Principles of Evidence-Based Abstract Dental Practice (EBDP) In an effort to improve patient care, there has been a grow- Hoda Abdellatif, B.D.S., M.P.H., Dr. PH., ing trend across the nation Paul C. Dechow, Ph.D., and the world to embed the Daniel L. Jones, D.D.S., Ph.D. principles of evidence-based into mainstream care Introduction delivery by private practicing dentists. Evidence-based To some the phrase “evidence-based dentistry” ap- dentistry is an essential tool pears odd insofar as the juxtapostioning of the words that is used to improve the quality of care and to reduce “evidence-based” and “dentistry” implies that not all the gap between what we dental care is based upon evidence. Those bothered know, what is possible, and by the phrase include dental practitioners who believe what we do. An evidence- that the training they’ve received in dental school was based practice is based upon current evidence and that that evidence one that includes the decision PDNHUҋVDELOLW\WRÀQGDVVHVV ZLOOUHPDLQVXIÀFLHQWO\FXUUHQWWKURXJKRXWWKHLUSUR- and incorporate high-quality, fessional careers. Those bothered by the phrase also valid information in diagnosis include dental patients who believe that their dental and treatment. The evidence FDUHSURYLGHUE\YLUWXHRIKLVFUHGHQWLDOVLQWKHÀHOG is considered in conjunction of health care — well-recognized to be scholarly chal- with the clinician’s experi- ence and judgment, and the lenging — delivers the best possible care known to the patient’s preferences, values, ÀHOGWRGD\ and circumstances. This article introduces the basic skills of evidence-based den- tistry. Their practice requires a discipline of lifelong learning in which recent and relevant VFLHQWLÀFHYLGHQFHDUHWUDQV- lated into practical clinical applications. Abdellatif Jones

Dr. Abdellatif is an assistant professor, Department of Public Health Sciences, Baylor College of KEY WORDS: Evidence- Dentistry-Texas A&M Health Science Center (TAMHSC). based dentistry, evidence- Dr. Dechow is a professor and vice chair, Department of Biomedical Sciences, Baylor College of based practice, hierarchy of Dentistry-Texas A&M Health Science Center (TAMHSC). evidence, steps in evidence- Dr. Jones is a professor and chair, Department of Public Health Sciences, Baylor College of Dentistry- Texas A&M Health Science Center (TAMHSC). based dentistry.

Corresponding Author: Dr. Hoda Abdellatif, Department of Public Health Sciences, Baylor College of Dentistry, 3302 Gaston Avenue, Dallas, Texas 75246. Phone: (214) 828-8164; Fax: (214) 874-4555; Tex Dent J 2011;128(2):155- E-mail:[email protected]. 164. 7KLVDUWLFOHKDVEHHQSHHUUHYLHZHG7KHDXWKRUVKDYHGHFODUHGQRFRQÁLFWVRILQWHUHVW

Texas Dental Journal l www.tda.org l February 2011 155 Three PubMed Skills to Support Abstract

Evidence-Based Dentistry The National S. Thomas Deahl II, D.M.D., Ph.D. Library of ’s PubMed database Introduction can powerfully assist dentists in PubMed at http://www.ncbi.nlm.nih.gov/pubmed can pow- evidence-based erfully assist the clinician seeking the best evidence. Peer- practice. Three reviewed journals contain the highest-quality evidence for useful PubMed decision-making in clinical practice, and PubMed indexes most skills can improve of these journals and their contents. PubMed, a database of the WKH HIÀFLHQF\ RI WKH U.S. National Library of Medicine, contains millions of citations clinician’s search: (1) of journal articles and other publications, many with abstracts, Use of MeSH terms; and is updated four times per week. PubMed is the electronic (2) Use of Limits; equivalent of the (now-discontinued) print publication Index Medicus, which clinicians may remember using during their (3) Use of Clinical university education. Queries.

Over 800 dental journals, including the Texas Dental Journal, are indexed in KEY WORDS: PubMed, along with many medical and journals which may con- PubMed Medical tain articles relevant to dentistry. Over 5,000 journals are currently indexed in this database. PubMed’s principal component is Medline, which covers Subject, Headings, references in the biomedical literature back to 1947. Evidence-Based Dentistry Although the dentist has many search options today, including databases such as Google and Bing, PubMed covers principally peer-reviewed clinical DQGVFLHQWLÀFSXEOLFDWLRQV2WKHUVHDUFKHQJLQHVPD\UHWXUQPDQ\RWKHU Tex Dent J 2011; ÀQGLQJVIURPOHVVUHOLDEOHVRXUFHVDVZHOOLQFUHDVLQJWKHYROXPHRIPDWHULDO 128(2):167-173. WKHFOLQLFLDQPXVWVFDQ3XE0HGWKHUHIRUHRIIHUVWKHSRWHQWLDOEHQHÀWRI reducing the amount of extraneous information the clinician must scan.

