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Evidence-Based Dental Practice

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Evidence-Based Dental Practice Evidence-based Dental Practice Asbjørn Jokstad University of Oslo, Norway Today’s agenda 1. The wisdom tooth controversy Why do you remove/retain "wisdom teeth"? 2. Implantology What is the scientific proof that one system is better than another? 3. Management of the dentition in the elderly How do you prevent and manage root caries? Singapore, 18th January 2003 Today’s agenda Why use of the term ”Evidence-based Dental Practice”? What’s the big deal? Singapore, 18th January 2003 Professional Practice 1.We want to do More Good than Harm 2.Our practice should be Science Based Singapore, 18th January 2003 Scientific evidence of doing more good than harm depends on adequate study design Sackett DL, Strauss SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine. 2nd. edit. Churchill Livingstone, 2000. Singapore, 18th January 2003 A rapidly changing society 1. The production of new knowledge is at maximum in historical context Singapore, 18th January 2003 Dental journals in circulation 1000 900 N=933 800 700 600 500 400 300 200 100 0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 Source: Ulrich’s International Periodicals Directory Singapore, 18th January 2003 Where and by who is new knowledge in oral sciences developed? Singapore, 18th January 2003 The clinical practitioners •Single handed GPs/ specialists in teams; secondary/tertiary care •Great diversity of experience, interest and capacity •Draw on a panoply of experience •Pragmatism: what works - what creates problems Singapore, 18th January 2003 The researchers •Creates “scientific evidence” •Formulation of ideas, hypotheses, study design, data collection •Peer review, internal/external validity, debates within paradigms •Report findings in probabilities, not absolutes Singapore, 18th January 2003 The appraisers of evidence for clinical practice •Epidemiologists, health economists, statisticians, social scientists, and clinicians •Collect, abstract and appraise practice related knowledge •Debates about value and balance between consensus and evidence, rigour of data and application of statistics Singapore, 18th January 2003 Developers of local guidelines and protocols •Local consensus, sometimes on national guidelines •Clinical specialists seeking ways to influence peers Singapore, 18th January 2003 A rapidly changing society 1. The production of new knowledge is at maximum in historical context 2. Incessant replacements of established ideas and concepts Singapore, 18th January 2003 Dentists’ daily situation: An information overload Advertising - producers - colleagues Dental Dental Meetings/ literature „science‟“Vitenskap courses 700 journals: 25” 000 articles/yr Colleagues WWW Patients & (-groups) Popular magazines & Media Singapore, 18th January 2003 We need to consider not only the amount of information, but also the quality of this information Singapore, 18th January 2003 Scientific evidence of doing more good than harm depends on adequate study design Sackett DL, Strauss SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine. 2nd. edit. Churchill Livingstone, 2000. Singapore, 18th January 2003 A rapidly changing society 1. The production of new knowledge is at maximum in historical context 2. Incessant replacements of established ideas and concepts 3. Information technology has improved the potential for information transfer to everybody Singapore, 18th January 2003 New patients? Singapore, 18th January 2003 Information transfer to patients Competitive health providers and information sources Patient information and communication Singapore, 18th January 2003 Information is not synonymous to knowledge Singapore, 18th January 2003 Scientific evidence of doing more good than harm depends on adequate study design Sackett DL, Strauss SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine. 2nd. edit. Churchill Livingstone, 2000. Singapore, 18th January 2003 Solution: Integrate evidence-based principles in clinical practice • A practical aspect –A strategy for solving clinical problems on a daily basis • An ethical aspect –A strategy for being reasonably certain that my advises and treatments are the best available to my patients Singapore, 18th January 2003 1.Information is not knowledge 2.General practitioners need guidance on professional issues in the information age Singapore, 18th January 2003 Singapore, 18th January 2003 Online secondary publication - EBD: Singapore, 18th January 2003 Online secondary publication - EBDP: Singapore, 18th January 2003 Today’s agenda 1. Evidence-based practice Apply a Problem-Based Learning – PBL - approach 2. The wisdom tooth controversy 3. Implantology 4. Management of the dentition in the elderly Singapore, 18th January 2003 A Problem-Based learning approach 1. What type of everyday clinical problem is described? 