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Table of Contents
REVIEW ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 49-52

Evidence-based dental practice and clinical diagnosis


1 Reader and Incharge, Department of Oral Medicine and Radiology, Index Institute of Dental Sciences, Indore, Madhya Pradesh, India
2 Senior Lecturer, Department of Oral Medicine and Radiology, Index Institute of Dental Sciences, Indore, Madhya Pradesh, India

Date of Web Publication25-Sep-2019

Correspondence Address:
Dr. Deepti Singh Hada
Department of Oral Medicine and Radiology, Index Institute of Dental Sciences, Indore, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INPC.INPC_32_19

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  Abstract 


Evidence-based dentistry and its application in making diagnosis result in a significant reduction of errors. The frequency of errors depends not only on accuracy of a diagnostic pathological test but also on the prior chance of disease being present. For deciding the usefulness of diagnostic test, an added component to take into account is the relative value of the probable health states resulting from diagnosis and therapy. These can be determined by information obtained from the patient and the numerical values of the probable dental health status with the help of a visual analogue scale (VAS) technique. Clinical decision analysis can then be accomplished to calculate the applicable diagnostic approach for the patient. Clinical decision analysis is commencing to imprint the development of guidelines for the diagnostic convenience of radiographs although its further use in dentistry needs refinement and development.

Keywords: Clinical decision analysis, clinical diagnosis, Cochrane Collaboration, decision-making, evidence-based dentistry


How to cite this article:
Hada DS, Srivastava A. Evidence-based dental practice and clinical diagnosis. Int J Prev Clin Dent Res 2019;6:49-52

How to cite this URL:
Hada DS, Srivastava A. Evidence-based dental practice and clinical diagnosis. Int J Prev Clin Dent Res [serial online] 2019 [cited 2020 Jan 18];6:49-52. Available from: http://www.ijpcdr.org/text.asp?2019/6/2/49/267798




  Introduction Top


Now, we are in the age of information, illumination, innovation, and transition. Clinical decision-making based on estimable quality evidence should point to be more effective and efficient treatments. Each practitioner has a role in evaluating this information. Diagnosis is only a medium to select the paramount treatment.[1] Combining clinical data with radiological estimations to achieve a diagnosis is one of the daily grinds of the general dental practitioner. If aberration occurs in diagnosis, then lesions will be unnoticed where they are present and “lesions” will be treated which are not there. Are these two types of mistake just as critical for the patient and if not, how can we attain the ideal accord between both types of mistakes in diagnosis? Precisely identifying pathology using a diagnostic test will, among other things, reckon on the chance that pathology was already present. These and other perspectives of the evidence base of diagnosis in dentistry will be the substance of this article. In this article, we will emphasize important aspects of evidence-based dentistry (EBD) and also outlines the role, together with the advantages and problems of introducing an evidence-based approach to dentistry. There is worldwide interestedness in making dental health services effective and containing health-care costs without conciliating quality of care in the face of technological advances, demographic change, and increasing public reliance.[2],[3]

However, analogously few decisions in the health services are made as a result of agreeable evidence. Shaw [1] pointed out in his recent leader on the Cochrane Collaboration that even when there is good evidence for a particular intervention or therapy, it is often many years before it comes into general use.


  Evidence-based dentistry and related issues Top


The aim of EBD is to encourage the general dental practitioner in primary dental care to look for and make significant sense of the evidence available to apply it to daily clinical issues. However, making clinical decisions based on evidence does put up several preissues for the practitioner.


  Amount/magnitude of evidence Top


Approximately, 2 million biomedical articles are published every year in around 20,000 journals. There are roughly 500 journals related to dental health. Most of the articles are not relevant to all areas of dental practice, nor can one read all the articles.


  Quality of evidence Top


Increasing volume of evidence is produced to enhance career prospects rather than to increase knowledge and this can trade-off quality. A number of publications read in dentistry are not subject to peer review and even when they are there is the drift for publication bias. This bias is not explicit, but there is a drift both by the researchers and editors to publish explicit reviews. Adverse trials can be equally valuable, and concerns have been made that increase in sponsorship of medical trials by commercial sources can result in nonpublication of adverse or unhelpful findings. Sir Robert Boyles [4] in 1661 pointed out that “many excellent notions or experiments are, by sober and modest men suppressed,” and there seems to have been little change.


