Evidence based dentistry etc Flashcards
What is evidence-based medicine
Using the best evidence to make decisions about diagnoses and treatment. Involves systemic location, appraisal and implementation of existing evidence.
Why do we need evidence-based dentistry
- Duty to the patient e.g. ethically and professionally have to do what’s best.
- Patient’s expectations are changing e.g. want compensation, better quality, etc.
- Greater need for healthcare and new interventions e.g. due to aging pop.
- New evidence/data about existing stuff
EBD benefits
- Information is clearer for the patient so expectations are realistic.
- Less damage caused by the dentist
- Limited resources used more efficiently.
- Clinical benefits/effectiveness of treatment assessed.
- Kept up to date.
The steps to carrying out evidence-based healthcare
- Finding a good question
- Collecting evidence
- Appraising the evidence
- Implementing the evidence
Defining the question for EBD
Needs to be specific to a healthcare problem or treatment. Should be searchable, realistic and important.
Collecting evidence for EBD/levels of evidence
Good quality evidence e.g. from Cochrane library, systemic research, online databases.
Level 1 = strong from 1+ SR
level 2 = strong from 1+ RCT
Level 3 = good non-randomised trials
Level 4 = non-experimental, from 2+ research groups
Level 5 = expert opinion
Appraising the evidence in EBD
Assessing the quality of the evidence e.g. the research method, conduct, and design. Using systemic review to appraise the evidence and levels of evidence.
RCT = group all start at baseline and then either given treatment or not, followed over a period of time and groups compared at the end.
Synthesizing the results e.g. into a Forrest plot, meta-analysis, statistical summary of results.
Implementing the evidence in EBD
Advice, payment or treatment shouldn’t be carried out without evidence.
Evidence can be used on one patient or one tooth,
Evidence can be turned into a clinical guideline/pathway
Evidence can be used to influence payment structure
Hypothesis testing research design
Hypothesis already present. Uses SR or RCT/ experimental or non-experimental testing etc. to collect data (quantitative)
Hypothesis synthesizing research design
Qualitative - looking at how people think and behave e.g. using surveys and focus groups.
Quantitative:
- Case series e.g. looking at a group with a disease and seeing if there are any similarities.
- Surveys to see if there is a pattern between data.
Still, need to test the hypothesis.
Types of research/studies, in order of strongest evidence to weakest.
- Meta-analysis
- Systemic review
- RCT
- Cohort study
- Case-control study
- Case series/case reports
- Animal/lab studies
Types of research/studies, in order of strongest evidence to weakest.
- Meta-analysis
- Systemic review
- RCT
- Cohort study
- Case-control study
- Case series/case reports
- Animal/lab studies
Meta-analysis
Statistical analysis of all the data and making one conclusion.
Systemic review
Looking at all the RCTs and secondary data and compiling them into one big study e.g. adding up the test group numbers.
Looks at prevention, treatment, and rehabilitation too.
Systemic review benefits
Can find results quickly.
Kept up to date.
Less bias and random error.
Reviewers report better e.g. more structured and documented.
Each stage is peer-reviewed.
Assesses validity, applicability, and implications of results
Randomised control trial
A group all at the same baseline split randomly into 1 receiving treatment and 1 not. Groups followed over a set time and treated the same and then results compared.
Starting group size is bigger than end because people drop out - this needs to be documented so can see if it is due to the study.
Better if blind trial.
Tells us that results are due to intervention only.
Cohort studies
Follow-up.
Group of people with suspected exposure to something or not recalled after a given time to see if there is an outcome or not for both groups.
Groups are not similar at the start and may not be treated the same over the set time.
Case-controlled studies
Study people with and without the disease and then look back to see potential risk factors.
Bad because is susceptible to bias and people w the disease will remember events differently to those without the disease.
Cross-sectional analytical study
Study w a hypothesis. Studies existing disease and risk factor at a set time.
Can’t determine cause and effect.
People may have died so isn’t representative of the whole population.
Quick and cheap.
Ecological studies
Comparing between populations/groups and not individuals.
Cheap, easy and data is available.
Can’t prove cause and effect.
What is validity and how can it be compromised
Validity is the degree to which research results are correct and generalized.
Sometimes have to make compromises so that the study is realistic and ethical etc. The reader determines if the compromises affected the validity of the results so that they’re not useful.
Threats to validity
Random and systematic errors.
Selection error
Information error
Confounding
Selection error
The sample might not represent everyone.
Bias e.g. one group might be more represented.
Some people don’t want to/can’t respond so won’t be represented in the study.
