Evidence-based dentistry

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Evidence-based dentistry (EBD) is the dental part of the more general movement toward evidence-based medicine and other evidence-based practices. The pervasive access to information on the internet includes different aspects of dentistry for both the dentists and patients. This has created a need to ensure that evidence referenced to are valid, reliable and of good quality. [1]

Contents

Evidence-based dentistry has become more prevalent than ever, as information, derived from high-quality, evidence-based research is made available to clinicians and patients in clinical guidelines. By formulating evidence-based best-practice clinical guidelines that practitioners can refer to with simple chairside and patient-friendly versions, this need can be addressed.

Evidence-based dentistry has been defined by the American Dental Association (ADA) 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." [2]

Three main pillars or principles [3] exist in evidence-based dentistry. The three pillars are defined as:

The use of high-quality research to establish the guidelines for best practices defines evidence-based practice. In essence, evidence-based dentistry requires clinicians to remain constantly updated on current techniques and procedures so that patients can continuously receive the best treatment possible.

History

Evidence-based dentistry (EBD) was first introduced by Gordon Guyatt and the Evidence-Based Medicine Working Group at McMaster University in Ontario, Canada, in the 1990s as part of the larger movement toward evidence-based medicine and other evidence-based practices.

Clinical decision making

Much praise has gone to the dentistry approach of clinical decision making. In an EB case report written by Miller SA, is focused on the "use of evidence-based decision-making in private practice for emergency treatment of dental trauma". The case concludes with high praise for this method, going as far to say that "[the] evidence-based method was efficient, and very helpful in optimizing the management of the emergency dental treatment". [4] However, it is important to ensure that the collection of data in the evidence during evidence-based clinical decision making isn’t corrupted. Crawford JM writes about publication bias, as well as the possible effects it can have on evidence-based clinical making. He writes that it is important to watch out for publication bias, as it can "hinder advancements in oral health care by decreasing the availability of scientific evidence and threatening the validity of evidence-based practice". [5]

There are many tools that have been developed for dental-based clinical decision making. Authors Rios Santos JV, Castello Castaneda C, and Bullon P all documented the "development of a computer application to help the decision making process in teaching dentistry." It offers the ability to review information, to help reinforce information that is learned by students. Teaching staff can also "design any theme they wish, increasing the efficiency and support capabilities of the program". [6]

Principles

In summary, there are three main pillars [7] exist in evidence-based dentistry which serves as its main principles. The three pillars are defined as:

Dentists' clinical expertise

Much less attention is paid to both the other two spheres of EBD, clinical expertise and patient values. [8]

Clinical expertise plays a part in the successful outcomes of treatment with diagnostic skills preventing over and under-treatments, technical dental skills maximizing the longevity of surgical and restorative procedures and communication skills being core to patient management and perceived success.

Patients needs and preferences

Not all patients have the same priorities for their care. Understanding a patient's individual needs, wants and circumstances gives the clinician a place from which to discuss treatment options available with the patient. This might be competing priorities between dentists, therapists, and hygienists who generally aim for longevity and aesthetics and patients who may be more interested in keeping costs down, aesthetics or would prefer less invasive treatments.

Relevant scientific evidence

Given that "Patient needs and preferences" and "Dentist's clinical expertise" are variable and will differ among numerous clinicians and population, "Relevant scientific evidence" is of critical importance. Therefore, it is imperative that information referenced to are derived from high-quality, evidence-based research, which can be used to establish the guidelines for providing the best practices.

In essence, Evidence-based dentistry can allow clinicians to remain constantly updated on the newest techniques and procedures so that patients can continuously receive the best treatment possible.

Evidence based process

Best scientific evidence

The new model set by EBM uses a systematic process to incorporate current research into practice. The evidence-based process requires the practitioner to develop five key skills:

The American Dental Association defined evidence-based dentistry like so:

Evidence-based dentistry (EBD) is 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 [10]

The American Dental Education Association (ADEA) has incorporated the definition of evidence-based dentistry into core competencies required by dental education programs. These competencies focus on graduates to become lifelong learners and consumers of current research findings and require students to develop skills that are reflective of evidence-based dentistry. [11]

A dentist's learning curve for using the evidence-based process can be steep, but there are continuing education courses, workbooks and tools available to simplify the integration of current research into practice.

