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Evidence based dentistry > Evidence based dentistry > Flashcards

Evidence based dentistry Flashcards

1
Q

What is evidence based dentistry

A

An approach to oral health care that requires the judicious integration of:​

-systematic assessments of clinically relevant scientific evidence, relating to the patients oral and medical condition and history, together with the​

-dentists clinical expertise and​

-the patients treatment needs and preferences​

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2
Q

What are the 5 As

A

Ask
Align
Acquire
Appraise
Apply

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3
Q

What is the process of evidence based practice

A

How to ask the clinical questions in a focused way so that you can FIND the evidence and APPRAISE the evidence [ASK-BDS1]​

Search for and retrieve evidence [ALIGN/ACQUIRE- BDS2]​
-Know where to go for good evidence​
-Be sure that you get all of it​
-And you understand the strengths and weaknesses of different sources​

Critically appraise the evidence for validity and clinical relevance [APPRAISE-BDS3/4]​
-Is it good evidence?​
-Is it important from a clinical point of view? ​

Applying this evidence to patient treatment/care [APPLY-BDS3+]​
-Does it apply to my patients?​

Reflection​
-Can I do things differently next time?​

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4
Q

What are some decisions and questions where evidence would be required

A

-Placing a stainless steel crown versus conventional restoration ?​
-Analgesia before treatment to reduce post-operative pain?​
-Powered versus manual tooth brush ?​
-Recommending flossing to your patients?​
-Is there any difference in effectiveness when undertaking root canal treatment in one visit compared to over several visits?​
-What are the effects on pain and complications?​
-What is the optimal interval for dental check-ups?​

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5
Q

What is evidence

A

Evidence is the available body of facts or information to show whether a belief or statement is true or valid

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6
Q

Study of 1000 patients treated in primary care in Australia​

Looked at 22 most common conditions seen in primary care​

What proportion of patients received evidence-based care for ​

Coronary heart disease – ​

Alcohol dependence –

A

Coronary heart disease – 90%​

Alcohol dependence – 13%

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7
Q

Why should you practice evidence based dentistry

A

Professionally: It is part of your professional role and a requirement of your regulatory body (GDC)​

Personally: you should be informed on how to spot a scare story/ fad/ pseudo-science to avoid you (or your loved ones) being ripped off, duped, wrongly treated, sub-optimally treated, exposed to harmful practices​

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8
Q

What can clinicians use to make decisions

A

Clinical experience
Text books
Patient groups
Teachers
Healthcare research
Popular media

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9
Q

What do the public believe about healthcare decisions​

A

Research funding and efforts are coordinated and prioritized​

The progress of research is steady and upwards​

The results of research are systematically applied to clinical practice​

All clinical practice is evidence based​

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10
Q

What is peer review

A

The system through which scientists/ researchers decide which research studies should be published in a scientific journal​

Eg British Dental Journal; British Medical Journal; The Lancet; Nature ​

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11
Q

How does peer review work

A

When researchers or a team of researchers finish their work, they usually will write a “paper” presenting their methods, findings and conclusions.​

This paper is sent to a scientific journal to be considered for publication​

The editor decides if the topic is suitable for their journal then sends the paper to peer reviewers (other scientists working in the same area who have expertise on the topic). The peer reviewers​
-Comments on the validity of the study (design, methods, results)​
-Judge importance​
-Judge originality​
-Should the paper be published/ improved/rejected ​

Peer review means that to some extent the research has passed the scrutiny of other scientists, and is considered valid, important and original.​

Peer review is also used to assess applications for grant funding.​

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12
Q

What are the issues with peer review

A

Corruption​

Cant prevent fraud, plagiarism or duplication (only in more obvious cases)​

Quality of the review process​

Skills of the reviewer​

Time-consuming

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13
Q

What makes bad research

A

Not needed ​
-No more research is required as we have the answer​

Poor design​
-Wrong design​
-Inappropriate control/ comparison group​
-Biased (many issues)​

Poorly reported​

Not reported​

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14
Q

How to ask the questions in a focused way so that you can FIND the evidence and APPRAISE the evidence

A

POPULATION​
-How would I describe a group of patients similar to this one?​

INTERVENTION​
-What is being “done” to the patients​
-Could be an exposure (eg carcinogen)​

COMPARISON​
-What are we comparing to?​

OUTCOME​
-Desired or undesired​

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15
Q

What clinical guidelines should dental professional follow

A

NICE
SIGN
SDCEP

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16
Q

A child presents with a carious primary molar. How do you manage this?

