Evidence-based dentistry in practice
This article considers what evidence-based dentistry means, how to begin to implement it in practice, and why it is important for clinicians and patients alike.
The General Dental Council requires its registrants to, ‘[…] provide good quality care based on current evidence and authoritative guidance’.1 Furthermore, evidence-based dentistry (EBD) is globally accepted as the ‘gold standard’ in healthcare delivery.2
The Centre for Evidence Based Dentistry (CEBD) defines EBD as, ‘[…] the integration of best research evidence with clinical expertise and patient values.’3
The CEBD also quotes the American Dental Association’s definition, whereby EBD encompasses, ‘[…] an approach to oral health care that requires the judicious integration of:
• Systematic assessments of clinically relevant scientific evidence, relating to the patients oral and medical condition and history, together with the
• dentist’s clinical expertise and
• the patient’s treatment needs and preferences.3
Adding a UK-based, practical perspective, Richards and Lawrence (1995) considered how EBD may affect clinical decisions. To this end, they wrote: ‘It is an approach to clinical problem solving that has evolved from a self-directed and problem based approach to learning rather than the more traditional didactic form.4
They continued: ‘The first stage is to identify the clinical problem, after which, evidence to help solve the problem must be located.4
Practical aspects of EBD
Given this, how might one implement this first stage in the EBD process? According to Richards and Lawrence (1995), there are four possible routes to finding good evidence, once an oral health problem has been identified, although some present the possibility of significant limitations:
• Ask someone – however, to avoid potential pitfalls, such as the person not being sufficiently current, ask for a specific reference so that you can assess the evidence for yourself
• Consult a textbook – but note that they are only as up to date as their last reference
• Find a relevant article in your own reprint file – though these are likely to be limited in scope, and may not cover the particular issue you are concerned about
• Use a bibliographical database such as MEDLINE – these are fast, inexpensive and easy to use, and are updated all the time.4
Effective research requires the right question to be asked. To achieve that, dental healthcare professionals may find the PICO system useful:
• ‘Population: which populations of patients are we interested in? How can they be best described? Are there subgroups that need to be considered?’
• ‘Intervention: which intervention, treatment or approach should be used?’
• ‘Comparators: what is/are the main alternative(s) to compare with the intervention being considered?’
• ‘Outcome: what is really important for the patient? Which outcomes should be considered? Examples include intermediate or short-term outcomes; mortality; morbidity and quality of life; treatment complications; adverse effects; rates of relapse; late morbidity and re-admission; return to work, physical and social functioning; resource use.’5
By way of an example, in their meta review exploring whether chemical mouthwash agents achieve plaque/gingivitis control, Van der Weijden and colleagues (2015) asked the focused question: ‘What is the effect of mouthwashes and their various chemical ingredients for plaque biofilm control in managing gingivitis in adults based on evidence gathered from existing systematic reviews?’6
Once you have found your evidence, the next step is to appraise it – in essence, making sense of it.4> One way of doing so involves using Critical Appraisal Skills Programme (CASP) questions:
• Did the review ask a clearly-focused question?
• Did the review include the right type of study?
• Did the reviewers try to identify all relevant studies?
• Did the reviewers assess the quality of the included studies?
• If the results of the studies have been combined, was it reasonable to do so?
• How are the results presented and what is the main result?
• How precise are these results?
• Can the results be applied to the local population?
• Were all important outcomes considered?
• Should policy or practice change as a result of the evidence contained in this review?7
Focusing further on this appraisal system, Richards (2010) wrote: ‘Two of the most important [aspects of these questions] are, to consider if your patients or setting is so different [from] that in the review that you could not apply the approach, or whether there are any important outcomes, for example potential side effects that have not been considered that would impact upon you using this approach in your practice. If not, the next thing to consider is how you might implement this treatment or approach in your practice and whether they may be any barriers to you doing so.’7
Following appraisal, you can either act on it, store it or discard it, but it is always important to be mindful that the information you have gathered will need to be continually updated.4
The benefits of EBD
In 2009, Gillette and colleagues considered the benefits of EBD over and above improved patient outcomes, suggesting the following advantages:
• Improved satisfaction for the dental team and patients alike
• Greater pride among dentists, staff and patients in high-quality care
• A more advanced decision-making capability in clinical terms
• An increase in confidence when it comes to planning treatment
• The chance to offer more treatment options, while minimising risk and maximising safety
• The opportunity to combine strong evidence with clinician judgment as well as experience, alongside the patient’s belief system and choices, ultimately resulting in greater professional satisfaction
• A happy team that is motivated by putting the patient first and working to a high standard
• Effective and efficient treatment processes that save time and money
• Increased treatment acceptance, as the dental healthcare professional is able to share meaningful evidence with the patient in support of proposed care. This also results in greater trust and rapport between the parties
• Greater numbers of referrals from patients, as they share with others their treatment journey in the practice.8
Informed decision making
Succinctly presenting an overview of EBD, Brignardello-Petersen and colleagues (2014) wrote: ‘Scientific evidence constitutes one of the fundamental tenets of dental practice. Evidence-based dental practice integrates the use of the best available evidence, clinicians’ expertise and patients’ needs and preferences to inform decision making in clinical practice.’9
- Standards for the Dental Team. General Dental Council 2013
- Kishore M et al. Evidence based dental care: integrating clinical expertise with systemaKishore M et al. Evidence based dental care: integrating clinical expertise with systematic research. Journal of Clinical and Diagnostic Research 2014; 8(2): 259-262
- https://www.cebd.org/what-is-cebd/. Accessed 4 May 2017
- Richards D, Lawrence A. Evidence-based dentistry. BDJ 1995; 179(7): 270-3
- https://www.nice.org.uk/process/pmg6/chapter/developing-review-questions-and-planning-the-systematic-review. Accessed 4 May 2017
- Van der Weijden FA et al. Can chemical mouthwash agents achieve plaque/gingivitis control? Dent Clin N Am 2015; 59: 799-829
- Richards D. Critically appraising systematic reviews. Evidence-Based Dentistry 2010; 11: 27-29
- Gillette J et al. The benefits of evidence-based dentistry for the private dental office. Dent Clin N Am 2009; 53(1): 33-45
- Brignardello-Petersen R et al. A practical approach to evidence-based dentistry. Understanding and applying the principles of EBD. JADA 2014; 145(11): 1105-1107