www.mddus.com


Figure 1 Components of evidence-based practice


Best Evidence


when looking for evidence. Another time-saving approach is to use the TRIP database (www.tripdatabase.com). This is a meta-search engine that automatically searches a range of the resources noted in Table 3 and allows you to select a particular type of resource. Searching is a key skill to support the evidence-based approach. Without a good search for information to answer your question there is a temptation to use the fi rst available piece of evidence to support an approach to treatment and claim that this is “evidence-based” when in fact it is neither good evidence nor the only treatment approach available.


Appraise Once you have found your evidence you need to appraise it. There are a range of appraisal tools and checklists to help with this element. The most useful of these are produced by the Critical Appraisal Skills Programme (www.casp-uk.net) which has checklists for a range of diff erent study designs. Regardless of the study design, there are essentially three core questions to address:


• Is the study valid? • What are the results? • Are the results relevant to my patients?


When appraising most studies the validity or correct methodology is key and most people can assess this for themselves most times.


Apply and assess So once you have identifi ed the evidence and have assessed it as sound and relevant to your patient you need to discuss it with your patient. This is particularly important if there are


options for care, as the evidence-based approach also includes taking the patient’s needs and values into consideration. Finally, once the treatment has been delivered you should assess whether


your experience with the treatment is the same as the evidence on which you based your decision-making in order to complete the loop. Talking of completing the loop, in relation to the question we asked at


the outset, probably the best evidence comes from a Cochrane review by Marinho et al4


, which found that fl uoride toothpaste provides about a 24


per cent reduction in dental decay, and that this eff ect was increased with higher disease levels, high toothpaste fl uoride concentration, higher frequency of use and supervised tooth brushing, but not infl uenced by exposure to water fl uoridation.


References 1.


2. 3.


Richardson W, Wilson M, Nishikawa J, Hayward RS. The well-built clinical question: a key to evidence-based decisions [editorial]. ACP J Club. 1995; 123: A12-13.


Sackett DL, Wennberg JE. Choosing the best research design for each question. BMJ. 1997; 315: 1636.


DiCenso A, Bayley L, Haynes RB. ACP Journal Club. Editorial: Accessing preappraised evidence: fi ne-tuning the 5S model into a 6S model. Ann Intern Med. 2009; 151: JC3-2, JC3-3.


4. Marinho VC, Higgins JP, Sheiham A, Logan S. Fluoride toothpastes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2003; Issue 1. Art. No.: CD002278. DOI: 10.1002/14651858. CD002278.


Derek Richards is an honorary senior lecturer at the University of Dundee Dental School, consultant in dental public health, and director of the Centre for Evidence-based Dentistry


Summaries


Synopsis of synthesis Synthesis


Synopsis of studies Studies


E B D


Patient Values


Clinical Experience


Table 1 The PICO question


P: Problem


I: Intervention C: Comparison O: Outcome


A child living in a fl uoridated area Fluoride toothpaste


Non-fl uoride toothpaste Additional caries reduction


Table 2 Levels of evidence


Evidence level Study type 1.


1


2. 3. 4. 5.


2 3 4


5 N/A Cohort


Case-control Case series


Narrative review, editorial Case report, epidemiology, animal studies


Table 3 Pre-appraised evidence- the 6S Model


Type of resource Systems


Evidence-based computerised decision support systems


Evidence-based guidelines, textbooks


Journals, website, blogs


Systematic reviews Journals, website, blogs Database, journals


SDCEP, SIGN, NICE


Evidence-based Dentistry, Dental Elf Cochrane Reviews


Evidence-based Dentistry, Dental Elf PubMed, Embase


Examples


Systematic review (e.g. Cochrane review) and randomised controlled trials


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