Evidence-based dentistry: a practitioner's perspective.

Basing practice decisions on evidence is neither contestable nor new. There are some concerns, however, that must be addressed. First, all published "evidence" is not of equal quality. Second, the practical experience of dentists must be recognized as constituting evidence. Additionally, third parties should not be allowed to use evidence if that use interferes with practitioners' judgment. Fourth, the call for more evidence may place a burden on dental schools already struggling to keep up with their demands of teaching basic dental skills. The Dental Practice Parameters developed by the ADA may provide a more realistic alternative because they preserve practitioner discretion.     

A clinician's perspective on evidence-based dentistry

Evidence-based dentistry seems to be more popular with researchers and those in policy positions than with clinicians. A private practitioner looks at the difference between the promise of evidence-based dentistry, which urges a blend of science, clinical judgment, and patient preferences, and the actuality of the rhetoric of rigorous and formulaic clinical trials. The same dichotomy exists in medicine, where the concept originated. Without subscribing to the formality of evidence-based dentistry, practitioners can place a valid scientific foundation under their practices by avoiding unproven assumptions, carefully monitoring outcomes, using measures that are clinically relevant, relating both positive and negative outcomes to possible explanations, and cautiously introducing new techniques. The standards for publishing clinical research seem to favor adherence to methodological rules over useful of outcomes.     

Evidence-based dentistry

Both panegyric and criticism of evidence-based dentistry tend to be clumsy because the concept is poorly defined. This analysis identifies several contributions to the profession that have been made under the EBD banner. Although the concept of clinicians integrating clinical epidemiology, the wisdom of their practices, and patients' values is powerful, its implementation has been distorted by a too heavy emphasis of computerized searches for research findings that meet the standards of academics. Although EBD advocates enjoy sharing anecdotal accounts of mistakes others have made, faulting others is not proof that one's own position is correct. There is no systematic, high-quality evidence that EBD is effective. The metaphor of a three-legged stool (evidence, experience, values, and integration) is used as an organizing principle. "Best evidence" has become a preoccupation among EBD enthusiasts. That overlong but thinly developed leg of the stool is critiqued from the perspectives of the criteria for evidence, the difference between internal and external validity, the relationship between evidence and decision making, the ambiguous meaning of "best," and the role of reasonable doubt. The strongest leg of the stool is clinical experience. Although bias exists in all observations (including searches for evidence), there are simple procedures that can be employed in practice to increase useful and objective evidence there, and there are dangers in delegating policy regarding allowable treatments to external groups. Patient and practitioner values are the shortest leg of the stool. As they are so little recognized, their integration in EBD is problematic and ethical tensions exist where paternalism privileges science over patient's self-determined best interests. Four potential approaches to integration are suggested, recognizing that there is virtually no literature on how the "seat" of the three-legged stool works or should work. It is likely that most dentists choose to wait for collective professional standards to reveal acceptable practice or follow a strategy of punctuated equilibrium, only switching out established practice habits when very conspicuous advantages are identified. Integration in medicine appears to follow the statistically sophisticated practice of updating estimates of clinical parameters (probabilities) for diagnoses, treatments, prognoses, and side-effects. This approach is likely beyond the skill or interest of clinical dentists and it fails to incorporate values in the integration. The use of decision trees to integrate both research and experiential parameters and values is illustrated and it is shown that such a technique identifies why there are very few cases in dentistry where evidence needs to be consulted and indicates what such cases are.     

Evidence-based dentistry: a model for clinical practice

Making decisions in dentistry should be based on the best evidence available. The objective of this study was to demonstrate a practical procedure and model that clinicians can use to apply the results of well-conducted studies to patient care by critically appraising the evidence with checklists and letter grade scales. To demonstrate application of this model for critically appraising the quality of research evidence, a hypothetical case involving an adult male with chronic periodontitis is used as an example. To determine the best clinical approach for this patient, a four-step, evidence-based model is demonstrated, consisting of the following: definition of a research question using the PICO format, search and selection of relevant literature, critical appraisal of identified research reports using checklists, and the application of evidence. In this model, the quality of research evidence was assessed quantitatively based on different levels of quality that are assigned letter grades of A, B, and C by evaluating the studies against the QUOROM (Quality of Reporting Meta-Analyses) and CONSORT (Consolidated Standards of Reporting Trials) checklists in a tabular format. For this hypothetical periodontics case, application of the model identified the best available evidence for clinical decision making, i.e., one randomized controlled trial and one systematic review of randomized controlled trials. Both studies showed similar answers for the research question. The use of a letter grade scale allowed an objective analysis of the quality of evidence. A checklist-driven model that assesses and applies evidence to dental practice may substantially improve dentists' decision making skill.     

Evidence-based dentistry: concepts and implementation

Evidence-based dentistry is the use by dentists of best research evidence, clinical judgment and patient values to guide practice. This article focuses on methods dentists can use to collect the best relevant evidence. Using the examples of systemic fluoridation and fluoridated dentifrices, the authors illustrate a five-step process of: 1) asking answerable questions; 2) conducting a systematic search; 3) critically appraising the literature; 4) applying results to practice; and 5) evaluating outcomes.