Patient satisfaction is of prime importance to the dentists of today. While patient expectations have gone up exponentially, so have the patient’s awareness of their own rights, and the different modalities of treatment available to them. Much of this revolutionary change can be attributed to the electronic boom, with knowledge being available to everyone just a click away. Information has become so easy available now that patients reporting for their routine appointments or consultations come with abundant information on the various treatment options available for their own dental problems, some of which even the treating dentist may be unaware of. It is hence imperative for all the dental practitioners of today to be up to date with all the recent advances knowing the pros and cons of each new technique.
In this scenario, evidence-based principles are widely being incorporated in most health care fields, as well as some non-health professions. Academic institutions, human resources, even library studies are using evidence-based principles to guide their day-to-day decisions. Evidence-based principles help strengthen professions by identifying knowledge gaps and encourage us to formulate clear questions regarding the evidence that we need. A cycle starts to emerge: the more gaps that are identified means more questions are asked, the more questions that are asked means more research is performed, the more research that is available means better decisions are made, thereby strengthening the profession.
It plays the role of a bridge, connecting real world dental practice to clinical research. Used correctly, it is the one tool that can help a dental practitioner to improve his practice and grow professionally without any fear or doubts.
|Evidence Based Dental Practice Advantage|
YOUR DENTAL TEAM AND PRACTICE
Though till date, in situations of doubt pertaining to treating any particular patient, practitioners often took the help of other fellow dentists, textbooks, colleagues, professors and/or electronic databases and we realized that in the event of a medico legal negligence issue arising, these opinions and advices don’t hold true unless backed scientifically. In such cases, it is evidence based dentistry (EBD) and not the opinions of others which help.
This is the importance of evidence based practice (EBP). The need for every dental procedure or advice to be based on sound scientific facts and the unrestricted access of patients to electronic information has given rise to an evidence-based healthcare to progress swiftly. EBD provides a dentist with additional armamentarium to form a decision based on sound thoughts and scientific backing. It hence helps exert only an influential role in decision making not an authoritarian one.
Evidence based dentistry is one additional factor that if added to the above factors, helps in making the best choice with a scientific backing. Evidence based dentistry and medicine is increasingly attracting worldwide attention in public policy, resulting in the mass production of evidence based clinical guidelines. It is not a new concept for the professionals in the United States, but is one of the recent evolutions in the dental practice in India. The easy access to colleagues and books prevents dentists from feeling the need to have a scientific backing to their practice.
Clinical Practice Guidelines (CPGs) are “systematically developed statements to assist practitioners and patients in arriving at decisions on appropriate health care for specific clinical circumstances.”
In India we need to formulate evidence-based clinical practice guidelines (EB-CPGs), using rigorous, explicit and reproducible methods to assemble and evaluate the evidence. These guidelines must be based on systematic reviews and incorporate values and preferences of patients and practitioners. The process of creating a well-developed EB-CPG includes external review and comment by those who will be using the guidelines - for example, a wide range of clinicians, as well as patients or their representatives. The development of EB-CPGs in dentistry is in the beginning stages.
Learning involves identifying and evaluating new methods that might improve care and prognosis, determining when to implement those that appear to improve care, and discarding old diagnostics and therapeutics that prove to be unsound. In this information age, it is not uncommon for a patient to rush home from the dentist’s office to look up on the Internet or in health reference texts the drug or diagnosis that was provided. Science in the form of statistical evidence is being introduced into everyday practice.
However, EBD when taught only in the classroom, may have little impact on the attitudes or behaviors of clinical practitioners. In other words, theoretical knowledge of EBD, obtained without opportunities to practice using an evidence-based approach to patient care decision making, may lead to no changes in dental practice at all. Therefore, it is crucial to implement evidence from research into clinical practice, and by doing this, the concept of EBD can become practically relevant to the dentistry.
The main principle of evidence based medicine (EBM) is that clinical decision making should be influenced by rational analysis of evidence and previous experience. It is a method introduced for assisting clinicians with obtaining information and synthesizing its usefulness to aid in clinical decision making. Dentistry has two important fields to be considered: the knowledge (i.e science) and the application of this knowledge (different specialties and clinical practice). EBD was made to relate this science to the clinical practice through the use of scientific methods in order to reach the best treatment for a specific clinical situation. The EBD process is not a rigid methodological evaluation of scientific evidence that dictates what practitioners should do or not do, rather, it aims at integrating the scientific basis for clinical care, using thorough, unbiased reviews and the best available scientific evidence at any given time.
Although considerable resources are spent on clinical research, little attention has been paid to the implementation of research evidence into clinical care. EBP may not be a concept that every dentist is familiar with, but increasing consumer pressures and the present economic, social, and political changes, will necessarily demand that evidence based principles are implemented.
