Evidence-Based Dentistry for Everyday Practice

The Changing World 

In recent years, dentists who wished to improve or expand their education in dentistry had limited opportunities to access high-quality information and lacked both the proficiency and time to interpret such information when found. Gaining additional information was limited to perusing textbooks, attending continuing education courses, reading journal articles, or making inquiries to respected mentors. All of these forms of learning still have their place today; however, it is my experience that most practitioners, like myself, have a difficult time sorting through the vast quantities of information available and finding sources they can trust. In addition to the immense volume of information available, many dentists have not had significant training with respect to skills designed to critically evaluate the quality of the research they are accessing. Time also becomes a crucial element for the busy practitioner. The staff, business, and clinical practice management aspects of a dentist's life can absorb a considerable amount of time. Consequently, the added time needed to critically evaluate research becomes a barrier to consistent implementation. Because the process of acquiring and evaluating research can be overwhelming, many tend to rely on gaining information the old-fashioned way. This often consists of finding a respected mentor who then teaches the inquiring dentist: “This is how I've done it for 25 years.” Certainly, clinical decisions need a certain amount of professional experience, but relying on the clinical experience of others often lacks the rigors of science.

There is a growing trend across the nation and the world to use evidence-based dentistry (EBD) to improve patient care. As noted earlier, practitioners like myself find this difficult because of an inability to access EBD resources, lack of evaluation skills, and the constraints of time. However, with the advent of new dental technology, Internet technology, and management information systems, updating knowledge and skill with relation to EBD as well as its implementation has become easier than ever for practitioners. Dentists can now quickly and effortlessly bring clinically relevant information to the point of care. The following are simple and cost-effective implementation strategies busy dentists can use to bring EBD into everyday practice.

Why EBD? 

There are many benefits to efficient and effective use of EBD by dentists. The most obvious and best reason is the potential for obtaining improved patient care. Certainly this invokes our duties under the Hippocratic Oath to “first do no harm” and, concomitantly, to provide the very best health care in order that patients may achieve and maintain optimum health. Other benefits of EBD include the following:

Harnessing the Brain Power of Others 

Within the past 10 years there has been an explosion of technologies that now allow dentists to access records and gather and transmit clinical patient care information in real time. Examples of such technology include the following:

These advances all allow EBD information to be used at the point of care wherever that may be. As an example, on any given Saturday a dentist can attend to a patient's toothache from the comfort of his or her couch. The practitioner can log on to the practice's server securely, review the patient's health history, write a prescription in the patient's chart, send a referral and radiographs to the local endodontist via e-mail, treatment plan, and schedule a gold crown.

There are numerous other technological accessories that simplify the quest for EBD such as Podcasts, Pocket PCs, and Smartphones. Several organizations are producing Podcasts that can be downloaded by dentists to media-playing software. These entities such as www.Dentalcast.com have various topics of interest to dentists such as “Assessing Patients' Caries Risk with Dr Margherita Fontana, cover story from Sept 2006 JADA” and “An Evidence-Based Approach to Crown and Bridge with Dr Dean Mersky.” Dentists who use Pocket PCs or Smartphones can easily download from their practice management software patient contact information and their upcoming weekly patient schedule. Practitioners employing this technology can not only keep in touch with the business aspect of their practice, but additionally the Journal of Evidence-Based Dental Practice (JEBDP), one of the leading journals on EBD, has recently added a feature that allows abstracts of critical reviews to be sent automatically to a dentist's Pocket PC or Smartphone.

Many offices now employ a combination of the above capabilities, which is quite conducive to the practice of EBD since they help facilitate the delivery of high-quality and accurate treatment at the point of care. However, dentists who do not use these technologies can still easily apply EBD principles in everyday practice. A simple high-speed Internet connection is the basic portal for the EBD-seeking dentist, regardless of whether that connection is in the office, at home, or at the local public library. The next section assumes the practitioner has access to such technology.

Accessing EBD Resources 

EBD sources can be classified as primary or secondary. Primary sources are the studies themselves, such as randomized clinical controlled trials. Secondary sources are the compilation and/or evaluation of primary sources. There are numerous EBD secondary sources and resources such as systematic reviews, critical evaluations, and online tutorials. Since the challenge for the provider with basic knowledge of EBD and limited time is finding simple EBD resources quickly, utilization of these secondary sources is essential. Three of the most uncomplicated, thorough, and economical resources are the following:

The JEBDP contains many useful items such as critical evaluations of recent publications on clinically relevant topics, Cochrane Reviews, and featured articles that often focus on expanding practitioners' knowledge of EBD. The cost for this journal is minimal and, in addition to the paper publication, the subscription also includes free online access to all content, free delivery of JEBDP abstracts and MD consult updates to Pocket PCs and Smartphones, and free e-mail alerts regarding topics of interest.

