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Teaching Evidence-Based Dentistry: Some Applications to Orofacial Pain

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

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  1. Teaching Evidence-Based Dentistry: Some Applications to Orofacial Pain Alan G. Glaros, Ph.D. University of Missouri - Kansas City

  2. 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

  3. Sources of Information • Manufacturers’ claims • Personal clinical experience • CE programs, study clubs • Published papers and research reports

  4. 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

  5. How Trouble Begins • Dentist removes amalgam restorations • I feel better • Patient and dentist increasingly convinced that removal of amalgams produced improvements

  6. 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

  7. 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

  8. 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

  9. Four Tasks • Ask a well-built clinical question • Search for the best evidence • Critically appraise the evidence • Apply the results and evaluate

  10. Four Elements • Who is the patient? What is the problem? • What intervention? What cause? What prognostic factor? • Comparison intervention • Outcome(s)

  11. 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?”

  12. 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

  13. 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

  14. Teaching The Asking of Answerable Questions • In clinic, instructors prompt students to ask questions

  15. Four Tasks • Ask a well-built clinical question • Search for the best evidence • Critically appraise the evidence • Apply the results and evaluate

  16. Select resource Design search strategy Search for Best Evidence

  17. Sources of Evidence • Database (Medline) • Journals and reference libraries • CD-ROM • Internet • Journal clubs • Colleagues

  18. 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

  19. 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

  20. Teaching Tips • Hands-on practice better than demonstration • Be prepared! • Computer lab • Use librarians • Follow-up in clinic

  21. Four Tasks • Ask a well-built clinical question • Search for the best evidence • Critically appraise the evidence • Apply the results and evaluate

  22. Critical Appraisal • Is the evidence valid? • Is the evidence useful?

  23. Evaluating Evidence From Clinical Research • Single trial • Multiple trials

  24. Potential Additional Topics • Prognosis • Meta-analysis • Economic analysis • Clinical decision analysis • Test characteristics • Numerical measures of effect

  25. Teaching Critical Appraisal • Grand rounds • Lectures/coursework • Workshops on EBD

  26. Teaching Critical Appraisal • Clinical patient presentation • Small groups • EBD journal clubs

  27. 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?

  28. Nihilism • “No study is perfect, so what good is the literature?”

  29. Avoiding Nihilism • Select good articles • Separate innocent problems from fatal flaws • Separate statistical significance from clinical significance • Emphasize methodology, not “box scores”

  30. Avoiding Nihilism • Describe editorial and publication process • Place articles in context • How would the reader design a better study?

  31. Changing the Culture • Cluster EBD teachers/practitioners • Encourage and value student input • Problem-based learning

  32. Four Tasks • Ask a well-built clinical question • Search for the best evidence • Critically appraise the evidence • Apply the results and evaluate

  33. Outcomes Assessment • Emphasize collection of outcome data • Quantification of outcomes, including side effects • Chart audits/quality assurance

  34. 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

  35. Cautions • EBD may not provide answer applicable to patient • EBD must be tempered with clinical expertise related to patient assessment, characteristics, and preferences

  36. Useful Web Sites • www.cochrane.org • www.cche.net • www.ihs.ox.ac.uk/cebd/index.html

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