Improving Biomedical Literature Search Skills within Evidence-Based Dentistry
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EVIDENCE BASEDDENTISTRY
Presented byMd. Zavir khan
Under the Supervision of;Prof.S H Hashmi
Co-Supervised by;
Prof Geeta Rajpoot
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Introduction
Dentistry is both an art &science
It is a science because ourfundamental understandings orbuilding blocks of knowledge arefounded on the scientific
process of research.Thisincludes basic,applied & clinicalresearch.
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It is an art in that it draws on
experience & personalobservation,because science cantaccount for the complexity of all
variables in each situation.the synthesisof scientific understanding & clinicalobservation provides the basis formeaningful dental care.
Evidence based dentistry is an attemptto synthesize both these aspects ofdentistry.
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WHAT IS EVIDENCE-BASED
DENTISTRY? The foundation for Evidence
based practise was laid byDavidSackett
Who has defined it as integratingindividual clinical expertise with
the best available externalclinical evidence from systematicresearch.
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It allows dentists, as wellas academic researchers,
to keep abreast of newdevelopments and to makedecisions that should
improve their clinicalpractice.
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ADA DEFINATION OF EBD
An approach to oral health care thatrequires the judicious integration of:
systematic assessments of clinicallyrelevant scientific evidence, relatingto the patients oral and medicalcondition and history, together with
the dentists clinical expertise andthe patients treatment needs andpreferences.
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SOME IMPORTANT TERMS
Randomized controlled trial:
RCTs are quantitative, comparative,controlled experiments in whichinvestigators study two or moreinterventions in a series of individualswho receive them in random order.
The RCT is one of the simplest andmost powerful tools in clinical research
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The principal of evidencebased dentistry are finding thebest information quickly when
it is needed,assessing itsquality and deciding whether itis relevent
Will help practitioner to useresearch evidence in making
everyday clinical decisions.3/17/2012 8
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META ANALYSIS : In statistics, a meta-analysis
combines the results of severalstudies that address a set ofrelated research hypotheses.
Meta-analyses are often, but
not always, importantcomponents of a systematicreviewprocedure
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http://en.wikipedia.org/wiki/Statisticshttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Statistics -
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Systematic review :
is a literature review focused on asingle question that tries toidentify, appraise, select andsynthesize all high quality researchevidence relevant to that question.
Systematic reviews of high-qualityrandomized controlled trials are
crucial to evidence-based medicine.3/17/2012 10
http://en.wikipedia.org/wiki/Literature_reviewhttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Literature_review -
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Cochrane Library : is a collection of databases in medicine
and other healthcare specialties providedby the Cochrane Collaboration and otherorganisations.
At its core is the collection of CochraneReviews, a database of systematic reviewsand meta-analyses which summarize andinterpret the results of medical research.
The Cochrane Library aims to make theresults of well-conducted controlled trialsreadily available and is a key resource inevidence-based medicine
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http://en.wikipedia.org/wiki/Health_carehttp://en.wikipedia.org/wiki/Health_carehttp://en.wikipedia.org/wiki/Databasehttp://en.wikipedia.org/wiki/Medicinehttp://en.wikipedia.org/wiki/Cochrane_Collaborationhttp://en.wikipedia.org/wiki/Cochrane_Collaborationhttp://en.wikipedia.org/wiki/Cochrane_Collaborationhttp://en.wikipedia.org/wiki/Cochrane_Collaborationhttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Clinical_trialhttp://en.wikipedia.org/wiki/Clinical_trialhttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Evidence-based_medicinehttp://en.wikipedia.org/wiki/Clinical_trialhttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Meta-analysishttp://en.wikipedia.org/wiki/Systematic_reviewhttp://en.wikipedia.org/wiki/Cochrane_Collaborationhttp://en.wikipedia.org/wiki/Health_carehttp://en.wikipedia.org/wiki/Medicinehttp://en.wikipedia.org/wiki/Database -
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CONTD..The Cochrane Library consists of the following
databases: The Cochrane Database of Systematic Reviews(Cochrane Reviews)
The Database of Abstracts of Reviews of Effects(DARE)
The Cochrane Central Register of Controlled Trials(CENTRAL)
The Cochrane Database of Methodology Reviews(Methodology Reviews)
The Cochrane Methodology Register (MethodologyRegister) Health Technology Assessment Database (HTA) NHS Economic Evaluation Database (NHS EED)
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WHY DO WE NEED EVIDENCE-BASED
DENTISTRY?
to improve the quality of health care
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CONTD
Demonstrate best use of limitedresources
Stay up to date
Medical information changesconstantly
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How to practice?
Identify the clinical problem
Formulate clear question
Clarify the relevant problem
Search for evidence
Ignore irrelevant information; interpret the
relevant evidence
Decide in appropriate action based on best evidenceavailable
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scenario Acute ulcerative gingivitis can be treated
with the antibiotic metronidazole. Why isit that not every patient givenmetronidazole recovers from the disease?Why do some untreated patients recover?
Given this, how can we say thatmetronidazole is an effective treatment?
the above example illustrates that people
are naturally variable in their responses toexposures or treatments. Different peoplerespond to the same exposure or sametreatment, in different ways.
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Clinical research allows us tomake decisions about causes of
and treatments for disease,while allowing for the naturaldifferences between people.
Evidence-based dentistry isfounded on clinical research.
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5 As
1. Asking answerable questions (Asking)
2.
Searching for the best evidence (Acquiring)
3. Critically appraising the evidence (Appraising)
4. Applying the evidence (Applying)
5. Evaluating the outcome (Assessing)
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Asking answerable questions
A prudent question is one half of
wisdom - Francis Bacon
Turning the clinical problems into
a well-built clinical question is a
key skill of evidence-based
practice.