2. Which study designs can best answer this specific clinical problem? Singapore, 18th January 2003 Problem-based learning approach 1. What type of everyday clinical problem is described? 8 categories Singapore, 18th January 2003 Type of everyday clinical problem? 1. Clinical findings: How to properly gather the most relevant findings from the history and physical examination, and interpret these correctly? 2. Etiology: How to identify causes for disease (including its iatrogenic forms) ? Singapore, 18th January 2003 Type of everyday clinical problem? 3. Differential diagnosis: When considering the possible causes of a patient’s clinical problem, how to rank them by likelihood, seriousness and treatability ? 4. Diagnostic tests How to select and interpret diagnostic tests, to confirm or exclude a diagnosis, based on considering precision, accuracy, acceptability, expense, safety,Singapore, etc? 18th January 2003 Type of everyday clinical problem? 5. Prognosis: How to estimate the patient’s likely clinical course over time and anticipate likely complications? 6. Therapy: How to select treatments to offer patients that do more good than harm and that are worth the efforts and costs of using them? Singapore, 18th January 2003 Type of everyday clinical problem? 7. Prevention: How to reduce the chance of disease by identifying and modifying risk factors & How do we diagnose disease early by screening? 8. Self-improvement: How to keep up to date, improve our clinical skills and run a better, more efficient clinical practice? Singapore, 18th January 2003 What type of everyday clinical problem is described? Why do you remove/retain "wisdom teeth"? A question about prognosis What is the scientific proof that one system is better than another? A question about therapy How do you prevent and manage root caries? A question about prevention Singapore, 18th January 2003 A Problem-Based learning approach 1. What type of everyday clinical problem is described? 2. Which study designs can best answer this specific clinical problem? Singapore, 18th January 2003 Clinical trial terminology - tower of Bable? analytical study ecological study prospective cohort study case control study (89) etiological study prospective follow-up study, case serie experimental study observational or experimental case study, case report explorative study prospective study (67) cause-effect study feasibility study (79) quasi-experimental study clinical trial (79) follow-up study (67) randomized clinical trial, RTC cohort study (89) historical cohort study randomized controlled trial, RCT (89) cohort study with historical incidence study retrospective cohort study controls intervention study retrospective follow-up study controlled clinical trial (95) longitudinal study (79) retrospective study (67) cross-sectional study (89) N=1 trial surveillance study descriptive study non-randomized trial with survey, descriptive survey diagnostic meta-analysis contemporaneous controls therapeutic meta-analysis diagnostic study non-randomized trial with trohoc study double blind randomized historical controls therapeutical trial with cross- observational study over design Singapore, 18th January 2003 Manipulation with intervention Yes No Experimental Non-experimental study study / observational Random Sampling according Sampling according allocation to exposition to (case) effect characteristics characteristics Yes No Quasi- Experimental experimental Case series / study (RCT) cohort study study (CCT) Case-control study Singapore, 18th January 2003 Clinical study designs (MESH terms): · (Case study/series) · Case-Control Study · Cohort Study · Cross-Sectional Survey · Randomised Controlled Trial Singapore, 18th January 2003 Scientific evidence of doing more good than harm depends on adequate study design Sackett DL, Strauss SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine. 2nd. edit. Churchill Livingstone, 2000. Singapore, 18th January 2003 Scientific studies can be graded according to the theoretical possibility of an incorrect conclusion. This is reflected by the design of the study. ...we will never know exact answers in science…. Singapore, 18th January 2003 Singapore, 18th January 2003 Appropriate Study Designs Qualitative Cross- Case Cohort RCT Sectional Control Diagnosis Therapy Prognosis Screening Views/beliefs perceptions Prevalence/ hypothesis generation Singapore, 18th January 2003 One Intention of this Lecture is to Demonstrate the Strength of the Scientific Evidence relative to the Three Selected Topics Singapore, 18th January 2003 An evidence-based critical apraisal approach 1. How many reports related to the topic can be identified? Singapore, 18th January 2003 An evidence-based critical apraisal
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