10


• Best practice


FOLLOWING THE


Evidence-based dentistry encourages clinicians to use the latest information in dealing with clinical problems. Derek Richards explains what this process involves


T


HE term evidence-based medicine was first introduced into medical literature in 1991, with a focus on assessing the validity and importance of evidence before applying it to day-to-day clinical problems. Since then it has been adopted by other health disciplines including dentistry. The American Dental Association (ADA) defines


evidence-based dentistry (EBD) as “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.” Putting this simply it means bringing together the best available


evidence on a topic with the dentist’s expertise and the patient’s needs and wishes (Figure 1) in order to deliver the right treatment in the right way at the right time and at the right place. While the best clinicians have always sought to practise in this manner, the explosion of information available and the pace of development mean that keeping up-to-date is increasingly challenging. Adopting an evidence-based approach helps manage this information overload. Evidence-based practice is a systematic approach for dealing with


this vast amount of information by providing methods for aggregating, distilling and delivering the best clinical evidence. The five stages have been referred to as the five As:


1. ASK - ask answerable questions 2. ACQUIRE - find the best evidence 3.


4. APPLY - apply the evidence 5. ASSESS - assess the outcome


Ask Consider the following scenario: A family attends for a routine check-up on your first day in a new practice. When you examine the mouths of the two young children you diagnose caries in some teeth. On questioning to establish possible risk factors, the mother indicates that they brush their teeth twice a day


with herbal toothpaste as they live in a fluoridated area. You ask the mother if the toothpaste contains fluoride and she confirms that it does not.


You can probably think of a large number of clinical questions related to this scenario but an important one for me is whether changing to fluoridated toothpaste would be beneficial. To help develop clear questions to aid searching for evidence a format called PICO has been developed1


. This stands for problem, intervention,


comparison and outcome. For the scenario above we could derive the following question: For a child living in a fluoridated area would fluoride toothpaste, compared with a non-fluoride paste, provide additional caries reduction? Armed with a clear question we can then look for the best evidence to answer it.


Acquire Before looking for evidence it is important to realise that not all evidence is of equal value. Essentially you are looking for the research that is best designed to suit the question you are trying to answer2


. For a question


seeking to find out if one treatment is better than another, a systematic review of randomised controlled studies is the highest level of evidence, and this decreases based on the potential for bias within the study design as shown in Table 2. (More information on levels of evidence is available on the Centre for Evidence-based Medicine website at: www. cebm.net/ocebm-levels-of-evidence) In an ideal world we would conduct our own systematic review of the


APPRAISE - critically appraise the evidence


evidence but this is unrealistic. The simplest approach is to look for some form of pre-appraised evidence. This can come in a number of different formats3


as shown in Table 3. While a formal search of evidence using the resources noted in the


table would be best practice (and a useful skill to develop), from a practical perspective good evidence-based guidelines such as those prepared by the Scottish Dental Clinical Effectiveness programme (SDCEP) and Scottish Intercollegiate Guidelines Network (SIGN) and journals and blog sites that produce summaries of good quality articles such as the Evidence-based Dentistry journal (of which I am editor) and the Dental Elf blog (www.thedentalelf.net) are good starting points


EVIDE NCE


IDENC NG THE


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