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Pico analysis
P:Patient (or Problem)
I:Intervention (or Cause,
Prognosis) C:Comparison (or Control)
O: Outcome(s)
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scenario
for an arthritic patient does
using electric toothbrush
provide more effective oralhygiene maintenance than by
using manual toothbrush??
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P:(problem)
arthritic patient
I:(intervention)
electric toothbrush
C:(comparison)manual toothbrush
O:(outcome)
oral hygieneCommonly referred to as PICO.
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Finding evidence
Traditional sources ofinformation
Modern sources- electronicdatabases. The most widely
available database is Medlinewhich can be accessed via thePub Med interface.
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All clinical research studies areencompassed under the broadheading of epidemiologic
studies. These studies can be further
subdevided Descriptive ,
Analytical & interventionalstudies
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A new type of studies hasemerged after the advent ofEB research I.E. integrative
studies Integrative studies include
Systematic reviews & Metaanalysis.
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The quality of various research designs
can be placed in a research designhierarchy. Position of each research design within
the hierarchy is a function of thestrengths & weakness of featureswithin each design.
The higher the study design ranks in
the research hierarchy,the better thestudy design minimizes bias &distributes random variation equallybetween the study groups.
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Sources of evidence
Sources of evidence
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Levels of evidence
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Drilling for the Best
InformationCochrane Library
Usefu
lness
Clinical Evidence
Clinical Inquiries
Specialty-specific
journals
ACP Journal Club
Textbooks, Up-to-
Date, 5-MinuteClinical Consult
Journals/
Medline
PubMed
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Sources of Systematic Reviews
Cochrane Collaboration (www.cochrane.org)
International Organization that develops and maintainssystematic reviews
Created in 1992 by the British National Health Service
Cochrane Library (electronic database of trials andsystematic reviews)
Cochrane Oral Health Group, University of Manchester
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Supplement of the British Dental Journal
Central Resource for EBD relevant issues andarticles
Aimed at general dental practitioners
http://www.nature.com/ebd/index.html
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Sources of Systematic Reviews
The Journal of Evidence-BasedDental Practice
original articles reviews of articles on the results
and outcomes of clinical procedures and treatment http://www.elsevier.com
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Other Sources of Information
National Guideline Clearinghouse: www.guideline.gov
Comprehensive source for guidelines and materials Summary of guidelines, side by side comparisons Standard set of guideline attributes Type of evidence supporting the recommendations
U. S. Preventive Services Task Force www.preventiveservices.ahrq.gov
Recommendations based on reviews of the evidenceof effectiveness of clinical preventive services
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Appraising the evidence
The important thing is not to stop
questioning. Curiosity has its own
reason for existing AlbertEinstein
Once the evidence is collected itmust be screened for
validity(closeness to the truth)
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Contd.
Impact (size of the effect) andapplicability (usefulness in clinical
practice). The users guide are designed to test
an article on these 3 parameters.
These guides are basically a set ofquestions whose answers should beprovided to the reader by the articlein order to obtain best clinicalevidence for the ues in focus.3/17/2012 36
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Acting on the evidence
"Remember, people will judge you by your
actions, not your intentions. You may have a
heart of gold -- but so does a hard-boiled
egg." - Anon.
There are a number of well documenteddelays between clinical practice and the
available research evidence.
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Integrate the criticalappraisal with clinicalexpertise and with the
patients unique biology,values& circumstances.
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Evaluating your performance
"I hear and I forget. I see and Iremember. I do and I
understand." Confucius Finally,evaluate performance in
terms of effectiveness & efficiencyby questioning the ability to completesteps 1-4 successfully & seek ways toimprove performance in future.
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Advantage of evidence based approach
compared with other assessmentmethod
Is objective Is scientifically sound Is patient focused
Incorporates clinical experienceStresses good judgment Is thorough and comprehensiveUses transparent methodology
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Dentistry based on evidence and
evidence based dentistry .Are they same??????????Dentistry based on evidence
Tends to include selected evidence ofvariable quality
Evidence-based dentistry
Relies on identifying all the available evidenceand assessing its quality
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Barriers to implementing EBD
Lack of time
Lack of appropriate skills for
formulating clearquestions,executing efficientelectronic searches & evaluating
the literature.Keeping up to date
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Perhaps the greatestimpediments to the EBD are thefear & mistrust on the part of
practitioners that the evidencewill be misused by decisionmakers,particularly 3rd party
funders & regulatory bodies &that the individual anatomy ofdentists ,in caring for their
patients ,will be threatened.3/17/2012 43
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Problems of introducing EBD
Amount of evidence
Quality of evidence
Dissemination of evidence Practice based on authority
rather than evidence
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Advantages
Improved patient,staff & dentistsatisfaction
Greater pride among patients,staff &
dentist in high quality care Improved clinical decision making
capability
Greater confidence in T/t planing More opportunity to provide T/t
choices selected for minimizing risk ofharm & maximizing T/t safety.
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Greater satisfaction
Reduced overhead & improvedproduction by saving time & money.
Higher T/t acceptance
Enhanced patient trust & rapport
Improved practice buildingopportunities as patients share withothers their trust,confidence & pride intheir EBD practicing dentist.
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Conclusion
Evidence based care is a globalmovement in all the health sciencedisciplines
It represents a philosophical shift inthe approach to practice-a shift thatemphasizes evidence over opinion &at that same time judgement overblind adherence to rules
This approach provides a bridgebetween research & everyday patientcare. 3/17/2012 47
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In near term future for EBpractice is likely to becharacterised by continuation ofcurrent trends in dissemination ofEB info to clinicians.
The primary means for
dissemination will consists ofevidence summaries & EB T/trecommendations & guidelines.
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THANK YOU