Background
Contemporary dental education and clinical treatment reflect the general medical trend to include an evidence-based approach to diagnosis, treatment planning, and clinical decision making. The American Dental Association has developed an evidence-based dentistry community brief detailing a general perspective of the interplay of a triad of scientific evidence, practitioner expertise/judgment, and the patient preferences or circumstances.1 As a practicing endodontist and university graduate endodontic program director, I am aware of the endodontic educational and clinical paradigm shift toward evidence justification throughout the entire spectrum of treatment decisions. The clinical operatory is most often the site or point of this decision-making process and subsequent care delivery. As such, locating and using information in the operatory is becoming a desirable and almost necessary practitioner skill.
Discussion
Involving the patient in the treatment decision process is an integral part of an evidence-based practice and encourages appropriate informed consent. Consent can be effectively improved by providing the patient with a reasonable explanation of the options, recommended procedures, and expectations. Several instructional and online resources are available to provide audio and visual dental procedure explanations. This type of information is appropriate to help the patient formulate informed preferences. The chair-side use of a Web site such as the Procter & Gamble patient resources provides a succinct single-page visual description of numerous common dental procedures (http://www.dentalcare.com/soap/patient/). The material is available in multiple languages and downloadable formats to provide the patient both text and visual information. Should additional language difficulties exist, several free Web-based translation engines exist that might allow communication in the patient's native language (http://translation2.paralink.com). Patients who are electronically literate may proactively seek additional explanatory information using search engines such as http://www.google.com/ to locate dental informational Web sites. An electronic basic medical dictionary such as http://medical-dictionary.thefreedictionary.com/ is itself a reasonable layman's source of explanatory information. It behooves the prudent practitioner to review sites such as Wikipedia (www.en.wikipedia.org/wiki/Main_Page) to understand the dynamic nature of the site and the dental information content available to the public . Unlike the Wikipedia content perspective, the Web page content at most dental informational sites is strictly controlled. National dental specialty groups have appropriate reviewed professional patient content available. An example of such a site is the American Association of Endodontists patient information Web page (http://www.aae.org/patients/patientinfo/). Individual practice Web sites can also provide very sophisticated, patient-directed information to help educate and inform the public. All these efforts may play an integral part in the patient's evidence-based clinical decision-making process. The use of Web site hyperlinks on individual practice Web sites can also help explain to patients the doctor's expertise with a particular product or procedure. Patients may also improve their understanding of medically related conditions or problems through sites such as WebMD (http://www.webmd.com/) or MDconsult (http://www.mdconsult.com/php/74347650-2/homepage). Patient involvement in the clinical decision process lastly should include consideration of the patient's ability to physically tolerate and cooperate with the intended clinical treatment.
The second portion of the evidence-based dentistry triad is the scientific evidence. Locating and interpreting the available scientific evidence can be a daunting task. Simply treating dental disease in the same manner as one did 20 or 30 years ago is likely no longer appropriate. Contemporary clinicians will likely avail themselves to the virtually unlimited content of the World Wide Web. Evidence-based dental resources can be accessed through university library Web portals such as the University of Detroit Mercy (http://www.geocities.com/mlshams/dnh/EBM.htm#RES) or the Virginia Commonwealth University (http://www.library.vcu.edu/tml/bibs/ebd.html). These sites can provide numerous starting points for both clinician and patient “trusted information” searches. In the United States, use of the PubMed search engine (http://www.pubmed.gov) to explore the MEDLINE database is a popular and effective information-gathering strategy. The National Library of Medicine (NLM) and National Institutes of Health (NIH) facilitate periodic updates of specific previous PubMed searches to help provide clinicians with current and appropriate information.
Formulating a searchable question is an integral part of any evidence-based information search. An aid to formulating a dental evidence question and searching MEDLINE is http://medinformatics.uthscsa.edu/EviDents/. This Web site leads the user through the process of using appropriate search words and formulating a PICO (Population/Problem, Intervention, Comparison, Outcome)-type question to help locate appropriate information.
Dental specialty–specific Web sites such as http://www.evidencebasedendo.com have been developed to help interested clinicians or researchers locate relevant evidence that can be cross-referenced by author, title, citation, date, program reading topic, and evidence-based ranking. This site provides a linking capability to available online abstracts or full-text articles.