The practice of dentistry presents many challenges on a daily basis. Keeping up with new materials and techniques, dealing with the numerous demands of running a small business, and meeting a variety of professional obligations, all compete for our time and attention. As healthcare providers, it is important that physicians and dentists offer the best possible care for their patients. This requires not only a sound educational base but also a good source of current best evidence to support their treatment recommendations. To do it successfully, certain skills need to be obliviously acquired, being the intention of evidence-based dentistry the providing better information for the clinician, improved treatment for the patient, and consequently an increased standing of the profession.
The translation of research into practice assumes that clinically relevant evidence is available. Unfortunately, in light of the billions of dollars invested in dental research during the last five decades in Europe and the US, the dental research community has paid relatively little attention to clinical aspects of care. Consequently, and contrary to the situation in medicine, there are relatively few randomized controlled trials and other outcomes oriented studies in dentistry that have evaluated clinically relevant interventions. For example, there are no clinical trials that have compared the outcomes of different methods of caries diagnosis using relevant outcome measures. Also, no outcome studies are available for disease-based management of dental caries, periodontal diseases, or facial pain.
The evidence needed for evidence-based dentistry must include a broader range of outcomes, including those considered important by patients. For example, a classic definition of appropriateness indicates that treatment is deemed appropriate when the expected health benefit exceeds the expected negative consequences by a sufficiently wide margin that the treatment is worth doing.
In many countries, there has been increasing concern about the use of Evidence-Based Practice (EBP) in oral health care. The principles and methods of evidence based dentistry give dentists the opportunity to apply relevant research findings to the care of their patients. As has been mentioned Evidence-based oral health care includes the search for the best evidence, critical evaluation of the evidence, and integration of the evidence with the practitioner’s experience and expertise. Therefore, dental educators, dental students, and dental practitioners need to be aware of the uncertainties surrounding scientific evidence, the ways that the results of clinical studies are collected and analyzed, and the importance of unbiased research on which to base clinical decision making.
The need for valid and current information for answering everyday clinical questions is growing. Ironically, the time available to seek the answers seems to be shrinking.
Common barriers to implementation of evidence-based practice are resistance and criticism from colleagues, difficulty in changing current practice model, and lack of trust in evidence or research.
Patient-associated barriers: Patient needs and preferences may be affected by dental advertising, financial considerations, and access to online information, which may be of questionable quality. These requests at times conflict with accepted guideline recommendations; thus to accommodate such patient preferences, dentists may be unable to implement proven interventions. These influence of the media on patients create demands or beliefs which are in fact disadvantage on patients’ access to care.
Healthcare organization associated barriers: Some barriers are inherently part of the oral healthcare training and delivery system due to inappropriate continuing education and failure to connect with program to promote better quality of life. There is lack of incentives to participate in effective educational activities. First, although dental students are taught how to access and interpret scientific evidence in didactic courses, their knowledge may not be reinforced by supervisors in clinical settings. Second, dentists in solo or small practices are slow to adapt, in part, because they are relatively free of peer influence. This resistance to change is not limited to dentists; changes in treatments may require behavioural adaptations among staff as well. Third, although guidelines most likely to be used regularly focus on prevention, financial reimbursement does not promote preventive procedures. Fourth guideline developers sometimes present recommendations that may not be actionable due to the need for additional equipment, skill, or training.
Internal Barriers Faced by Clinicians: Given the rate of change in clinical dentistry and availability of continuing education courses, clinicians practice in the same fashion as they were taught. Due to obsolete knowledge and influence of opinion leaders along with beliefs and attitudes besides this there are also limitations of time and organization of the practice (for example, a lack of disease registers or mechanisms to monitor repeat prescribing). Though a more conservative and less profitable procedure may be evidence-based, clinicians still need to deal with the temptation of providing a more profitable procedure as many of the procedures and decisions are financially based.
External Barriers Faced by Clinicians: Due to lack of financial resources and defined practice populations. Failure to provide practitioners with access to appropriate information as these factors not under the clinician’s control; for example, necessary access to certain equipment or changes in facility design may be cost prohibitive, insufficient staff support, poor reimbursement, escalating practice operational costs, and increased liability impact practice of evidence-based dentistry.
Their findings suggested that educators should provide communication skills to aid decision making, address the technical dimensions of dentistry, promote lifelong learning, and close the gap between academics and general practitioners (dentists) in order to create mutual understanding.
Evidence based dentistry also does not mean clinicians abandon everything they learned in dental school. It does not force clinicians to go backwards to justify things the profession universally accepts. EBD therefore does not provide a “universal panacea” that dentists must follow, nor does it establish a standard of care.
Evidence-based dentistry does offer the opportunity for the practice of dentistry to enter a new era. Educators have an important role to play in providing communication skills to aid decision making, addressing the technical dimensions of dentistry, promoting lifelong learning, and closing the gap between academics and general dentists in order to create mutual understanding The ultimate goal would be assisting dental students in learning the skills to practice evidence-based dentistry so that they can provide their future patients with the best clinical evidence and judgment for optimal and cost-effective dental care. There is, therefore, a need to apprise current practitioners on the new method of thinking. Dentistry needs to make strides to keep pace with the prevailing paradigm of evidence-based care. There is a strong “need for the science behind our treatment decisions”.