Written by Debra Seidel-Bittke, RDH, BS Friday, 28 February 2003 19:00
ADA Definition of EBD
EBD is an approach to oral healthcare 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.3 The term "evidence" must not be considered synonymous with "science." All information about a dental/health topic must be considered "evidence" and must be considered as such. Evidence in a courtroom can be considered strong or weak. This also applies to the information we receive regarding dental healthcare. What is important is the ability to critically appraise and synthesize all relevant studies on a specific topic. Even if all of these analyses have been considered, we still have to avoid the danger of being misled by the "play of chance." This is a problem when the research assessing the effects of treatments has not been conducted on a sufficiently large scale. In these circumstances, it can sometimes be helpful to combine the evidence from separate but similar studies by using a statistical approach. For example, in a comparison of a new treatment with a standard treatment, 5 patients improved with the new treatment and 7 patients improved with the standard treatment. It would be wrong to draw the conclusion that the new treatment was worse than the standard treatment. These results might simply reflect chance. If the comparison were to be repeated, the number of patients who improved might be reversed (7 against 5), or have the same results (6 against 6). However, if 50 patients improved with the new treatment and 70 patients improved with the standard treatment, chance becomes a less likely explanation for the difference, and if 500 patients evidenced improvement with the new treatment and 700 patients evidenced improvement with the standard treatment, it would be clear that the new treatment was indeed worse than the standard treatment (which is true of about half of new treatments). The way to reduce the likelihood of being misled by the play of chance is to take into account the experiences of sufficiently large numbers of patients.
Pauline is a 70-year-old new patient who came for a dental exam today. Upon review of her health history, you note that she has slight hypertension and is taking blood pressure medication. She is also taking the antidepressant Paxil. Upon visual examination, you note that she suffers from dry mouth (xerostomia). When questioning the patient about any other symptoms, she indicates a difficulty in swallowing occasionally. You are aware that Lasix is a diuretic and Paxil is a selective serotonin reuptake inhibitor. Both can cause dry mouth. Should we call her physician to discuss alternate medications and a daily fluoride treatment?
|Figure 1. Steps to take when generating evidence into actual therapy.|
Steps to Take
Exactly what steps can be taken to provide the best appropriate treatment for the patient mentioned above? We need information, but our textbooks are probably out of date. Possibly our journal is disorganized. Consequently, our knowledge, performance, and patient care are probably far from optimal. We gain information through continuing education courses and journals we read. Even though we earn our mandatory CEUs, we might be suffering from "information overload." Possibly only a fraction of the information we have received can be directly applied to our patients. Our practice is busier now than it was 10 years ago. In addition, we have the pressures of insurance companies and reimbursement, which take up our time (Figure 1).
Our first instinct is to go to the library or research our textbooks. In this age of the Internet, we have helpful resources available at our fingertips. Among these are medline.com, medscape.com, and cochranelibrary.com. When in these Web sites, you can query clinical articles or "related articles." Although dental and medical information can be found on the Internet, beware of the quality, reliability, and accuracy of the specific article. MEDLINE, because of its breadth, depth, and continuous maintenance by the US National Library of Medicine (NLM), is the best source of evidence for healthcare. The University of Southern California has an Evidence-Based Web Tutorial at usc.edu/hsc/nml/lis/tutorials.
How Do We Find the Information?
• Internet links offer opportunities to find EBM/ dentistry.
• We learn about this via relevant words or phrases found on the Internet.
• Locate evidence-based policies provided by other colleagues.
• Look for journals that critically appraise primary studies.
• Systematic reviews can be found online by going to (1) the Cochrane Collaboration at cochranelibrary.com and (2) the NLM at nlm. nih.gov. The NLM offers free Internet access through NLM Gateway.4 It is targeted to Internet users who are unfamiliar with the vast contents of the NLM and how to access them. It permits simultaneous, seamless searching in multiple retrieval systems at the NLM. The NLM resources allow users to perform thorough searches that formerly required the expertise of highly trained individuals. The latter statement is not in any way intended to downplay the invaluable role of medical librarians, the real information experts. Indeed, for many scientific endeavors, such as systematic reviews, the expertise of a librarian should be sought.
What Do These Submissions Provide?
• A clear statement of purpose and scope.
• A comprehensive search and retrieval of the relevant research.
• An explicit criteria search.
• Reproducible results because of relevance, selection, and methodological rigor of the primary research.
• Acceptance of proven, evidence-based practice protocols developed by our colleagues (Figure 1).
us.elsevierhealth.com:Information on Periodical Resources along with abstracts.
|Figure 2. Understanding the literature pyramid.|
UNDERSTANDING THE LITERATURE PYRAMID
ANATOMY OF A GOOD CLINICAL QUESTION
Five questions we must ask to provide EBD:
(3) Translate the findings from systematic reviews for use by practitioners.
(4) Assess the healthcare outcomes following the findings of the previously outlined steps. This evaluation is conducted as part of the outcome assessment that healthcare providers integrate into their practices.
Reading and Evaluating
• What are the results?
|Figure 3. The type of question that leads to the right research.|
MORE QUESTIONS TO ASK WHEN REVIEWING THE RESEARCH
MEASURING THE QUALITY AND STRENGTH OF AN ARTICLE
Grading of the evidence is very important. The purpose of assigning these levels is to give a better idea of the quality and strength of the study. Just because a study has a low grade does not necessarily mean it is an invalid study. It might be the first study of its kind and might hold significance for your consideration.7
WHAT IS NECESSARY TO PROVIDE EBD? All of the following are needed to provide quality of care for your patients (Figures 3 and 4):
(1) individual clinical expertise;
(2) clinicians who increase their judgment through clinical experience and clinical practice; and
(3) the best external clinical evidence is clinically relevant research not only from the basic sciences of medicine, but especially from patient-centered research, accurately diagnostic and clinical exams, and preventive regimens.8
|Figure 4. Evidence-based protocol.|
FORMING EVIDENCE-BASED PROTOCOLS
We have come a long way in the past 200 years. Two hundred years ago, we determined treatment by blindfolding and mesmerism. Today we have a systematic approach using EBD. This is an improvement over the earlier theory of "bias," "blind studies," and "placebos." Through technology and the Internet, we are able to more easily research the most current information for the best treatment on an individualized basis for each patient.
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