A

Complete removal of carious tissue before restoring tooth?​

Seal in caries?​

Does the Hall Technique for sealing in caries offer long-term benefits over current GDP practice?​

Population​
-Children with caries in primary teeth​

Intervention​
-Hall technique​

Comparison​
-Current practice​
-Removal and restoration (eg)​

Outcomes​
-Rate of failure

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17
Q

When researching for evidence we should consider, have the authors used:

A

Population​

Intervention​

Comparison​

Outcome​

That are relevant to your question

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18
Q

WHAT IS THE PICO:
A child patient requires a dental extraction via General Anaesthetic (GA). Some surgeons administer Local Anaesthetic (LA) intra-operatively to reduce post-operative pain​

…but anecdotally some report this is distressing, uncomfortable, causes excessive dribbling and inadvertent lip/cheek biting

A

Population: Children undergoing dental general anaesthetic​

Intervention: Local Anaesthetic intra-operatively​

Comparison: placebo / no treatment​

Outcome: post-operative pain/distress​
-Bleeding​
-Cardiac ​
-Lip biting/cheek biting​
-Satisfaction​
-anxiety

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19
Q

FORM A PICO
The common cold causes enormous morbidity worldwide and the search for simple and effective preventive or therapeutic agents has been elusive. Even if vitamin C might have modest effects in restricted population groups, that could be important from a public health point of view.​

There has been 70 years of conflicting evidence around the benefit of Vitamin C in preventing the cold and in shortening the number of “sick days”. Some have suggested that high doses may be more effective

A

Population: In the general population (adults/children/males/females)​

Intervention: Vitamin C (dosage/ frequency)​

Comparison: Placebo/ No treatment​

Outcome: Incidence of cold/ days sick with cold

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20
Q

GENERATE PICO:
A 35 year old patient attends for a routine appointment and asks you if she should purchase a powered toothbrush (~£100)- She wants to know if it will improve her oral health…

A

Population: In the general population (adults/children)​

Intervention: powered toothbrush (different types)​

Comparison: manual toothbrush​

Outcome: decay/ periodontitis/ plaque/ gingivitis

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21
Q

What are the criticisms of evidence based dentistry

A

The tendency of a group of young, confident and highly numerate medical academics to belittle the performance of experienced clinicians using a combination of epidemiological jargon and statistical sleight-of-hand or ​

the argument, usually presented with near-evangelistic zeal, that no health-related action should ever be taken by a doctor, a nurse, a purchaser of health services, or a policy maker, unless and until the results of several large and expensive research trials have appeared in print and approved by a committee of experts.

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22
Q

What is risk

A

The chances of something happening
Can be good or bad

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23
Q

What is outcome

A

“something” that might happen​

Death, heart attack, cancer diagnosis​

Tooth decay/ periodontitis/ TMJD​

Caries free

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24
Q

What are statistics

A

Numbers that summarize information​

Based on observations of large numbers people ​

Useful in predicting what is likely to happen in the future​

The chance that an outcome will happen​

Risk statistics​

Fractions

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25
Q

How is odds calculated

A

odds = number of events of interest / number without the event

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26
Q

How is risk interpreted

A

Risk of what?​
-What is the outcome?​
-Getting a disease? Dying from a disease
-Developing a symptom? Surviving a disease?​

How big is the risk?​
-What are the chances of experiencing the outcome?​
-Out of how many?​

What is the timeframe? Next year? Next 10 years? Lifetime?​
-Out of 1000 people in the last 10 years​

Does the risk information reasonably apply to me or my patient?​
-Age/sex/lifestyle​

How does this risk compare with other risks?​
-Perspective- which risk should I do something about?​

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27
Q

What is ARD

A

Absolute risk difference

28
Q

What value would the RR take if the risks in both groups were equal (ie no benefit of paracetamol over placebo) ?

A

1

29
Q

When is a case report/case series used

A

Used for​

Identify new disease outcome​

Hypothesis generation

30
Q

What is a case report/case series

A

A report on a single patient or series of patients with an outcome of interest​

No control group is involved

31
Q

What are the disadvantages of case report/series

A

Disadvantages​

Cannot demonstrate valid statistical associations​

Lack of control group

32
Q

What study is used:
What is the incidence of oesophageal cancer in adults?

A

Cohort study

33
Q

What study is used to determine:
Does nystatin prevent oral candidiasis in patients receiving treatment for head and neck cancer?

A

Randomised controlled trial
Systemic review and meta analysis

34
Q

How can we determine:
What are parents’ experiences of their child’s dental anaesthesia?

A

Cross-sectional study

35
Q

What study is best to find:
Are teenagers with crossbites more likely to go on to develop temporomandibular joint disorders ?

A

Case control study
Cohort study

36
Q

What study can be used to determine:
What is the prevalence of cleft lip and palate in children born in the West Coast of Scotland?

A

Cross-sectional study
Cohort study

37
Q

How can we answer this question:
What risk factors are associated with root resorption in patients who have undergone orthodontic treatment ?

A

Case-control study
Cohort study

38
Q

What is a confidence interval

A

A confidence interval tells us the range of values that a true population treatment effect (eg RR) is likely to lie

39
Q

If the value of no difference is 1 and the confidence interval embraces/overlaps/contains or straddles this what does it indicate

A

insufficient evidence that there is a difference between paracetamol and placebo (check sample size)​

40
Q

If the value of no difference isnot within the CI what does it show

A

If this interval does not embrace/overlap/contain/ straddle 1 sufficient evidence to suggest there is a difference

41
Q

Hersh 2000
63% vs 18%
63/18= 3.42
RR= 3.42
95% Confidence Interval = 1.52 to 7.73
Is there sufficient evidence that paracetamol is effective in pain relief for extraction in the population ?