Assessing the quality of evidence

Drawn image illustrating the Hierarchy of Evidence Drawn image illustrating the Hierarchy of Evidence.png
Drawn image illustrating the Hierarchy of Evidence

Need for continuing education

Dental graduates around the globe are possibly up to date at the time they graduate, but usually are fundamentally lacking in the understanding of trials/studies design and relevance/importance. Dental specialty training, however, stresses evidence-based outcomes, results and methodologies. But this becomes out of date as new information and technology appear. Hence it is important, especially with regards to patient safety, for dentists to be able to keep up to date with developments. Having an understanding of how to interpret research results, and some practice in reading the literature in a structured way, can turn the dental literature into a useful and comprehensible practice tool. For this to happen, EBD learning absolutely needs to be at the heart of dental education. Dental students can be taught EBD concept during their time in dental school so that they will develop the ability to evaluate critically new knowledge and determine its relevance to the clinical problems and challenges presented by the individual patient. They also acquire the ability to interpret, assess, integrate, and apply data and information in the process of clinical problem solving, reasoning, and decision making. EBD is a lifelong learning process and help to develop ability to learn independently.

Medication prescribing

Dentists can prescribe medications upon initial registration. [13] This is important as evidence has shown that general practitioners prefer to refer to dentists for the management of dental emergencies. [14] Research has shown that there are potential limitations in the knowledge of dental students for conventional and complementary and alternative medications. [15] [16]

Organisations that develop evidence-based guidelines and policies

Scottish Intercollegiate Guidelines Network

Formed in 1993, the Scottish Intercollegiate Guidelines Network (SIGN) goals are to decrease the discrepancy in treatments and results, through the creation and dissemination of nationwide clinical guidelines encompassing recommendations for effective practice established on up-to-date evidence to improve the quality of health care for patients in Scotland. [17]

SIGN guidelines are established using a clear methodology [18] constructed on three fundamental principles, which are:

As of 2009, SIGN has also adopted the practise of implementing [19] the GRADE methodology to all its SIGN guidelines.

Scottish Dental Clinical Effectiveness Programme

Part of NHS Education for Scotland (NES), the Scottish Dental Clinical Effectiveness Programme (SDCEP) [20] is an initiative of the National Dental Advisory Committee (NDAC) which is an organisation of dental professionals, across all specialities, that functions as consultative wing to the Chief Dental Officer. Its main goal is to appraise the best available and pertinent information with regards to dentistry and convert it into guidelines which are easily comprehensible and executable.

The Scottish Dental Clinical Effectiveness Programme consist of a central group for Programme Development and multiple other groups for guideline development. With

the principal objective of developing guidance that delivers the best quality of patient care through supporting dental teams, the SDCEP uses the most suitable high-quality evidences from a plethora of sources to make guidelines recommendations.

Founded under the intention of NDAC to give a systematized methodology [21] when providing clinical guidance for the dental profession, the SDCEP has since become a crucial factor between the gold standard practice guidelines and dental education and practice.

Limitations and criticism

Despite the high praise for evidence-based dentistry, there are a number of limitation and criticism that has been given to the process. Chambers DW provides quite a bit of criticism, as well as a number of limitations that evidence-based dentistry provides. In no particular order of importance, a number of mentioned objections towards this format are:

Literature

Evidence-based dental journals have been developed as resources for busy clinicians to aid in the integration of current research into practice. These journals publish concise summaries of original studies as well as review articles. These critical summaries, consist of an appraisal of original research, with discussion of the relevant, practical information of the research study.

Systematic reviews are also helpful for the busy practitioner because they combine the results of multiple studies that have investigated the same specific phenomenon or question.

Related Research Articles

<span class="mw-page-title-main">Dentistry</span> Branch of medicine

Dentistry, also known as dental medicine and oral medicine, is the branch of medicine focused on the teeth, gums, and mouth. It consists of the study, diagnosis, prevention, management, and treatment of diseases, disorders, and conditions of the mouth, most commonly focused on dentition as well as the oral mucosa. Dentistry may also encompass other aspects of the craniofacial complex including the temporomandibular joint. The practitioner is called a dentist.