Deahl II

Dr. Deahl II is n adjunct associate professor, Department of Developmental Dentistry, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, and The Institute for Natural Resources, Concord, California. Contact Information: Department of Developmental Dentistry, UTHSCSA Dental School, 7703 Floyd Curl Drive, San Antonio, TX 78258. Telephone: (210) 567-3500. E-mail [email protected] 7KH DXWKRU KDV QR SRWHQWLDO FRQÁLFWV RI ÀQDQFLDO LQWHUHVW UHODWLRQVKLSV DQGRUDIÀOLDWLRQV UHOHYDQW WR WKH VXEMHFW PDWWHU RU materials discussed in the manuscript.

Texas Dental Journal l www.tda.org l February 2011 167 How Effective is That Treatment? Abstract

The Number Needed to Treat The Number Needed S. Thomas Deahl II, D.M.D., Ph.D. to Treat (NNT) is a tool useful for comparing the Introduction relative effectiveness of two or more therapeutic As you consider adopting a new treatment (or a new or preventive interven- preventive agent) in clinical practice, you should ask a tions. The NNT may be series of questions. Among the most important ques- presented by authors of tions you can ask are as follows: a clinical research article, or, if not provided, may be ‡ ,VWKHHYLGHQFHIRUWKLVQHZWUHDWPHQWWUXH LQRWKHU calculated by the reader if words, is the evidence valid)? the authors have reported ‡ ,VWKLVQHZWUHDWPHQWIHDVLEOHIRUP\SUDFWLFHDV outcomes as positive or ZHOODVEHQHÀFLDODQGDIIRUGDEOHIRUP\SDWLHQWV" negative per research ‡ ,VWKLVQHZWUHDWPHQWVXIÀFLHQWO\HIIHFWLYHWKDWLWLV subject. The NNT is worth my efforts to adopt (in other words, how ef- simply calculated as the fective is this treatment)? inverse of the absolute risk reduction. The NNT is Applying these critical questions is especially important today as most meaningful when re- marketing of dental equipment, instruments, and materials increas- SRUWHG ZLWKLQ D FRQÀGHQFH ingly complete, for the dentist’s attention, with the results of long-term clinical studies. interval and when describ- ing clinical trials of higher At least these three questions should be answered before adopting a validity such as random- new treatment or preventive agent. This article aims to help you ad- GUHVVWKHWKLUGTXHVWLRQ6SHFLÀFDOO\ZHZRXOGOLNHWRNQRZ+RZFDQ ized controlled trials and we best describe the relative effectiveness of a new treatment (com- meta-analyses of such pared to some other treatment we are already using)? This article trials. Several example NNTs from the dental and medical literature are reported.

KEY WORDS: Evi- dence-based dentistry, Deahl II number needed to treat,

Dr. Deahl is an adjunct associate professor, Department of Developmental Dentistry, University of Texas Health effectiveness, clinical trials Science Center at San Antonio Dental School, San Antonio, Texas, and The Institute for Natural Resources, Concord, California. Tex Dent J 2011; Send correspondence to S. Thomas Deahl II, DMD, PhD, Department of Developmental Dentistry, UTHSCSA, 7703 Floyd Curl Drive, San Antonio, Texas 78258. Phone: (210) 567-3500; E-mail [email protected]. 128(2):211-219.

This article has been peer reviewed.