The ADA has developed and continues to develop an amazing section on EBD with grant support from the National Library of Medicine and the National Institute of Dental and Craniofacial Research (NIDCR). This portion of the ADA's Web site has a glossary of EBD terms, links to additional EBD resources, and systematic reviews arranged by topic. The sources of the systemic reviews include among others the Cochrane Library, the Centre for Reviews and Dissemination, the Journal of the American Dental Association, and other journals. Additionally, the ADA will make copies of journal articles for members.

The Trip Database is an extensive Web site that will search many databases (ie, DARE, Cochrane) and journals (ie, JEBDP) at once. It allows practitioners to search by topic and limit searches to critical evaluations or systematic reviews. This Web site also provides links to clinical guidelines developed by various organizations.

The following are 3 examples of clinical situations I faced in my practice, how I identified the current evidence on the topic, and how this information was ultimately applied in my practice.

EBD example search: Does subantimicrobial dose doxycycline (SSD) with scaling and root planing result in improved pocket depth reduction compared with scaling and root planing alone?

1.Go to http://www.jebdp.com/home

2.Login to your account (must have a subscription to JEBDP)

3.In the search window type in “doxycycline”

4.Access critical evaluation of “Subantimicrobial dose doxycycline improves probing parameters associated with periodontitis” (Figure 1)

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Figure 1. JEBDP critical evaluation of SSD and periodontitis.

Result: SDD with scaling and root planing can result in a higher percentage of patients with statistically significant attachment gains and probing depth reductions when compared with scaling and root planing and a placebo. Notice that the level of evidence for this study is “1b.” This means that the study design was of reasonably high quality and that the practitioner can adequately rely on the validity of the study results.

EBD example search: For young children, which fluoride treatment if any is the most effective at preventing caries?

1.Go to www.ada.org/prof/resources/ebd/index.asp

2.Search topics by “Fluoride, Topical” (Figure 2)

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Figure 2. ADA EBD systematic reviews collection on topical fluoride.

3.Access and assess systematic reviews from organizations such as Cochrane Library (Figure 3), DARE, and National Library for Health

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Figure 3. One of the Cochrane Collaboration systematic reviews on fluoride varnish and young children.

4.Access through ADA Web site clinical recommendations for fluoride http://www.ada.org/prof/resources/ebd/clinical.asp

Result: Fluoride varnish is effective at preventing caries in young children at 3- to 6-month intervals and it is the topical fluoride of choice for this age group.

EBD example search: Will fluoride varnish application in the medical setting reduce the caries incident in young children compared with no treatment? Is this approach cost effective when compared with no treatment?

1.Go to www.tripdatabase.com/oral and search by “fluoride varnish medical”

2.Access the Centre for Reviews and Dissemination Web site subcomponent NHS Economic Evaluation Database to view “Simulating cost-effectiveness of fluoride varnish during well-child visits for Medicaid-enrolled children” (Figure 4)

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Figure 4. The Centre for Reviews and Dissemination includes NHS Economic Evaluations, which contain data as to the cost-effectiveness of protocols and procedures.

Result: Fluoride varnish application during well-baby visits delayed caries onset by only 1.52 months. Restorative costs for fluoride varnish babies were $52.00, although the application of fluoride varnish was $64.00. The application of fluoride varnish was associated with an overall cost increase of $10.93 per child.

Putting it into Practice 

Using secondary sources such as systematic reviews and critical evaluations saves practitioners precious time. Producing these secondary sources of EBD would take time and training that busy dentists rarely have. However, if practitioners do desire to conduct these reviews and evaluations themselves, there are several training resources that offer instruction. One of the best online resources is the Centre for Evidence-Based Medicine (CEBM) at http://www.cebm.net/?o=1021. This Web site has many excellent tutorials including step-by-step guides on how to evaluate randomized controlled trials (RCTs).

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 the following:

Any of these approaches is adequate and the dentist may want to start with 1 topic per week and slowly begin to integrate the new knowledge into clinical practice. Information resulting from searches can be organized several ways including:

Introducing EBD concepts to staff and recommending appropriate changes according to the level of evidence may be uncomfortable at first. Staff and dentist alike can become very invested in a treatment philosophy, protocol, or procedure and occasionally after reviewing evidence a dentist may find information contrary to these ideas. It is important that the dentist clearly define and voice to the staff from the beginning the practice's overall commitment to providing the very best patient care and the humility and open-mindedness it may take to get there. Additionally, it is important to educate staff that EBD support is only part of the clinical decision-making process. Other equally as 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 take great pride in knowing that they are providing the highest level of care. Proud, informed, and engaged staff help transmit this excitement to patients.

Conclusions 

Evidence-based dentistry can easily be implemented by busy dentists into everyday practice with the help of advanced technology and secondary resources. Key components of this include:

Employing simple elements of EBD support resources can have high-impact results for dental practices such as (1) improved patient care outcomes; (2) improved patient, dentist, and staff pride and satisfaction; and (3) saved time and money by using protocols and procedures that work.