<span class="mw-page-title-main">Dental dam</span> A thin, rectangular sheet used in dentistry to isolate the operative site

A dental dam or rubber dam is a thin, 6-inch (150 mm) square sheet, usually latex or nitrile, used in dentistry to isolate the operative site from the rest of the mouth. Sometimes termed "Kofferdam", it was designed in the United States in 1864 by Sanford Christie Barnum. It is used mainly in endodontic, fixed prosthodontic and general restorative treatments. Its purpose is both to prevent saliva interfering with the dental work, and to prevent instruments and materials from being inhaled, swallowed or damaging the mouth. In dentistry, use of a rubber dam is sometimes referred to as isolation or moisture control.

<span class="mw-page-title-main">Dentist</span> Health care occupations caring for the mouth and teeth

A dentist, also known as a dental surgeon, is a health care professional who specializes in dentistry, the branch of medicine focused on the teeth, gums, and mouth. The dentist's supporting team aids in providing oral health services. The dental team includes dental assistants, dental hygienists, dental technicians, and sometimes dental therapists.

Tooth whitening or tooth bleaching is the process of lightening the color of human teeth. Whitening is often desirable when teeth become yellowed over time for a number of reasons, and can be achieved by changing the intrinsic or extrinsic color of the tooth enamel. The chemical degradation of the chromogens within or on the tooth is termed as bleaching.

<span class="mw-page-title-main">Dental extraction</span> Operation to remove a tooth

A dental extraction is the removal of teeth from the dental alveolus (socket) in the alveolar bone. Extractions are performed for a wide variety of reasons, but most commonly to remove teeth which have become unrestorable through tooth decay, periodontal disease, or dental trauma, especially when they are associated with toothache. Sometimes impacted wisdom teeth cause recurrent infections of the gum (pericoronitis), and may be removed when other conservative treatments have failed. In orthodontics, if the teeth are crowded, healthy teeth may be extracted to create space so the rest of the teeth can be straightened.

<span class="mw-page-title-main">Dental assistant</span> Medical profession

Dental assistants are members of the dental team. They support a dental operator in providing more efficient dental treatment. Dental assistants are distinguished from other groups of dental auxiliaries by differing training, roles and patient scopes.

<span class="mw-page-title-main">Denturist</span>

A denturist in the United States and Canada, clinical dental technologist in the United Kingdom and Ireland, dental prosthetist in Australia, or a clinical dental technician in New Zealand is a member of the oral health care team and role as primary oral health care provider who provides an oral health examination, planning treatment, takes impressions of the surrounding oral tissues, constructs and delivers removable oral prosthesis treatment directly to the patient.

Focal infection theory is the historical concept that many chronic diseases, including systemic and common ones, are caused by focal infections. In present medical consensus, a focal infection is a localized infection, often asymptomatic, that causes disease elsewhere in the host, but focal infections are fairly infrequent and limited to fairly uncommon diseases. Focal infection theory, rather, so explained virtually all diseases, including arthritis, atherosclerosis, cancer, and mental illnesses.

<span class="mw-page-title-main">Dental public health</span>

Dental Public Health (DPH) is a para-clinical specialty of dentistry that deals with the prevention of oral disease and promotion of oral health. Dental public health is involved in the assessment of key dental health needs and coming up with effective solutions to improve the dental health of populations rather than individuals.

<span class="mw-page-title-main">Dental fear</span> Medical condition

Dental fear, or dentophobia, is a normal emotional reaction to one or more specific threatening stimuli in the dental situation. However, dental anxiety is indicative of a state of apprehension that something dreadful is going to happen in relation to dental treatment, and it is usually coupled with a sense of losing control. Similarly, dental phobia denotes a severe type of dental anxiety, and is characterised by marked and persistent anxiety in relation to either clearly discernible situations or objects or to the dental setting in general. The term ‘dental fear and anxiety’ (DFA) is often used to refer to strong negative feelings associated with dental treatment among children, adolescents and adults, whether or not the criteria for a diagnosis of dental phobia are met. Dental phobia can include fear of dental procedures, dental environment or setting, fear of dental instruments or fear of the dentist as a person. People with dental phobia often avoid the dentist and neglect oral health, which may lead to painful dental problems and ultimately force a visit to the dentist. The emergency nature of this appointment may serve to worsen the phobia. This phenomenon may also be called the cycle of dental fear. Dental anxiety typically starts in childhood. There is the potential for this to place strains on relationships and negatively impact on employment.

