentistry began to take on more of the look of a medical subspecialty, with dental education paralleling many of the educational changes occurring in medicine.
In the latter part of the 20th century, due to the parallel development of clinical epidemiology and evidence-based medicine, there was a call for changes in medical education and clinical practice. Teaching the principles of evidence-based medicine during medical education was seen as an important component of the broader changes to medical practice that were needed. These changes occurred rapidly and, by the end of the 1990s, nearly 90% of United States medical schools offered EBM courses.
Dentistry found itself similarly afflicted by wide variations in practice patterns and continued use of outdated approaches to treatment. In reviews of dental education, both the Institute of Medicine and the Santa Fe Group indicted the dental school curriculum as contributing to the problem and both called for substantial reforms. These reforms included a significant increase in curriculum time devoted to teaching the principles of EBD.
The degree to which dental schools have incorporated these recommended changes is not well documented. However, it is unlikely that the proportion of United States dental schools devoting significant curriculum time to EBD is anywhere near the 100% rate now found in medical schools. The University of Kentucky’s efforts to use evidence-based protocols as a foundation for clinical teaching are described elsewhere in this issue.
Pressure to improve the teaching of EBD will continue in dentistry as the need for effective and efficient dental care continues to grow. Fortunately, awareness of the importance of EBD is now increasing through the efforts of the ADA and the American Dental Education Association. The legitimacy and visibility provided to EBD by the activities of organized dentistry will ultimately lead to greater participation by practicing dentists and dental schools. Many believe that universal teaching of EBD in dental school will only be assured, however, by the incorporation of EBD into accreditation guidelines.
Introducing EBD concepts at the level of first professional dental education is perhaps the most efficient and effective means of increasing its use in private practice. However, it will take many years for this approach alone to diffuse into the profession. If we hope to see important changes in professional behavior within a reasonable time period, efforts must be made to increase EBD competency within the existing practicing community. We realize that, as with any significant change in the approach to practice, efforts to promote change will meet with resistance as it runs into well-established behaviors and attitudes set over years of practice. Nevertheless, we believe that the benefits of developing an evidence-based approach to care are well worth the effort. Moreover, when the full extent of these benefits are realized and the relative ease with which EBD can be incorporated into daily practice is understood, we feel that many dentists will embrace the concept and readily move into the next phase of dentistry. To that end, we provide below some of the benefits that can be derived from incorporating evidence-based thinking into the dental office.
Benefits for the practicing dentist
There are many potential benefits to dentists who use EBD in clinical practice. The most obvious and best reason is the prospect of obtaining improved patient health outcomes. Certainly this invokes our duties under the Hippocratic oath to “first do no harm” and, concomitantly, to provide the very best health care so patients may achieve and maintain optimum health. Other advantages dentists may garner include:
Improved patient, staff, and dentist satisfaction
Greater pride among patients, staff, and dentists in high-quality care
Improved clinical decision-making capability
Greater confidence in treatment planning
More opportunity to provide treatment choices selected for minimizing risks of harm and maximizing treatment safety
Greater satisfaction derived from creating customized treatment plans based on the powerful combination of stronger scientific evidence, clinician judgment, and experience, as well as patient preferences and values
Increased day-to-day enjoyment working with a happier team motivated by working to a higher standard that puts the patient first in the dental care process
Reduced overhead and improved production by saving time and money using techniques and materials that are effective and efficient
Higher treatment-plan acceptance as dentists add to their presentation tool box the sharing of high-quality meaningful evidence with patients
Enhanced patient trust and rapport when patients who know their dentist relies on the highest level of evidence for making treatment recommendations
Improved practice building opportunities as patients share with others their trust, confidence, and pride in their EBD-practicing dentist
Staff who are employed by EBD-practicing dentists also harvest many benefits, including:
Increased staff confidence, pride, trust, and personal satisfaction
Enhanced recognition in the community and with peers as a thought-leader practice
Increased engagement and satisfaction in work when taught how to conduct EBD searches themselves, thereby directly contributing to the health of patients
Additionally and most importantly patients receive many benefits from EBD as well, including:
Saved time and resources by choosing treatments that are more effective and efficient
Customized treatment plans based upon the highest level of evidence, the lowest risk of harm, and the patient’s personal preferences and needs
Increased trust and confidence in the doctor and his or her practice
Greater incentive to invest in quality oral health care
Increased pride from being a patient of a community thought leader and distinctive practice
Once practitioners have mastered how and where to find EBD resources, they are ready for the next phase: prioritize clinical topics, organize the information found, and share the information with staff. There are many ways for dentists to prioritize the order of their searches. These include:
According to diagnoses or interventions commonly found in the practice
According to gaps in knowledge
According to questions commonly asked by patients
According to the procedure, treatment, or device considered for purchase or introduction into the practice
Each of these approaches is appropriate and the dentist may want to start with one topic per week and slowly begin to integrate the new knowledge into clinical practice. Information resulting from searches can be organized several ways, including on a computer in the office accessible to all staff (in a document or desktop folder or through the use of Microsoft OneNote), or printed and kept in a three-ring binder in the office and made accessible to all staff.
Clinicians may be uncomfortable at first with the tasks of introducing EBD concepts to staff and recommending appropriate changes according to the level of evidence. Staff and dentist alike can become very invested in a treatment philosophy, protocol, or procedure and, after reviewing evidence, a dentist may find information contrary to these ideas. The dentist must clearly define and voice to the staff from the beginning the practice’s overall commitment to providing the very best patient care and the need to have the humility and open-mindedness to fulfill that commitment. Additionally, it is important to educate staff that EBD support is only part of the clinical decision-making process. Equally important factors are clinical experience and patient desires and needs. All data collected by EBD searches should be made easily accessible to staff. Regular staff meetings are the perfect opportunity to help explain EBD concepts, teach EBD searching techniques, and discuss levels of evidence found during recent searches. Staff can take great pride in knowing that they are providing the highest level of care. Proud, informed, and engaged staffmembers are likely to transmit this excitement to patients.