Overview of EBD

DENTISTRY is the science and art of preventing, diagnosing and treating diseases, injuries, developmental and acquired defects of the teeth, joints, oral cavity and associated structures. As science and technology, information evolves and becomes more readily available, dental professionals with hectic schedules face the challenge to obtain, understand, evaluate and integrate this new information into daily clinical practice. It can be difficult to tell what works and what doesn't. Dentists are also responsible for avoiding techniques and technologies that have been shown to be ineffective, unsafe and unethical.

Dental practice should be based on a commitment to sound science and an ethical obligation to protect patient health. To address these challenges, dentistry and dentists fortunately, have a system in place - an evidence-based approach to help determine what works best: better known as evidence-based dentistry, or EBD and is endorsed by Indian Dental Association (IDA).

The association advocates that dental professionals must interpret and apply the best available evidence in everyday practice as they have a responsibility to ensure that the basis for informed consent and treatment of patients reflects the best available evidence, applied in accordance with the clinical expertise of the dentist and the wishes of the patient. We also recognize that there is insufficient evidence at present to guide all aspects of oral healthcare, and that gaps in knowledge exist.

What is Evidence Based Dentistry?

EBD or Evidence Based Dentistry is an approach which combines various factors like current scientific knowledge, patient needs and experience of dental surgeon to make better treatment plan which are in best interest of the patient. These interventions are scientific, safe, efficient and cost effective based on the best clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs, values and circumstances.

We turn towards EBD to consider the best way to serve our patients with factual information and scientifically informed treatment regimens. EBD places value not only on clinical evidence, but also on listening to the patient's history and needs to help inform a treatment decision. EBD is a conscious process to identify the best and most up-to-date research that addresses a patient’s clinical problem keeping in mind the patient’s values, aspirations and preferences, combined with the practitioner’s own clinical proficiency and judgment. For instance, you can use study results to wean patients off oil pulling, show them the safety of amalgam fillings, or to help choose fluoride options to prevent and manage dental caries treat gingival inflammation.

Evidence-based practice is a process of lifelong, self-directed learning in which providing health care creates the need for important information about diagnosis, prognosis, treatment, and other clinical and health care issues. It can be defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients”.

Definition

EBD is an approach to oral healthcare that requires the judicious integration of: Systematic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical condition and history, with the dentist's clinical expertise, and the patient's treatment needs and preferences.

Available evidence will vary depending on the particular healthcare issue being addressed and the urgency demanded, with some clinical areas having little or no existing evidence base. Rapid reviews and classic systematic reviews are the foundations of healthcare decision-making, irrespective of whether they are pre-existent or developed specifically to inform a new policy or clinical practice guideline.

Goals of EBD

The goal of practicing EBD is to help dentists provide the best possible care for their patients in day to day clinical practice.  Evidence-based dentistry has two main goals: best evidence/research, and the transfer of this in practical use. This involves a systematic five basic phases:

1. Creating a structured question from a clinical problem.
2. Searching for research evidence from scientific literature.
3. Critically appraising the evidence so as to make a judgment on its validity.
4. Applying the evidence to clinical practice using judgment and an assessment of one’s own clinical proficiency and incorporating patient’s values, aspirations and preferences.
5. Reflection: Evaluating the process.

Steps in Practicing Evidence Based Dentistry

In traditional dental care, emphasis is placed on the dentist’s accumulated knowledge and experience, adherence to accepted standards, and the opinion of experts and peers. Evidence-based practice, in contrast, places a premium on using current evidence to solve clinical questions. It presupposes two things about the dentist: one, that he or she is conversant with the current literature, and two, that he or she is competent to evaluate it. The first requires that dentists read the scientific literature, particularly in clinical research, and the second requires that they can critically appraise the literature.

The five steps or "5 A's" in clinical decision making that the evidence-based dentist must be involved in are the following:

Ask: Convert clinical information into an answerable question with PICO (population / intervention / comparison / outcome)

Acquire: Find the best evidence using electronic database

Appraise: Critically appraise the evidence found for validity and importance

Apply: Integrate evidence into practice with the patient’s perceived needs

Assess: Evaluate their own performance in the clinical setting.

History of Evidence based movement

The evidence-based movement first took hold in the medical field. Formally introduced in the 1990s by David Sackett and Gordon Guyatt of McMaster University, evidence-based medicine outlines a methodical way to incorporate the best available evidence into the decision making process for clinical practice and patient treatments.