Texas Dental Journal l www.tda.org l February 2011 211 The American Dental Abstract Association’s Center For Through its website (http:// Evidence-Based Dentistry: www.ada.org/prof/re- A Critical Resource For21st sources/ebd/index.asp), the American Dental Associa- Centuryy Dental Practice tion’s Center for Evidence- Based Dentistry offers Julie Frantsve-Hawley, R.D.H., Ph.D. Arthur Jeske, D.M.D., Ph.D. dental health professionals access to systematic re- Introduction views of oral health-related UHVHDUFK ÀQGLQJV DV ZHOO DV $VKHDOWKFDUHSURIHVVLRQDOVWUDLQHGLQDVFLHQWLÀ- Clinical Recommendations, cally-structured educational model, dentists have a which summarize large bod- special responsibilityy to their patients to provide care that is evidence-based, and to be able to effectively LHV RI VFLHQWLÀF HYLGHQFH LQ communicate the evidence for dental treatments to the form of practice recom- their patients, so that patients can make informed mendations, e.g., the use decisions about their care. This principle is effec- of professionally-applied tivelyy enunciated byy the American Dental Associa- WRSLFDO ÁXRULGH DQG SLWDQG WLRQ·V $'$ GHÀQLWLRQRIWKHWHUP´HYLGHQFHEDVHG ÀVVXUH VHDODQWV $QRWKHU dentistry” (EBD) as follows: Evidence-basedd dentistry feature of the site of great (EBD)) iss ann approachh too orall healthh caree thatt requires practical importance to the thee judiciouss integrationn off systematicc assessments practicing dentist is the RIFOLQLFDOO\UHOHYDQWVFLHQWLÀFHYLGHQFHUHODWLQJWRWKH Critical Summary, which patient’ss orall andd medicall conditionn andd history, with is a concise review of an thee dentist’ss clinicall expertisee andd thee patient’ss treat- individual systematic re- mentt needss andd preferences. view’s methodology and ÀQGLQJV DV ZHOO DV WKH importance and context of the outcomes, and the strengths and weaknesses of the and its implications for dental practice. Frantsve-Hawley Jeske

Dr. Frantsve-Hawley isthe director of the ADAA Center for Evidence-Based Dentistry. Tex Dent J 2011; 128(2):201- Dr. Jeske is a professor, Department of Restorative Dentistry and Biomaterials, University of Texas Dental Branch at Houston. 205.

7KLV DUWLFOH KDV EHHQ SHHU UHYLHZHG 7KH DXWKRUV KDYH QR GHFODUHG ÀQDQFLDO LQWHUHVWV

Texas Dental Journal l www.tda.org l February 2011 201 The Challenges of Transferring Abstract Evidence-Based Dentistryy Into The goal of evidence-based Practice dentistry is to help Richard T. Kao, D.D.S., Ph.D. practitioners pro- Reprinted byy permission off the California Dental Association. Copyright 2006. vide their patients with optimal care. Introduction This is achieved by integrating The dental profession is committed to providingg the best sound research possible dental care for patients. This is provingg to be more evidence with complexx due to a virtual “informationexplosion” on new personal clini- cal expertise and , techniques, and materials; increased consumer patient values to understandingg off treatment possibilities and therapeu- determine the best tic outcomes; and changingg socio-demographic patterns. course of treat- Though the profession advocates the importance off evi- ment. Though dence-based dental prevention and treatment, prac- clinicians embrace this concept, its titioners have been slow to implement this concept. implementation In 2003, the Californiaa Dental Association (CDA) formulated an evidence- in clinical practice based dentistryy action plan that included the formation off a task force to has been slow. In monitor evidence-based dentistryy efforts and implement programs to educate this paper, bar- CDA members on this methodology. The challenges off transferringg evidence- riers against the based dentistryy into clinical practice were keyy issues addressed byy the task IRUFHDQGPXFKRIWKHLUGHOLEHUDWLRQVDQGSHUVSHFWLYHVDUHUHÁHFWHGLQWKLV implementation of paper. Possible solutions for eliminatingg barriers against evidence-based care evidence-based will also be explored. care are examined and possible solu- tions are offered.

Tex Dent J 2011; 128(2):193-199.

Kao

'U .DR LV DQ DVVRFLDWH DGMXQFW SURIHVVRU 'HSDUWPHQW RI 3HULRGRQWRORJ\ 8QLYHUVLW\ RI WKH 3DFLÀF $UWKXU $ 'XJRQL 6FKRRO of Dentistry. He also is past chair, TaskForce on Evidence-based Dentistry, California Dental Association, and has a private practice in Cupertino, California.

Send correspondence and reprint requests to: Dr. Richard T. Kao, 10440 S. De Anza Blvd., Suite D-1, Cupertino, CA, 95014.

