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Introduction to Evidence Based

Dentistry (BRC 101)

Presented by :

Ahmed Kotb

Assistant lecturer –Prosthodontic Department

Member of Centre for Evidence Based

Dentistry– Cairo University

Welcome to the Evidence

World!

But what do you actually

know about the word

EVIDENCE?

So..........

You didn’t start to

believe until you

started to SEE

Evidence!

And from here

starts our

JOURNEY!!!

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Course objectives

1. Get acquainted with the term Evidence Based

Dentistry (EBD)

2. Apply the EBD process

3. Be capable of formulating a well structured

question from different clinical situations

4. To formulate a statement of the problem

So let’s start,

Ready ?

A closer look on

Evidence Based Dentistry

The What, Why & When

issue?

1.The When Issue? In 1990s Gordon Guyatt

(a professor of epidemiology,

biostatistics, and medicine)

first introduced what was called as

Evidence- Based Medicine

As a working group at McMaster

University in Ontario, Canada

David Sackett former professor of

medicine at McMaster University

is regarded by many as

“The Father Of Evidence Based

Medicine.”

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It started in 1990 when

Gordon Guyatt (a professor of epidemiology,

biostatistics, and medicine)

at McMaster University,

took over as a

Director of the

Internal Medicine

Residency Program

The first name was

“Scientific Medicine.”

The next name was

“Evidence Based Medicine.”

In Faculty of Oral and

Dental Medicine

When did the evidence start ?

Started by

In 2009

Dr. Ahmed Elkhadem

Evidence Based Dentistry

Committee

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2.The Why issue?

أغرب المعتقدات الطبة الت سادت عبر التارخ عادل فؤاد

تحك المصادر عن أن األطباء لدهم خلفة تارخة طولة من

عدم معرفة ما هو األفضل لمرضاهم، والتارخ ملء

.بالممارسات الطبة غر المعقولة

دماء الخفاش تعالج العمى

المدارة ذات المستنقعات حول نهر النل جعلت من البئة

قدماء المصرن عدوى العن أمرا شائعا، وهذا ما جعل

هو تقطر خترعون أدوة لتفادها، وكان أحد تلك الحلول

.ف أعنهمدماء خفاش

المنطق وراء هذه الطرقة العالجة هو اعتقاد المصرن

القدماء بأنه إذا كانت الخفافش تطر باللل، فمن المؤكد أن

وربما تحتوي دماؤهم إذا على لدها حاسة بصر قوة،

بالطبع، فإننا نعلم اآلن . خصائص سحرة للحفاظ على الرؤة

أن الخفافش سئة الرؤة، وطرانهم ف الظالم تم بمساعدة

.الصدى لتحدد المواقع

المالرا تعالج الزهري

قتل حوال -المرض المنتقل عن طرق البعوض-المالرا

.عامثالثة ملون شخص كل

اكتشف أحد األطباء أن للمالرا أثرا 1920لكن، ف عام

ا جدا، وهو ، المرض األقل فتكا مقارنة قتل الزهريجانب

إذا أثر على % 100بالمالرا، لكنه ؤدي إلى الوفاة بنسبة

.الدماغ

كانت الفكرة وراء هذا االعتقاد أن حمى المالرا تصل إلى

. درجات حرارة عالة تكف لقتل البكترا المسببة للزهري

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Cont. Why do we need

evidence? To guide in decision-making in dentistry

An approach to apply and examine

relevant scientific data and relate it to

the oral health

Allows dentists to stay up to date on

recent procedures and technologies

Improve the received treatment to the

patients

To bridge the gap between the

Research

and

Policy Making Organizations

How are universities

ranked?

According to:

1. Academic reputation (40%)

2. Employer reputation (10%)

3. Student-to-faculty ratio (20%)

4. Citations per faculty (20%)

5. International faculty ratio (5%) &

international student ratio (5%)

Academic reputation

40%

Employer reputation

10%

Student-to-faculty ratio

20%

Citations per faculty

20%

International faculty ratio

5%

International student ratio

5%

QS World University Rankings®

http://www.topuniversities.com/qs-world-university-rankings/methodology

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Why do we need EBD in

our Faculty? Plenty of researches are done in our faculty, but

how many are published?

Do you know the rating of Cairo University

universally?

Evidence based dentistry-Cairo University

(CEBD) aims to develop, teach and promote

Evidence-Based Dentistry through workshops

and EBD tools so that all dental professionals

can maintain the highest standards of dentistry.