These principles ensure that decisions regarding patient care are not only based on experience and expertise, but on current medical research. EBD’s incorporation into dentistry is progressing quickly. Dental schools are integrating the principles into their curriculum and resources are becoming more widely available. Various countries have established centres for evidence-based dentistry (most notably the Centre for Evidence-Based Dentistry in the United Kingdom and DSM-Forsyth Center for Evidence-Based Dentistry in the United States) and the Cochrane Collaboration has an Oral Health Group.

In addition, there are journals focusing on EBD practice which offer reviews of the current literature on dental-related topics.

Need for Evidence-based Dentistry

The world in which dental professionals practice dentistry is changing at an astonishing rate due to two phenomena: the information explosion and the consumer movement. There unfortunately a gap is seen between commonly followed clinical practice and the scientific evidence from research with new innovations in the fields of materials and equipment, the understanding and acceptance of new scientific theories are updating at a very fast pace.

The nature of the relationship between the patient and the clinician has changed; patients are now partners in the decision-making process which have been fortified by the extraordinary advancement in internet.  Traditionally the primary sources of information were teachers, textbooks and, occasionally, journal articles, but the methods of delivery of information have changed over time. There is an increasing trend toward web-based courses and instruction, as well as computer-based interactive learning. To provide the best known treatment to patients seeking oral healthcare the practice of evidence-based dentistry has become inevitable.

Why EBD?

• Information Overloaded
• Resources Finite
• Focus is on quality and consistency of treatment
• Plus avoid unnecessary treatment
• Questioning attitude of traditional beliefs
• Lifelong learning
• Patient empowerment

Following the practice of EBD not only benefits the patient but also the clinician, as they get updated with the latest scientific evidence which promotes self-growth of the clinician along with providing best available treatment to the patient.

Awareness of EBD among dentists

Evidence-based practice (EBP) is an approach that promotes critical thinking through the integration of patient values, best available evidence and clinical expertise. Today evidence based principles are widely being incorporated in most health-care fields as well as non-health professions. Academic institutions, human resources library studies are using evidence-based principles to guide their day-to-day decisions. The goal of EBP is to provide patients with up to date treatment that research has shown to be safe effective and efficient and is to continuously improve patient care based on new research developments and also to provide high quality clinically orientated and relevant research which provides better information for the clinician and improved treatment for the patient.

The American Dental Association defined it as “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, with the dentist's clinical expertise and the patients treatment needs and preferences.” In dentistry, EBP can be defined as the practice of dentistry that integrates the best available evidence with clinical experience and patient preferences in making clinical decisions. Evidence-based dentistry (EBD) closes the gap between clinical research and real world practice and provide dentists with powerful tools to interpret and apply research findings.

EBP is becoming increasingly common in dentistry. The use of an evidence-based approach helps clinicians who want to stay abreast of changes in their areas of health care by assisting them with the selection of relevant articles and will aid them to efficiently extract and apply the information. Computerized medical databases such as Medline, Google scholar have made easier the access to information. Today other strategies are available to help dentist keep abreast with the current information like journals which are available online, web-based continuing education programs. Books audio and videotapes; professional and university continuing education meetings give the possibility to interact with new evidence.

Although this concept of EBP was born two decades ago its arrival is new in India and is in its developmental stages especially in dentistry. There are very few studies reported from India with regard to awareness of EBD to assess the knowledge, attitude, and practice and factors affecting dentists.

EBD Global Scenario

The evidence is available from a wide range of sources. To keep up with recent advances in the field of dentistry is a daunting task for any practitioner. Each of them has advantages and disadvantages. Whatever the sources, if professionals are to be evidence-based, they should remember that the evidence found should be appraised critically before applying it to the patient

1. Colleagues: The first option for most as most healthcare professionals remember learning to carry out various procedures from senior colleagues or from a peer who has had experience of the procedure.
2. Books: A good source of comprehensively established information in which the information is laid out in well-defined sections with an index of terms making them useful as quick references for basic background information.
3. Journals: One method of keeping track of the latest advances in the field of interest as they have more up-to-date information than books because articles are generally published within months of submission.
4. Internet: A revolutionized way through which most people work as they can access information from any number of sources electronically.
5. Electronic searching: Tracking down literature through electronic searching is an art which can be learned through practice but at times even the experienced researchers do miss relevant literature; so a thorough knowledge and understanding of the rules for effective searching through databases should be acquired by one.  

