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Teaching Evidence-Based Dentistry: Some Applications to Orofacial Pain. Alan G. Glaros, Ph.D. University of Missouri - Kansas City. Evidence-Based Dentistry.
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Teaching Evidence-Based Dentistry: Some Applications to Orofacial Pain Alan G. Glaros, Ph.D. University of Missouri - Kansas City
Evidence-Based Dentistry • An approach to clinical practice that involves the ability to locate, critique, summarize and apply best available information to patients • Best available external evidence • Individual clinical expertise
Sources of Information • Manufacturers’ claims • Personal clinical experience • CE programs, study clubs • Published papers and research reports
How Trouble Begins • A relationship is established between mercury ingestion and health • There is mercury in dental amalgam • I don’t feel well and I have dental amalgams • Therefore, my symptoms are due to mercury in dental amalgams
How Trouble Begins • Dentist removes amalgam restorations • I feel better • Patient and dentist increasingly convinced that removal of amalgams produced improvements
Why EBD? • New evidence constantly being generated which will significantly change the way we care for patients, but most clinicians usually fail to get it • Therefore, both our up-to-date knowledge and our clinical performance deteriorate with time
Evidence on TMD • Glass, Glaros, & McGlynn (1993) • 47% of general dentists and 46% of dental specialists recommend irreversible procedures for TMD patients • Glaros et al. (2001) • 61.6% of Internet sites on TMD recommended irreversible procedures
Why EBD? (2) • Trying to overcome clinical entropy through traditional CE programs doesn’t improve clinical performance • EBD approaches to clinical learning may keep practitioners up-to-date
Four Tasks • Ask a well-built clinical question • Search for the best evidence • Critically appraise the evidence • Apply the results and evaluate
Four Elements • Who is the patient? What is the problem? • What intervention? What cause? What prognostic factor? • Comparison intervention • Outcome(s)
A Well-Built Clinical Question • “In a sixty-eight year old woman complaining of TM joint pain, would fabricating a splint or the use of non-steroidal anti-inflammatories provide sufficient relief from pain without causing significant side effects?”
Teaching The Asking of Answerable Questions • UMKC requires all first year students to take course in research design and methodology • 15-20% of in-class time devoted to EBD • Students practice elements of EBD in 4 of 5 brief reviews of assigned literature • Students prepare EBD final project
Teaching The Asking of Answerable Questions • In class, practice with prompted examples from instructors • Ask students to formulate their own questions on items that interest them • Bleaching • Medications for treating aphthous ulcers • Anti-virals for oral herpes lesions
Teaching The Asking of Answerable Questions • In clinic, instructors prompt students to ask questions
Four Tasks • Ask a well-built clinical question • Search for the best evidence • Critically appraise the evidence • Apply the results and evaluate
Select resource Design search strategy Search for Best Evidence
Sources of Evidence • Database (Medline) • Journals and reference libraries • CD-ROM • Internet • Journal clubs • Colleagues
Teaching Skills on How to Search • Explicit instruction on how to use search software and how to in design search strategy • At UMKC, one hour instruction • Structure of information source • Available search terms • How to operate searching software • Grateful Med
Teaching Tips • Searching specific terms better than broad, vague terms • Students familiar with Internet searches • Unstructured searches fun, but not suitable to clinical environment • Students given EBD question and asked to search on their own, then asked to use specific search strategy
Teaching Tips • Hands-on practice better than demonstration • Be prepared! • Computer lab • Use librarians • Follow-up in clinic
Four Tasks • Ask a well-built clinical question • Search for the best evidence • Critically appraise the evidence • Apply the results and evaluate
Critical Appraisal • Is the evidence valid? • Is the evidence useful?
Evaluating Evidence From Clinical Research • Single trial • Multiple trials
Potential Additional Topics • Prognosis • Meta-analysis • Economic analysis • Clinical decision analysis • Test characteristics • Numerical measures of effect
Teaching Critical Appraisal • Grand rounds • Lectures/coursework • Workshops on EBD
Teaching Critical Appraisal • Clinical patient presentation • Small groups • EBD journal clubs
Is the Evidence Useful? • Apply critical appraisal to individual patient • Intervention appropriate for patient? • Intervention consistent with patient circumstances and attitudes? • Are costs, both financial and clinical, acceptable to patient and clinician?
Nihilism • “No study is perfect, so what good is the literature?”
Avoiding Nihilism • Select good articles • Separate innocent problems from fatal flaws • Separate statistical significance from clinical significance • Emphasize methodology, not “box scores”
Avoiding Nihilism • Describe editorial and publication process • Place articles in context • How would the reader design a better study?
Changing the Culture • Cluster EBD teachers/practitioners • Encourage and value student input • Problem-based learning
Four Tasks • Ask a well-built clinical question • Search for the best evidence • Critically appraise the evidence • Apply the results and evaluate
Outcomes Assessment • Emphasize collection of outcome data • Quantification of outcomes, including side effects • Chart audits/quality assurance
EBD • Conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients • Best available external evidence • Individual clinical expertise Sackett et al., 1998
Cautions • EBD may not provide answer applicable to patient • EBD must be tempered with clinical expertise related to patient assessment, characteristics, and preferences
Useful Web Sites • www.cochrane.org • www.cche.net • www.ihs.ox.ac.uk/cebd/index.html