3. The What Issue ?

The American Dental

Association defined evidence-

based dentistry as

“.......... an approach to

Oral Health Care

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.”

ADA Policy Statement on Evidence-based Dentistry. http://www.ada.org/en/about-the-

ada/ada-positions-policies-and-statements/policy-on-evidence-based-dentistry Accessed 17

Aug 2010

In other words

Best Available Evidence

Patient’s Needs And Preferences

Clinical Expertise

This Evidence Based Dentistry

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Facing clinical

situations

What shall you do in the

following case?

Consider the EBD while you

think!

Group work

activity ( 2mins

)

Then

How to practice

EBD in your

daily practice?

You Need To

Apply Five Skills:

The 5

(A)s

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Steps of EBD

1. Ask

2. Acquire

3. Appraise

4. Apply

5. Assess

1. Ask Your first step in EBD is to start asking

questions!

Think inside, outside and around the box to

reach a focused, properly-formulated,

answerable question.

Need examples!!!!!

Isaac Newton and the

Apple Some Tips #1 Ask yourself is the aim you are

searching for sensible?

#2 Is it worth to the management of

your patient?

#3 Can I really apply it to my practice?

#4 Will this question/search have an

impact on my practice?

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Scenario 2

An old lady with arthritis in her hands

presented to your clinic and said that

she read an article about tooth

brushing . She asked you if she

should shift to an electric tooth brush

rather than the conventional manual

one? What would you tell her?

Think about: Available Options ?

Which is more

effective?

Is there any better

than the other?

How to Formulate a

properly focused

question?

It should include what we call it

a PICO(T) elements :

P stands for

Problem\Population\ Patient

I stands for Intervention

C stands for comparator\

Control

O stands for Outcome

T stands for Time

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Let’s try an example Third Scenario :

A patient presented to your clinic

with sever pain in her lower left first

molar, after examining the patient

you diagnosed the case as acute

pulpitis with periapical periodontitis.

You explained the situation to your

patient and recommended a root

canal treatment. After finishing your

first visit your patient asked you if

you will prescribe to her an antibiotic

or not because she is afraid of pain

and doesn’t want to get hurt ?

Formulate a PICO and a well-structured

answerable question.

P : Patient with acute

pulpitis with periapical

periodontitis

I: Prescribing an

antibiotic

C: Placebo

O: Reduction of

postoperative pain

And the question is:

Will the use of postoperative

antibiotic in comparison to

placebo, reduce pain in patients

with acute pulpitis with periapical

periodontitis ?

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Continued Tips #5 Try to make the

outcome a patient

relevant one

#6 The outcome should

be measurable using a

tool or device

#7 Try to identify the

measuring unit

4th Scenario This young lady heard that you

are a wonderful implantologist.

She had a awful accident that

made the crowns of the anterior

teeth lose. She is really unhappy

and asks if she could remove

these crowns and place

implants immediately or shall

she wait for a healing period?

She is really concerned will

these implants survive or not? Try to formulate a PICO format and a

properly focused question.

1. P: patients with fractured

anterior teeth indicated for

extraction

2. I: immediate implants

3. C: delayed implants

4. O: implant loss

5. The properly formulated

question is?

Group Activity (2 min)

Scenario 2 Alaa’s mother presented to your

fancy clinic, and during your

conversation with her she asked

weather or not to give her

daughter commercially available

fluoride supplements.

Alaa is 4 years old and adores

candy making her teeth very liable

to decay.

Please formulate PICO elements and

a well structured question.

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1. P: children liable to tooth decay

2. I: fluoride containing tooth

paste

3. C: conventional tooth paste

4. O: DMF score

5. The properly formulated

question is?

Steps of EBD

1. Ask ✔

2. Acquire

3. Appraise

4. Apply

5. Assess

2. Acquire Nowadays you could acquire

published articles from:

Online search of medical and

dental journals using electronic

databases such as (PubMed,

EMbase, Cochrane Library)

Reference list

Hand searching of journals

Conference proceedings

And so on......

Articles available in

literature may be delivered

from various types of

studies as:

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Types of Studies

Interventional studies

Observational studies

Reviews

Steps of EBD

1. Ask ✔

2. Acquire ✔

3. Appraise

4. Apply

5. Assess

3. Appraise

It is the most time consuming step and most difficult aspect of reading research

paper.

Why?