• MEDLINE: This is the US National Library of Medicine’s (NLM) premier bibliographic database that contains over 11 million references to journal articles and can be accessed free of charge.
• PubMed system: Developed by the National Library of Medicine, located at the National Institutes of Health (NIH), and through the National Centre for Biotechnology Information (NCBI), serves as an search tool for accessing dental, medical, and biomedical literature citations and provides links to full-text journals at the web sites of participating publishers.
• Cochrane Collaboration: An international non-profit, independent organization dedicated to making up-to-date, accurate information about the effects of healthcare readily available worldwide. It produces and disseminates systematic reviews of healthcare interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions.
• Search Engines: Helps in selective retrieval of information from countless websites, which otherwise be an almost impossible task.
• Meta-search engines: Saves time as these searches multiple databases instead of multiple websites. Though the search results are organized, the quality of the searches is still dependent on the quality of the databases.
  1. Google (www.google.com): Largest search engine available on the web which evaluates sites according a system called Page Ranking.
  2. MetaCrawler (www.metacrawler.com): One of the earliest meta-search engines which search the major search engines including Google, Yahoo!, AltaVista, Ask Jeeves, LookSmart, Overture and FindWhat. The search results are integrated and ranked according to relevance with summaries for each.
  3. BIOME (biome.ac.uk)Created by a team of information specialists and subject experts based at the University of Nottingham Greenfield Medical Library. This is a collection of subject gateways that provides access to resources in the health and life sciences.
  4. SUMSearch (sumsearch.uthscsa.edu): Searches the internet much like a meta-search engine but also does contingency searches; i.e. that if there are too many hits from a particular site, an additional four searches are done until it finds an optimum number of hits.
  5. EviDents (medinformatics.uthscsa.edu/EviDents): A straightforward program with a series of boxes to help focus search.
  6. Centre for Evidence-based Dentistry website (www.cebd.org): Developed to promote evidence-based dentistry (EBD) and to provide its users who have an interest in the subject with a comprehensive range of high-quality resources to enable them to understand and practice evidence-based dentistry.
  7. TRIP Database: Answers clinical question‟s using the principles of evidence-based medicine and identifies them in a variety of ways with regular systematic searches of the internet and regular collaboration with clinical answering services.

Indian Dental Association Stand on EBD

IDA supports and recognizes the following:

• Incorporating the principles of EBD in the dental curriculum and in continuing professional education.
• Adopting the principles of EBD to guide development of clinical practice guidelines and policy will provide the means for making clinical decisions taking into consideration take into consideration beliefs, values, patient preferences and the cultural context of the local environment. EBD approach will help dentists interpret and apply the best available evidence in everyday practice. Treatment recommendations should be determined by the dentist for each patient individually.
• Training dental researchers for answering the questions and undertaking the research to fill gaps in the knowledge base and to validate modes of treatment.
• Ensuring that governments, industry, research foundations, universities and the profession must help ensure that sufficient funds and research workforce are available to support EBD.  All parties with an interest in patient care must take responsibility for identifying relevant questions to be addressed by EBD. The practicing profession, researchers, and the community must play key roles in identifying issues.
• The EBD process must not be used to interfere in the dentist/patient relationship, nor is it to be used as a cost-containment tool by funding agencies.

IDA's Center for EBD

IDA Center for Evidence-Based Dentistry helps dentists improve patient care through informed decision-making. Evidence-based dentistry (EBD) is about providing dentists with the best evidence so they can make informed treatment decisions and improve the quality of dental care.

It’s an approach to making clinical decisions that integrates three important aspects of clinical practice:

1. A dentist’s expertise; 
2. A patient’s needs and preferences; and
3. The best available scientific evidence.

Vision
To lead in the promotion of oral health by disseminating the best available scientific information and helping practitioners implement it into clinical practice.

Mission
IDA's Center for EBD assists practitioners and improves the oral health of the public by:
appraising and disseminating the best available scientific evidence on oral health care; and
helping practitioners understand and apply the best available evidence in their clinical decision-making. The ability to search for, discriminate, evaluate, and use information is the most important skill that can be learned as a professional.
Dental schools are expected to develop specific core competencies that focus on the needs for graduates to become critical thinkers, problem solvers and consumers of current research findings to enable them to become lifelong learners. These skills parallel those of evidence based practice by teaching students to find, evaluate and incorporate current evidence into their decision making.