Additional useful US government–endorsed Web sites such as the national guideline clearinghouse (http://www.guideline.gov) may provide a clinical overview of current state-of-the-art treatment recommendations. Also helpful in providing valuable drug information are sites such as http://www.medlineplus.gov/. Entire drug monographs are available to describe pertinent prescribing and interaction information.
To exclude international Web-based information from an evidence search is a perspective that can be described as both provincial and short-sighted. The genesis of the Web-based health care evidence process is from the United Kingdom's “The Cochrane Collaboration” (http://www.cochrane.org/index.htm). Considered the gold standard of medical evidence, their oral health review section is 1 of about 50 specific groups involved in the production of protocols and clinically relevant systemic literature reviews available in their library. Currently over 100 dental topic reviews have been published. This nonprofit group is recognized worldwide for its timely and trusted approach to answering clinical questions. Additional international evidence locating sites include the German Institute of Medical Documentation and Information (DIMDI) (http://www.dimdi.de/static/en/index.html) and the Pan American Centers for Evidence-Based Dentistry (http://www.evidentista.org). These sites can also produce information relevant to answering clinical questions. International sites such as Dental India (http://www.dentalindia.com/retvimp.html) and Indian HealthMantra (www.healthmantra.com) provide a wealth of product, technique, frequently asked clinical question, and literature link information.
Practitioner expertise and judgment make up the final third of the evidence-based dentistry triad of considerations. Clinical expertise development is hopefully a lifelong goal of all practicing dentists. Dental schools attempt to develop competent individuals who continue to develop their skills throughout their treating career. As clinical expertise improves, clinical treatment decisions and referral patterns would reasonably be expected to change. Clinical experience and confidence certainly influence the decision-making process. Continuing education has also now entered the era of online availability. Numerous dental suppliers provide instructional information detailing the recommended use of their products. An endodontic product example is Tulsa Dental's Web site (www.tulsadentalspecialties.com). Here both product and technique guidance are available. Video format educational material is also readily available from numerous presenters in multiple formats such as the Sybron's rather extensive selection (http://www.sybronendo.com/index/sybronendo-videos-02). Instructional technique videos such as those available from Dental Education Laboratories (http://endobuchanan.com/media.aspx) offer succinct instruction to specific endodontic problems or treatment steps. Other individual contemporary clinical practice Web sites such as http://www.endodonticpracticemastery.com share information they consider relevant to elevating the overall level of specific dental care. Even textbook publishers are now able to provide timely Web-based updating of their individual materials. An example of such a text is Mosby's Pathways of the Pulp (www.PathwaysofthePulp.com). Individual topical updates are regularly generated and even additional chapters can be added. E-learning can provide information on how to perform a specific procedure and the equipment necessary.
The very dynamic nature of the pharmaceutical industry blends well with online information availability. In addition to sites such as the NLM/NIH-provided medlineplus, several commercial product sites such as Epocrates (http://www.epocrates.com) and Empowerx (http://www.empowerx.com/index.html) offer trusted drug information solution packages that intend to help improve health care decisions and e-prescribing delivery.
Another form of online information sharing is the Web log or blog. Online blogs can offer relative immediacy of information exchange that may permit clinicians to exchange ideas, treatment options, technique guidance, constructive criticism, and mental support. Docere's Dentaltown (www.docere.com) is an example of an active blog with multiple communities of interest sharing dialogue. Another active blog that has significant international participation with specific endodontic and implant communities is the Canadian http://www.rxroots.com site. The blogs are effective only when the entire community recognizes their importance, viability, timely responsiveness, and the ability to participate without concern of intimidation or ridicule.
In spite of the philosophical shift toward evidence-based treatment, the value of individual clinician experiences should not be minimized. While experience may only be considered the lowest level of evidence, the value of clinical experience must be appreciated and blended into the treatment decision-making process. Clinicians should be encouraged to join the organized dentistry and academic communities' embracement of the decision-making process intended to provide the most appropriate treatment for each individual patient.
Conclusions
Point-of-care information availability can significantly improve the overall treatment experience. Our information age now allows clinicians and patients the opportunity to participate in and become advocates of using skills and knowledge to routinely effect quality treatments.
∗The dynamic nature of Internet Web sites is such that all the hyperlinks included in this article, although active as of April 1, 2008, should be verified to confirm their continued intended functioning.
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