Texas Dental Journal l www.tda.org l February 2011 193 Teaching Evidence-Based Practice Abstract at the University of Texas Health The overarching goal of the Evidence-Based Science Center at San Antonio Practice Program at San Antonio is to provide our Dental School graduates with life-long John D. Rugh, Ph.D.; William D. Hendricson, M.A., M.S.; Birgit J. Glass, D.D.S., M.S.; learning skills that will en- John P. Hatch, Ph.D.; S. Thomas Deahl II, D.M.D., Ph.D.; Gary Guest, D.D.S.; Richard able them to keep up-to- Ongkiko; Kevin Gureckis, D.M.D.; Archie A. Jones, D.D.S.; William F. Rose, D.D.S.; Peter date and equip them with Gakunga, D.D.S., M.S., Ph.D.; Debra Stark, D.P.H.; Bjorn Steffensen, D.D.S., M.S., Ph.D. the best possible patient care skills during their 30-40 years of practice. Introduction Students are taught to One of the most serious challenges facing all health profes- (1) ask focused clinical sionals is dealing with the explosion of new biomedical in- questions, (2) search the biomedical research formation and products. The exponential increase in new literature (PubMed) for knowledge and the useful half-life of knowledge (7-10 years) the most recent and DUHPDNLQJLWH[WUHPHO\GLIÀFXOWIRUFOLQLFLDQVWRNHHSXS highest level of evidence, to-date. The number of articles published annually in peer- (3) critically evaluate the reviewed dental journals has grown from 6,212 in the year evidence and (4) make clinical judgments about 1970 to 13,600 in 2009. Adding to the problem is the in- the applicability of the evidence for their pa-

Dr. Rugh, professor, tients. Students must Department of demonstrate competency Developmental Den- tistry and Director of with these “just-in-time” the Evidence Based Practice Program, learning skills through UTHSCSA, San writing concise one-page Antonio, Texas. Mr. Hendricson, Critically Appraised Top- assistant dean ics (CATs) on focused for educational and Rugh Hendricson Glass Deahl II Guest faculty development, clinical questions. The UTHSCSA, San Antonio, Texas. Dr. Glass, professor, Department of school has established Comprehensive Dentistry and Associate Dean for Academic Affairs, UTHSCSA, an online searchable San Antonio, Texas. library of these Critically Dr. Hatch, professor, Department of De- velopmental Dentistry and Department of Appraised Topics. This Psychiatry Behavioral Medicine Division STRONG STAR Multidisciplinary PTSD library provides students Research Consortium, UTHSCSA, San and faculty with rapid, up- Antonio, Texas. Ongkiko Gureckis Jones Rose Dr. Deahl , adjunct associate professor, to-date evidence-based Department of Developmental Dentistry, UTHSCSA, San Anto- nio, Texas, and The Institute for Natural Resources, Concord, answers to clinical ques- California. tions. The long-range Dr. Guest, professor, Department of Comprehensive Dentistry and Assistant Dean for Predoctoral Clinics, UTHSCSA, San plan is to make this online Antonio, Texas. library available to practi- Mr. Ongkiko, database administrator, UTHSCSA, San Antonio, Texas, and Instructor at the University of the Incarnate Word tioners and the public. ADCaP, San Antonio, Texas. Dr. Gureckis, associate professor, Department of Comprehen- sive Dentistry, UTHSCSA, San Antonio, Texas. Tex Dent J 2011; Gakunga Stark Steffensen Dr. Jones, associate professor, Department of Periodontics, UTHSCSA, San Antonio, Texas. 128(2):187-190. Dr. Rose, assistant professor, Department of Comprehensive Dentistry, UTHSCSA, San Antonio, Texas. Dr. Gakunga, assistant professor, Department of Developmental Dentistry, UTHSCSA, San Antonio, Texas. Dr. Stark, evaluation specialist in the Academic Center for Excellence in Teaching, UTHSCSA, San Antonio, Texas. Dr. Steffensen, professor, Department of Periodontics, professor, Department of Biochemistry and Associate Dean for Research, UTHSCA, San Antonio, Texas.

Texas Dental Journal l www.tda.org l February 2011 187 Teaching Evidence-Based Abstract

Practice at The University of This brief report outlines the current curriculum for evi- Texas Dental Branch at Houston dence-based practice at The Richard D. Bebermeyer, D.D.S., M.B.A. University of Texas Dental Branch at Houston (UTDB). This curriculum is now based Introduction on the American Dental As- sociation’s Commission on In 2002, the American Dental Association (ADA) de- Dental Accreditation 2010 YHORSHGWKHIROORZLQJGHÀQLWLRQIRUWKHWHUP´HYLGHQFH Accreditation Standards for based dentistry,” or EBD: “an approach to oral health Dental Education Programs. Evidence-based practice is care that requires the judicious integration of sys- introduced to students in the WHPDWLFDVVHVVPHQWVRIFOLQLFDOO\UHOHYDQWVFLHQWLÀF ÀUVW\HDU FXUULFXOXP 6WXGHQWV evidence, relating to the patient’s oral and medical learn to be clinically effective condition and history, with the dentist’s clinical exper- through use of the components tise and the patient’s treatment needs and preferences of evidence-based practice, in- formation search and retrieval, (1).” More recently, in August of 2010, the ADA’s critical thinking (appraisal), and Commission on Dental Accreditation adopted new Ac- through information resource creditation Standards for Dental Education Programs evaluation and then application (2). This change evolved over the past 3 years, with to the patient or population. input from all constituents. Among the new stan- Planned innovations in curricu- lum include further implementa- dards is an emphasis on evidence-based practice. tion of evidence-based deci- 0RUHVSHFLÀFDOO\WKHUHLVDVWDWHPHQWWKDW´JUDGXDWHV sion-making in clinical courses, must be competent in the use of critical thinking and including development of the clinical prescription as a means of demonstrating competence in asking and answering clinical questions, and of the portfolio as a means of demonstrating overall competence.