A

There is sufficient evidence to suggest that patients in paracetamol group are 3.42 times more likely to experience pain relief than patients in placebo group. This may be as low as 1.52 or as high as 7.73 times more likely in the population. The wide CI may reflect the small sample size.

42
Q

How do confidence intervals prove significance

A

For a DIFFERENCE between two quantities​
-If two values are equal, the difference would be 0​
-The “value of no difference” is 0​
-There is sufficient evidence for a difference between two values in the population if the CI for the difference does not overlap 0​

For a RATIO between two quantities​
-If two values are equal, the ratio would be 1​
-The “value of no difference” is 1​
-There is sufficient evidence for a difference between two values in the population if the CI for the ratio does not overlap 1

43
Q

What do obdervational uncontrolled studies look like

A

Researchers watch what happens to a group of people​

A group of patients has disease A and is treated with drug X​

The researchers observe how many get better​

How believable?

44
Q

What is a controlled study

A

Cohort or case control​

Researchers observe what happens to people in different situations-without intervening

45
Q

Rank the studies from most to least evidence

A

-Systemic reviews and meta analysis
-Randomised controlled trials
-Cohort studies
-Case-contolled studies
-Cross-sectional surveys
-Ecological studies
-Case series and case reports
-Ideas,editorialsand opinions

46
Q

What is a cross-sectional study

A

The observation of a defined population at a single point in time (or time interval)​
-Exposure and outcome are determined at the same time

47
Q

When is a cross-sectional study used

A

Estimating prevalence of a disease​

Investigate potential risk factors

48
Q

What are some disadvantages of cross-sectional study

A

Causality​

Confounding​

Recall bias

49
Q

What is a case-control study

A

The study of people with a disease and a suitable control group of people without the disease​
-Looks back in time at exposure to a particular risk factor in both groups

50
Q

What is a case-control study used for

A

Looking at potential causes of disease

51
Q

What are the disadvantages of case-control study

A

Confounding​

Recall / selection bias​

Selection of controls​

Time relationships (did exposure occur before disease?)

52
Q

What does a case-control study look like

A

100 peoplewith oral cancer (who smokes, who doesnt)

100 people without oral cancer (who smokes, who doesnt)

COMPARE

53
Q

What is a cohort study

A

Cohort Study​

Establish a group of individuals in population​

Measure exposures​

Follow up over a period of time​

Identify those that develop disease (outcome of interest)

54
Q

What disadvantages does a cohort study have

A

Controls difficult to identify​

Confounding​

Blinding difficult​

For rare diseases- need large samples​

Very expensive/ time consuming

55
Q

When is a cohort study used

A

Estimating incidence of disease​

Investigating causes of disease​

Determining prognosis​

Timing and direction of events

56
Q

What is a randomised controlled trial

A

Sometimes referred to as a Clinical Trial​

RCTs considered the gold standard study design​

For effectiveness and efficacy​

Particularly useful for clinical studies​

Provides strongest evidence on effectiveness of treatments

57
Q

What study provides the strongest evidence

A

Randomised controlled trials

58
Q

What are the 4 elements to a RCT

A

Specification of participants (inclusion/ exclusion criteria)​

Control/ Comparison groups​

Randomisation​

Blinding/ Masking

59
Q

What are the inclusion or exclusion criteria of a randomised controlled trial

A

Age​

Disease severity/ diagnosis

Unambiguous​

Exact definitions

60
Q

What is a comparison group

A

Placebo (control group)

61
Q

Why is a comparison group needed

A

To prove the treatment is the cause for the results and not just the patient getting better by themselves

62
Q

Why is randomisation needed

A

To minimise Bias​

Older patients​

Patients with more severe disease

63
Q

What is allocation concealment

A

A technique used to prevent selection bias by concealing the allocation sequence from those assigning participants to intervention groups, until the moment of assignment. Allocation concealment prevents researchers from (unconsciously or otherwise) influencing which participants are assigned to a given intervention group.​

64
Q

What are the advantages of RCTs

A

Provide strongest and most direct epidemiologic evidence for causality​
​
BUT ​

Non-blinded RCTs may overestimate treatment effects eg estimates of effect from trials with inadequately concealed allocation have been 40% larger than clinical trials with adequately concealed random allocation

65
Q

What are the disadvantages of RCTs

A

More difficult to design and conduct than observational studies​

ethical issues​

feasibility​

costs​

Still some risk of bias and generalisibility often limited​

Not suitable for all research questions

66
Q

What does consort stand for

A

Consolidation of the standards of reporting trials

67
Q

What is a consort

A

Statement called Consolidation of the Standards of Reporting Trials (CONSORT)​

Aimed to improve the standard of written reports of RCTs ​

Evidence based dentistry (1 decks)

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