<span class="mw-page-title-main">Fluoride varnish</span> Highly concentrated form of fluoride

Fluoride varnish is a highly concentrated form of fluoride which is applied to the tooth's surface, by a dentist, dental hygienist or other health care professional, as a type of topical fluoride therapy. It is not a permanent varnish but due to its adherent nature it is able to stay in contact with the tooth surface for several hours. It may be applied to the enamel, dentine or cementum of the tooth and can be used to help prevent decay, remineralise the tooth surface and to treat dentine hypersensitivity. There are more than 30 fluoride-containing varnish products on the market today, and they have varying compositions and delivery systems. These compositional differences lead to widely variable pharmacokinetics, the effects of which remain largely untested clinically.

Special needs dentistry, also known as special care dentistry, is a dental specialty that deals with the oral health problems of geriatric patients, patients with intellectual disabilities, and patients with other medical, physical, or psychiatric issues.

In the United States and Canada, there are twelve recognized dental specialties in which some dentists choose to train and practice, in addition to or instead of general dentistry. In the United Kingdom and Australia, there are thirteen.

Dental antibiotic prophylaxis is the administration of antibiotics to a dental patient for prevention of harmful consequences of bacteremia, that may be caused by invasion of the oral flora into an injured gingival or peri-apical vessel during dental treatment.

The American Dental Society of Anesthesiology (ADSA) is an American professional association established in 1953 and based in Chicago.

Holistic dentistry, also called biological dentistry, biologic dentistry, alternative dentistry, unconventional dentistry, or biocompatible dentistry, is the equivalent of complementary and alternative medicine for dentistry. Although the holistic dental community is diverse in its practices and approaches, common threads include strong opposition to the use of amalgam in dental fillings, nonsurgical approaches to gum disease, and the belief that root canal treatments may endanger systemic health of the patient through the spread of trapped dental bacteria to the body. Many dentists who use these terms also regard water fluoridation unfavorably.

The Hall Technique is a minimally-invasive treatment for decayed baby back (molar) teeth. Decay is sealed under preformed crowns, avoiding injections and drilling. It is one of a number of biologically orientated strategies for managing dental decay.

<span class="mw-page-title-main">Tooth mobility</span> Medical condition

Tooth mobility is the horizontal or vertical displacement of a tooth beyond its normal physiological boundaries around the gingival area, i.e. the medical term for a loose tooth.

<span class="mw-page-title-main">Dental aerosol</span> Hazardous biological compound

A dental aerosol is an aerosol that is produced from dental instrument, dental handpieces, three-way syringes, and other high-speed instruments. These aerosols may remain suspended in the clinical environment. Dental aerosols can pose risks to the clinician, staff, and other patients. The heavier particles contained within the aerosols are likely to remain suspended in the air for relatively short period and settle quickly onto surfaces, however, the lighter particles may remain suspended for longer periods and may travel some distance from the source. These smaller particles are capable of becoming deposited in the lungs when inhaled and provide a route of diseases transmission. Different dental instruments produce varying quantities of aerosol, and therefore are likely to pose differing risks of dispersing microbes from the mouth. Air turbine dental handpieces generally produce more aerosol, with electric micromotor handpieces producing less, although this depends on the configuration of water coolant used by the handpiece.

Atraumatic restorative treatment (ART) is a method for cleaning out tooth decay from teeth using only hand instruments and placing a filling. It does not use rotary dental instruments to prepare the tooth and can be performed in settings with no access to dental equipment. No drilling or local anaesthetic injections are required. ART is considered a conservative approach, not only because it removes the decayed tissue with hand instruments, avoiding removing more tissue necessary which preserves as much tooth structure as possible, but also because it avoids pulp irritation and minimises patient discomfort. ART can be used for small, medium and deep cavities caused by dental caries.

References

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Further reading