KEY WORDS: evidence-

Bebermeyer based practice (EBP);

Dr. Bebermeyer is professor and chairman, Department of Restorative Dentistry and Biomaterials; education, dental The University of Texas Dental Branch at Houston; Houston, Texas, 77030. Phone: (713) 500-4286; Fax: (713) 500-4108; E-mail: [email protected] Tex Dent J 2011; 128(2):183- Please address all reprint requests to: Richard D. Bebermeyer, D.D.S. 185.

Texas Dental Journal l www.tda.org l February 2011 183 The Evidence-Based Abstract

Dentistry Initiative at This report describes the impact Baylor College of Dentistry of an R25 Oral Health Research Education Grant awarded to Daniel L. Jones, D.D.S., Ph.D., Robert J. Hinton, Ph.D., the Texas A&M Health Science Paul C. Dechow, Ph.D., Hoda Abdellatif, B.D.S., M.P.H., Dr. PH., Center-Baylor College of Dentistry Ann L. McCann, RDH, Ph.D., Emet D. Schneiderman, Ph.D., (BCD) to promote the applica- Rena D’Souza, D.D.S., Ph.D. tion of basic and clinical research ÀQGLQJVWRFOLQLFDOWUDLQLQJDQG Introduction encourage students to pursue careers in oral health research. The NIH-NIDCR R25 Oral Health Research Edu- At Baylor, the R25 grant supports cation Grant initiative at the Texas A&M Health a multi-pronged initiative that Science Center-Baylor College of Dentistry (BCD), employs clinical research as a designated “CUSPID”, is based on the theme that vehicle for acquainting both stu- “Clinicians Using Science Produce Inspired Den- dents and faculty with the tools of tists”. CUSPID complements the recent advances evidence-based dentistry (EBD). New coursework and experiences in all 4 years of the curriculum plus a variety of faculty develop- ment offerings are being used to achieve this goal. Progress RQWKHVHIURQWVLVUHÁHFWHGLQD

Jones Hinton Abdellatif nascent “EBD culture” charac- terized by increasing participa- tion and buy-in by students and faculty. The production of a new generation of dental graduates equipped with the EBD skill set

McCann Schneiderman D’Souza as well as a growing nucleus of

Dr. Jones is a professor and chair, Department of Public Health Sciences, TAMHSC-Baylor Col- faculty who can model the impor- lege of Dentistry, Dallas, Texas. Dr. Hinton is a professor, Department of Biomedical Sciences, TAMHSC-Baylor College of Den- tance of evidence-based practice tistry, Dallas, Texas. Dr. Dechow is a professor and vice chair, Department of Biomedical Sciences, TAMHSC-Baylor is of paramount importance for the College of Dentistry, Dallas, Texas. Dr. Abdellatif is an assistant professor, Department of Public Health Sciences, TAMHSC-Baylor future of dentistry. College of Dentistry, Dallas, Texas. Dr. McCann is an associate professor and Director of Assessment, TAMHSC-Baylor College of Dentistry, Dallas, Texas. Dr. Schneiderman is an associate professor, Department of Biomedical Sciences, TAMHSC- KEY WORDS: evidence-based Baylor College of Dentistry, Dallas, Texas. Dr. D’Souza is a professor and chair, Department of Biomedical Sciences, TAMHSC-Baylor Col- dentistry, curriculum, clinical re- lege of Dentistry, Dallas, Texas. search, faculty development Send correspondence and reprint requests to: Dr. Daniel L. Jones, Department of Public Health Sciences, Baylor College of Dentistry, 3302 Gaston Avenue, Dallas, TX 75246; Phone: (214) 828-8350; Fax: (214) 874-4555; E-mail: [email protected] Tex Dent J 2011; 128(2):177-180. Supported by NIH-NIDCR grant DE018883 (to Dr. Robert J. Hinton and Dr. Daniel L. Jones).

Texas Dental Journal l www.tda.org l February 2011 177