Information error
When the difference between groups’ results isn’t large enough or study measurements aren’t correct.
Decrease by increasing sample size and by reducing bias e.g. don’t use recall data and make measurements more objective and standardized.
Confounding
When the results/relationship can be completely explained by another factor.
Risk of this happening increases as the level of evidence decreases.
Reduce risk by changing the design or analysis etc. of the study.
Evidence based prevention in children - caries
Risk assessment =
- Previous disease/dental history
- Diet
- SES
- Systemic illness/saliva/bacteria
- Fluoride use/tooth brushing
Toothbrushing
- Motivator was having fresh breath and good appearance e.g. relate caries to diet not brushing.
- Morning brushing > evening
- The effect increases w [F], frequency and technique.
Diet
- No evidence that diet advice is effective
- Use a diet diary
Preventing oral diseases in adults
Recommend smoking cessation
Diet advice e.g. eat less sugar
Preventative treatments e.g. fluoride varnish
High F toothpaste, mouthwash, interdental brushes.
Steps to the prevention of disease (primary, secondary, tertiary)
- Stop healthy people from getting the disease
- Halt the progression of the disease in people at risk or at an early stage.
- Treat the symptoms for people w the disease to stop further complications etc.
Ways to implement EBD
Clinical guidlines
Payment structures
On treatment decisions
On management decisions
Clinical guidelines and how they’re used
Systematically developed from reviews of evidence and research.
An example of clinical governance e.g. they influence the way a court judges the case (doesn’t mean that following them means you avoid negligence and vice versa).
+/- of clinical guidelines
Good =
- The same standard of care for all specialties and dentists etc.
- Interventions that are beneficial vs ineffective can be identified.
Bad =
- go out of date quickly
- doesn’t allow for freedom of choice/professional opinion or special cases or patient’s preferences.
Steps/stages of guideline development.
- Scope and purpose
- Stakeholder investment
- Rigour of development
- Clarity and presentation
- Applicability
- Editorial independence
- Implementation
what is NICE/its role?
The national institute of health and clinical excellence.
Publishes guidance on the most recent best practice for the public, patient’s and professionals to increase public confidence.
An example of EBD clinical guidelines
Recall intervals:
- Studies (by NICE and systemic reviews) = inconclusive for a 6-month interval.
- Too short interval = waste of dentist’s and patient’s money and time and false positives more likely.
- Too long interval = diseases not diagnosed early enough e.g. oral cancer.
- Caries take 2-4 years to develop in permanent teeth so, for over 18s, maximum recall interval is 24 months.
- Minimum interval = 3 months, for high-risk patients.
- for under 18s, maximum interval = 12 months.
- Review interval at next appointment.
Smoking information
Most people want o stop but only 2% do.
The dentist needs to check then smoking status of their patient every year, and always recommend quitting.
Cigarettes burn really hot (60-700 degrees) and contain tar, nicotine, CO2, CO, acetone, arsenic (toxins, poisons, etc).
Diseases and oral health problems associated w smoking
Pulmonary diseases e.g. bronchitis, COPD Cardiovascular problems - narrowing and stiffening of the arteries = increased blood pressure etc. Cancers Periodontal disease No healing e.g. of ulcers Aesthetics e.g. staining Trauma due to the heat (smoker's palate)
Symptoms of smoking (oral)
Difficulty swallowing and speaking (numbness in the mouth)
Hairy tongue and leukoplakia (white patch)
Swellings in neck
Bad breath
Earache
Ulcers don’t heal.
What is the dentist’s role to their smoker patient
ASK, ADVISE, ACT
Different definitions of health
Medical = absence of disease. Social = social, economic, political, environmental, phsycological well being. WHO = physical, emotional and social well-being Oral = Ability to speak, smell, eat, express emotions through facial expressions, etc without pain or disease.
Key features of health promotion
Education, prevention, protection.
Can involve politica and environmental action.
Examples of health promotion models
Ottowa Charter (WHO) Tannahill's model
Ottawa charter (WHO)
Creating a public health policy that can be used everywhere e.g. prisons too.
Empower the local community e.g. selling and buying locally sourced stuff.
Develop personal skills - education and life skills.
Creating supporting environments.
Tannahill’s model
Educate - influence attitudes.
Prevent - e.g. using medical interventions.
Protect - e.g. legislative, social measures.
Benefits of health promotion
- Cost much less to prevent than to treat illnesses etc.
- Reduces the inequalities between poor and rich people.
- Some conditions just need education/a change in behavior to treat them.