  Distribution of evidence Top


Until and unless acceptable methods of dissemination are available even where there is agreeable evidence, it can take several years for a particular treatment modality to become the specific norm.[5]


  Practice based on authorization rather than evidence Top


The application of techniques or treatment modalities based on the concept of authority rather than evidence leads to the faulty treatment being performed.


  What is evidence-based dentistry? Top


EBD is a process that restructures the approach, in which we envision about clinical issues. It is an approach to clinical issue resolving that has evolved from a self-directed and issue-based approach to acquirements rather than the traditional advisory form.[6]

This issue-based technique of learning has been extensively developed at McMaster University Medical School in Hamilton, Canada. EBD is the process of taking decisions based on accepted evidence. There are several stages in this process. The first stage is to identify the clinical issue, after which, evidence to help resolve the issue must be located.[7],[8],[9]


  What is valuable and quality evidence? Top


The gold standard for evidence is concrete evidence from at least one published review of multiple systematically designed randomized controlled trials (RCTs). However, this is not the only evidence, and there is a list of levels of evidence.[10]


  Strength and type of evidence Top


  1. Concrete evidence from at least one published systematic review of multiple systematically designed RCTs
  2. Strong evidence from at least one published systematically designed RCT of adequate size and in an adequate clinical setting
  3. Evidence from published trials without randomization, single-group pre, post, cohort, series, or matched case–controlled studies
  4. Evidence from systematically experimental studies from various center or research group
  5. Views of respected authorities based on clinical evidence, descriptive studies, and reports of expert committees.


Well-designed reviews accurately integrate present information and provide evidence to establish whether the findings are consistent and can be generalized across populations, settings, and variations in treatments. Meta-analysis is a form of well-designed review that looks at all the literature, whether acceptable, atrocious, or indifferent. The next stage is to work out grading and a conclusion for every trial. The results are then compounded with high weight being given to large studies. This produces a single estimate of the scientific effectiveness. The benefits of a meta-analysis are that it summarizes the available evidence and because of its well-designed nature, it can be appraised rapidly, and the results can be applied to patient care [11],[12],[13]


  Finding the evidence Top


There are four basic paths over which evidence can be found as follows:

  1. Confirm or ask
  2. Consult authentic textbook
  3. Refer relevant articles/publications
  4. Use a bibliographical database like MEDLINE.



  Evidence – its acceptability and sense Top


Determining the evidence is the first stage in the process. The next stage is appraisal, that is, making sense of the evidence. This appraisal should be critical and crucial that is systematically considering its effectiveness, conclusion, and applicability to work. The Cochrane Collaboration and various other agencies such as the Center for Reviews and Dissemination in York also have significant role in reviewing evidence.[14],[15]


  Action Top


Following appraisal of the evidence, there are four ways of action. We have choice to act on it, to discard it, or to keep it in storage, but one should be cautious that new evidences are always emerging, and so, there is a need to continually update it.


  Advantages of this approach Top


It enhances the effective use of research evidence in clinical trials

The clinical issue resolving approach to dental practice favors the prior uptake of new and improved treatment modalities, or results in the early rejection of less effective or ineffective therapies.

It uses resources more effectively

Systematic reviews of materials, for example, may lead to the earlier adoption of the most effective ones. This, in turn, should lead to a reduction in replacement levels, thereby saving resources.[16]

It depends on evidence rather than authority for clinical decision appraisal

Regular and legitimate reviewing of the presently available evidence should develop and enhance us as dental practitioners, so that we develop the skills to evaluate and determine the available evidence based on our clinical practice and assessment of the evidence, rather than books or authorities who may not be revised. This appraisal of evidence is essential to aid the approach to clinical/scientific decision-making as described by Kay and Nuttall [17] in their recent series of article.

