3/20/2018
1
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!!!
3/20/2018
2
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.”
3/20/2018
3
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
3/20/2018
4
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
3/20/2018
5
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
3/20/2018
6
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
3/20/2018
7
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
3/20/2018
8
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?
3/20/2018
9
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
3/20/2018
10
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 ?
3/20/2018
11
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.
3/20/2018
12
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:
3/20/2018
13
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.
3/20/2018
14
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
3/20/2018
15
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
3/20/2018
16
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
3/20/2018
17
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”
3/20/2018
18
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!
3/20/2018
19
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”
Top Related