Because it is important to be able to interpret results your self to evaluate the

evidence on you own.

What do some people do

while reading a scientific

article ? They rely directly into the

conclusions made by the

authors without having a

sensible look at the results

upon which the

conclusions were built.

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So Take care

Sometimes authors may have a natural

desire to emphasize positive results of

their findings and minimize potential

negatives obtained from their studies.

So take a look on the

results Try to assess the evidence you came out

with by asking yourself:

1. Are the results of the study valid? Can

you rely on them?

2. Are these valid results of any clinical

importance?

3. Are these valid important result of that

specific study applicable to my patient or

not?

Types of

outcomes!!! True end point and

surrogate measure!

A

B

True end point

A clinical endpoint is a sign or symptom that

presents the target outcome in a clinical trial

In other words: A clinically meaningful endpoint

measures directly how a patient

Feels Function Survive

s

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But in reality, finding a clinical

representable clinical endpoint

is not applicable in some

studies

The National Institutes of

Health (USA) defines surrogate

endpoint as "a biomarker

intended to substitute for a

clinical endpoint".[1][2] 1.Controlled Clinical Trials 22:485–502 (2001) 2. Cohn JN (2004). "Introduction to Surrogate Markers". Circulation (American Heart Association) 109 (25 Suppl 1): IV20–1. doi:10.1161/01.CIR.0000133441.05780.1d. PMID 15226247.

Surrogate measure Following: Surrogate

measure A surrogate measure of a clinical trial is

a laboratory measurement or a physical

sign used to substitute for a clinically

meaningful endpoint that measures

directly how a patient

Feels Function Survive

s

In clinical trials, a surrogate measure

(or marker) is a measure of effect of a

specific treatment that may correlate

with a real clinical endpoint

BUT does not necessarily have a

guaranteed relationship.

Then when do we use

surrogate measures? Surrogate measures are used when the

primary endpoint is undesired (e.g.,

death), or when the number of events

is very small, thus making it impractical

to conduct a clinical trial to gather a

statistically significant number of

endpoints

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Group working

Define which is a surrogate

measure and which is a true

end point?

Lymphocyte count Plaque index

Tooth loss Gingival swellings

Pocket depth Bacterial count on the fitting surface of a denture

Postoperative pain

True end point

1. Tooth loss 2. Gingival swellings 3. Postoperative pain

Surrogate measure

1. Lymphocyte count 2. Plaque index 3. Pocket depth 4. Bacterial count on the

fitting surface of a denture

Steps of EBD

1. Ask ✔

2. Acquire ✔

3. Appraise ✔

4. Apply

5. Assess

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4. Apply (Act on the

evidence)

Now try to relate the

obtained evidence in

relation to the question that

first urged you to undertake

that specific search

Apply the information you

got to your patient together

with your clinical expertise

and patient preference to

deliver optimal treatment .

Steps of EBD

1. Ask ✔

2. Acquire ✔

3. Appraise ✔

4. Apply ✔

5. Assess

5. Assess

Last but not least you should assess

(evaluate) what you have applied to your

patient

Today’s final ILO

You should be familiar with the

term

“Statement of the problem”

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A problem statement is a brief piece of

writing that usually comes at the

beginning of a report or proposal to

explain the problem or issue the

document is addressing to the reader.

1. Outline the basic facts of the

problem,

2. Explain why the problem

matters and

3. Pinpoint a Solution as quickly

and directly as possible.

In general, a problem statement

will:

Some tips to write a

statement of a problem: 1. Explain your problem.

In the words of the inventor Charles

Kettering, "A problem well-stated is a problem

half-solved.”

2. Back up your claims with evidence

3. Propose a solution

4. Explain the benefits of the solution

5. Conclude by summarizing the problem and

solution

http://www.wikihow.com/Write-a-Problem-Statement

Let’s apply on the example

of delayed and immediate

loading!

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So to cut it short

It is your responsibility as a dentist and/or

researcher to elicit and decide how to

optimally use the information gathered from

Patient

s

Literature Colleagu

es

Experts

in field

And this could be achieved through using

a systematic approach when practicing

evidence based dentistry to help you

reach a clear decision when treating your

patient to enhance your patient safety and

well being!

Today’s learning outcomes

Getting acquainted with EBD

Applying the process of EBD

True end point & surrogate measure

Know how to write a “Statement of the problem”

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E-mail address : ahmed.kotb@dentistry.cu.edu.eg

If you wish you could contact me @