Developing and monitoring clinical performance

The use of the outlined skills enables us to monitor and develop our clinical practice. The successfulness of these results in clinical audit introduced to clinical practitioner on experimental basis. This provides an exemplary opportunity for audit to be properly structured on framework depending on evidence. The proposed clinical audit coordinator in clinical practice can play a key role in encouraging EBD which will enhance the quality and focus of audit.[18]


  Conclusions Top


This approach needs to be executed not only among the postgraduates but is equally essential in the dental colleges. This will ensure that students are not only taught about clinical techniques in different departments but also learn to make use of critical appraisal treatments modalities and their outcomes, so that they are routinely assessed for overall health benefits for their patients. It is equally important to structure postgraduate program on an evidence base and to encourage dental professionals to take a broader view in forming EBD units. While this is understandable, it overlooks the need to consider the effectiveness and entire impact on dental health of the patients. It is equally important that the whole dental fraternity and not just few dentists are involved. The pressure of clinical practice tends to make practitioners “off” the “learn mode,” but there is a necessity to switch the learn mode “on” again. Being able to offer advanced information depending on accurately evaluated evidence will definitely help with increasing demands of patients. It also helps dental professionals to check claims of various representatives of different dental and drug companies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shaw WC. The Cochrane Collaboration: Oral health group. Br Dent J 1994;177:272-3.  Back to cited text no. 1
    
2.
Crowley P, Chalmers I, Keirse MJ. The effects of corticosteroid administration before preterm delivery: An overview of the evidence from controlled trials. Br J Obstet Gynaecol 1990;97:11-25.  Back to cited text no. 2
    
3.
Lau J, Antman EM, Jimenez-Silva J, Kupelnick B, Mosteller F, Chalmers TC. Cumulative meta-analysis of therapeutic trials for myocardial infarction. N Engl J Med 1992;327:248-54.  Back to cited text no. 3
    
4.
Hall MB. In defence of the experimental essay. In Boyle R, editor. Natural Philosophy. Bloomington: Indiana University Press; 1965. p. 119-31.  Back to cited text no. 4
    
5.
Chalmers I, Haynes B. Reporting, updating, and correcting systematic reviews of the effects of health care. BMJ 1994;309:862-5.  Back to cited text no. 5
    
6.
Weatherall DJ, Ledingham JG, Warrell DA. Oxford Textbook of Medicine. 2nd ed.. London: Oxford University Press; 1987.  Back to cited text no. 6
    
7.
Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical Epidemiology. A Basic Science for Clinical Medicine. 2nd ed.. Boston: Little, Brown and Co.; 1991.  Back to cited text no. 7
    
8.
DePaola PF, Soparkar PM, Triol C, Volpe AR, Garcia L, Duffy J, et al. The relative anticaries effectiveness of sodium monofluorophosphate and sodium fluoride as contained in currently available dentifrice formulations. Am J Dent 1993;6:S7-12.  Back to cited text no. 8
    
9.
Hayes C, Antczak-Bouckoms A, Burdick E. Quality assessment and meta-analysis of systemic tetracycline use in chronic adult periodontitis. J Clin Periodontol 1992;19:164-8.  Back to cited text no. 9
    
10.
Bulman JS. A critical approach to the reading of analytical reports. Br Dent J 1988;165:180-2.  Back to cited text no. 10
    
11.
Milne R, Chambers L. Assessing the scientific quality of review articles. J Epidemiol Community Health 1993;47:169-70.  Back to cited text no. 11
    
12.
Mulrow CD. Rationale for systematic reviews. BMJ 1994;309:597-9.  Back to cited text no. 12
    
13.
Oxman AD. Checklists for review articles. BMJ 1994;309:648-51.  Back to cited text no. 13
    
14.
Knipschild P. Systematic reviews. Some examples. BMJ 1994;309:719-21.  Back to cited text no. 14
    
15.
Eysenck HJ. Meta-analysis and its problems. BMJ 1994;309:789-92.  Back to cited text no. 15
    
16.
Clarke MJ, Stewart LA. Obtaining data from randomised controlled trials: How much do we need for reliable and informative meta-analyses? BMJ 1994;309:1007-10.  Back to cited text no. 16
    
17.
Kay E, Nuttall N. Clinical decision making an art or a science? Part I: An introduction. Br Dent J 1995;178:76-8.  Back to cited text no. 17
    
18.
Kao RT. The challenges of transferring evidence-based dentistry into practice. J Evid Based Dent Pract.  Back to cited text no. 18
    




 

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  In this article
   Abstract
  Introduction
   Evidence-based d...
   Amount/magnitude...
  Quality of evidence
   Distribution of ...
   Practice based o...
   What is evidence...
   What is valuable...
   Strength and typ...
  Finding the evidence
   Evidence –...
  Action
   Advantages of th...
  Conclusions
   References

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