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Evidence- Based Dentistry Julie Frantsve-Hawley, RDH, PhD Director, Research Institute and Center for Evidence-Based Dentistry American Dental Association Evidence Patients needs & preferences Clinical Expertise

Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

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Page 1: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

Evidence-

Based

Dentistry

Julie Frantsve-Hawley, RDH, PhD

Director, Research Institute and Center for Evidence-Based Dentistry

American Dental Association

Evidence

Patients needs &

preferences

Clinical Expertise

Page 2: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved

Then….

Page 3: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved

Now….

Page 4: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved

Information

Page 5: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved

Information Overload

Page 6: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved

Page 7: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved

Evidence-Based Dentistry

Evidence

Patients needs &

preferences

Clinical Expertise

Page 8: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved

Evidence-Based Dentistry

• Evidence-based dentistry (EBD) is 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.

The ADA Definition

Page 9: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved

Levels of Evidence

(IA) Systematic Review

(IB) 1+ RCT

(IIA) 1+ controlled study without randomization

(IIB) 1+ quasi-experimental study

(III) Non-experimental descriptive studies

(i.e. comparative, correlation, cohort and case-control studies)

(IV) expert committee reports or opinions or clinical experience of respected authorities

Page 10: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

What is an RCT?

Population

Intervention

Outcome

Control

Outcome

Root Canal Treatment

Randomized Controlled Trial

Page 11: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

Will using a parachute save lives?

People in Airplane

Jump with parachute

Survival

Jump w/o parachute

Survival

Page 12: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

Ask the question

Access the

evidence

Appraise the

evidence

Apply in practice

Assess the

outcome

Page 13: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

• Periodontal disease in

pregnancy is a risk factor

for preeclampsia. Shetty et

al. Acta Obstet Gynecol

Scand. 2010

May;89(5):718-21.

• Maternal periodontal

disease and risk of

preeclampsia: a case-

control study.

Lohsoonthorn et al. Am

J Hypertens. 2009

Apr;22(4):457-63. Epub

2009 Jan 22.

• CONCLUSIONS: This

study provides no

convincing evidence that

periodontal disease is

associated with

preeclampsia risk among

Thai women.

Page 14: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

Systematic Review

Study

Study Study

Page 15: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

Systematic Review

Traditional Review

Page 16: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved Egger at al., 2001

Data Analysis

• Qualitative Analysis

– Discussion of individual designs and outcomes

– If study designs are so different that data cannot be combined

• Quantitative Analysis

– Preferred

– Meta-Analysis (Forest Plot)

– Publication bias (Funnel Plot)

– Heterogeneity

Page 17: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved

Thrombolytic Therapy

13901

Page 18: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious
Page 19: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious
Page 20: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved

Meta-analysis is a quantitative approach to

evaluate multiple studies

• Increase sample size

– Evaluating multiple small studies

• When studies disagree

– Magnitude

– Direction

• Enhance scientific credibility

• Using statistical methods to combine the results of different studies

Page 21: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious
Page 22: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious
Page 23: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious
Page 24: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

Sources of Pre-appraised Evidence

Summaries of Systematic Reviews

Guidelines/recommendations

Page 25: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

• A short (1-2 page) summary of a systematic review

• Critical appraisal

• Clinical Applications (some)

• Time saving

• Usually a single author, but peer reviewed

Summaries of

Systematic Reviews

Page 26: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

• Recommendation by an expert panel

• Based on the best evidence available

• Multiple systematic reviews and/or clinical studies

• Critical appraisal

• Implications for practice

Guidelines/ Recommendations

Page 27: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

Benefits of Using Pre-Appraised Evidence

• Fast, simple, efficient

• combines the search and appraisal

processes

• Utilizes appraisals completed by “experts”

Page 28: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

• Where can I find summaries? – EBD.ADA.org

– JADA

– Database of Abstracts of Reviews of Effects (DARE)

– Bandolier

– Evidence-based Dentistry (Nature Publishing Group)

– The Journal of Evidence-based Dental Practice (Elsevier)

• Where can I find Guidelines? – EBD.ADA.org

– Guidelines.gov

– National Institute for Health and Clinical Excellence (NICE)

– Scottish Intercollegiate Guidelines Network (SIGN)

Page 29: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

ebd.ada.org

Page 30: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

• Over 1700 systematic reviews

• Each is 6-200 pages long

Page 31: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

•600-800 words

•Summarizes a systematic reviews

•Clinical implications

Critical Summaries

Page 32: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved

Page 33: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious
Page 34: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious
Page 35: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved

ebd.ada.org

Page 36: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved

Levels of Evidence

(IA) Systematic Review

(IB) 1+ RCT

(IIA) 1+ controlled study without randomization

(IIB) 1+ quasi-experimental study

(III) Non-experimental descriptive studies

(i.e. comparative, correlation, cohort and case-control studies)

(IV) expert committee reports or opinions or clinical experience of respected authorities

Page 37: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

© 2011 American Dental Association, All Rights Reserved

Strength of Recommendation

A = Category I Evidence

B = Category II Evidence or

extrapolated from category I evidence

C = Category III Evidence

or extrapolated from category I or II evidence

D = Category IV Evidence

or extrapolated from category I, II, or III evidence

Page 38: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious
Page 39: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

Strength of Recommendation

Page 40: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

Treatment Decisions

Page 41: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious
Page 42: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious
Page 43: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious
Page 44: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

mobile.ebd.ada.org

Page 45: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

Supported by a grant from the NLM and the NIDCR

(Grant Number G08 LM008956)

Page 46: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious
Page 47: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

To recruit practitioners to

be local community

leaders helping their

peers implement EBD

Page 48: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious
Page 49: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

Comments • “Thank you for the privilege and honor to

participate in this meeting, one of the best I’ve attended and one that I believe will produce a lot of fruit in academia, education, research, and practice.”

• “I really enjoyed this experience and initiation into being a champion for EBD. There are high expectations for me to disseminate this information in my dental school, component societies and study clubs. I feel this has been a good preparation for me to go home and start working on this.”

• “Excellent program. The passion in the presenters has to be contagious!”

Page 50: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

September 19-23, 2011

"Perhaps the best course of my dental career.“ "Highly recommend the program . . . a great means of extending the practice of EBD."

Page 51: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

• Write Critical Summaries

for EBD Web site

• Attend 2 day workshop

• Professional development

Page 52: Evidence- Evidence Based Dentistry - NNOHA · 2013. 9. 17. · Evidence-Based Dentistry •Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious

Thank you

ebd.ada.org

mobile.ebd.ada.org