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

The term “evidence-based” has evolved through certain iterations through the years. Archie Cochrane initiated the discussion of putting into action the concept of science-based medicine when in 1971 he published Effectiveness and Efficiency: Random Reflections of Health Services (Cochrane 1972). In 1992 a clinical epidemiology group at McMaster University in Canada (Evidence Based Medicine Working Group 1992) published a paper on evidence-based healthcare (EBM 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 well-defined use of the term “evidence-based” in the UK was in a 1996 British Medical Journal article by David Sackett et al. (Sackett et al. 1996) 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 digital technologies in scanning, designing, milling, or printing restorations and appliances; the newer adhesive systems; newer generations of composites; more nonsurgical and adjunctive periodontal therapies; different dental implant systems, shapes, sizes, components or engineered surfaces; and more procedure-specific use of biomaterials as well as therapies, all 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.

(Sackett et al. 1996)

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 (scaling and root planing) 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 (at the time of print) of 174 reviews, 28 protocols, and 214 subtopics in dentistry (https://oralhealth.cochrane.org). Summaries of the reviews are listed on the OHG website.

   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” topics, “English” language articles, a certain period of time (certain decade of research and beyond), and so on (many more filtration strategies are available). For the abovementioned example, a search of the best evidence yielded the following number of articles (at the time of print):

   • 199,124 articles that include the word “pregnant”
   • 100,793 articles that include the words “periodontal disease”
   • 716 articles that include the words “pregnant” and “no periodontal disease”
   • 59,888 articles that include the words “low-birth-weight”: Clearly, reading more than 360,000 articles to address our clinical scenario is neither indicated nor necessary. By using just “human” subjects and “English” language as our limits for our filtration strategy, we came up with 198 articles that describe the association (or lack thereof) between periodontal disease in pregnant patients and low-birth-weight babies. A further review of the articles and additional filtration (specificity and sensitivity) yielded 37 articles that describe the potential link between pregnant patients with periodontal disease and the risk for preterm and low-birth-weight babies.

3. Critically appraise the evidence.

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