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Evidence-Based Practice: More Than Just Facts

The following appeared in the December 2012 issues of SUNSTAR E-Briefs.

Developing the skills necessary to find and evaluate quality data is a vital component of providing state-of-the-art oral health care. Dental hygienists are directly accountable for the quality of services they provide, and this tenet is first among the edicts listed in the American Dental Hygienists' Association Policy Manual.1 In this important guidebook, the association also advocates evidence-based, patient-centered practice, which can help clinicians improve the level of care they deliver.1

But what is evidence-based practice? This is an approach to care that blends clinical expertise with the highest-quality research, taking into account the patient's own values.2 Effectively leveraging this research, however, requires the ability to carefully evaluate the quality of the information presented. This Sunstar E-Brief provides guidance to help dental hygienists understand the characteristics of high-quality data, and offers strategies to help locate and vet this information.

A steady stream of oral health care research is conducted each year, and clinicians who wish to evaluate emerging data may feel overwhelmed by the flow of new reports. One tool that can help simplify the task of finding and evaluating quality research is a "quality-of-evidence" pyramid, such as that used by the Turning Research Into Practice Database Plus.3 This pyramid ranks quality of evidence in descending order, and includes systematic reviews; critically appraised topics (evidence syntheses); critically appraised individual articles (article synopses); randomized control trials; cohort studies; case-controlled studies and case series reports; and background information/expert opinion sources.

SYSTEMATIC REVIEW: THE GOLD STANDARD

Most commonly found in specialty oral health journals, systematic reviews represent the highest-quality information found in the evidence-based paradigm. The goal of a systematic review is to synthesize the findings of multiple original studies, and then set limits on the bias of those studies.4 Researchers value prefiltered evidence, as it has been reviewed by one or more individuals with specific expertise to summarize and present the strongest data from a particular field according to methodology.5 Dental hygienists can save significant time reading systematic reviews, as opposed to locating and analyzing individual studies.6

The intent of evidence-based practice is to close the gap between what is known from scientific research and what is practiced, notes Jane L. Forrest, RDH, EdD, director of the National Center for Dental Hygiene Research & Practice at the Ostrow School of Dentistry, University of Southern California in Los Angeles. The goal, she says, is to improve patient care through informed decision-making. "Evidence-based decisions provide a systematic way to manage the information overload, and help increase efficiency when searching the literature to answer clinical questions," she explains.

This approach also provides a basis for lifelong learning and serves as a foundation for adapting to practice changes, such as the introduction of innovative approaches to disease prevention and therapy.

FOLLOW THE EVIDENCE

Although an abundance of research is available online, sifting through volumes of unfiltered data may not be feasible from a time-management perspective. To speed the process, there are at least two sources where dental hygienists may find quality systematic reviews. One is the Cochrane Collaboration, a United Kingdom-based international network that offers primary research for evidence-based health care known as Cochrane Reviews. Another is offered by the federal National Institutes of Health's National Library of Medicine, which manages PubMed, a searchable database comprising more than 22 million citations for biomedical literature.

Once quality evidence is found, research skills are critical in analyzing the data. Forrest explains that evidence-based decision-making skills have only recently been taught in dental hygiene programs, however, and were not covered under traditional curriculums. Clinicians who wish to acquire these skills can take advantage of continuing education (CE) courses and online resources, she notes, including the National Center for Dental Hygiene Research & Practice's website. In addition, the Guide to Research Methods, the Evidence Pyramid provides a review of research designs and levels of evidence that can help dental hygienists decide whether a study's findings are clinically relevant in their practice.

Recognizing that patients like to have their oral health questions answered quickly, Forrest stresses the need for clinicians to be skilled enough to find and evaluate scientific literature to determine its validity and whether it applies to their patients. "Attending CE courses periodically does not address the ability to answer specific questions in a timely manner," she says. "In addition, many courses do not necessarily present information based on clinical practice guidelines—which represent one of the highest levels of evidence."

Forrest further suggests it is critical for dental hygienists to understand the underlying scientific rationale for the care they deliver. They should also be able to distinguish scientifically based developments from those based on belief or opinion. The American Dental Association Commission on Dental Accreditation Standards for Dental Hygiene Programs, she notes, requires students to master these skills in order to stay current with the scientific literature.

CONSIDER THE PATIENT

Evidence-based practice does not succeed solely on the evidence itself, however. It also requires clinicians to consider how the evidence will integrate with "patient values." Patients arrive at the dental appointment with their own sets of concerns, expectations and values, and some may hold strong religious or cultural beliefs that will affect their choice of care.7 Others prefer to be treated according to personal circumstances. For example, treatments for a patient diagnosed with larynx cancer might include radiation and surgery. And though evidence indicates that surgery may increase life expectancy, the procedure leaves a hole in the throat; knowing this, the patient may opt for radiation therapy out of quality-of-life considerations.8

Ultimately, while evidence-based practice may not come easily to all clinicians, the extra effort required by this approach allows oral health professionals to deliver a high level of care to their patients—which is a reward in itself.

  1. American Dental Hygienists' Association Policy Manual. Available at: www.adha.org/resources-docs/7614_Policy_Manual.pdf. Accessed November 21, 2013.
  2. Sackett DL, Richardson SW, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh: Churchill Livingstone; 2000:1.
  3. Trustees of Dartmouth College and Yale University. Evidence-Based Medicine Resources. Available at: www.ebmpyramid.org/samples/simple.html. Accessed November 21, 2013.
  4. Saltaji H, Cummings GG, Armijo-Olivo S, et al. A descriptive analysis of oral health systematic reviews published 1991–2012: cross sectional study. PLoS One. 2013;8:e74545.
  5. Guyatt G, Rennie D, Meade M, Cook D. Users' Guides to the Medical Literature: Essentials of Evidence-Based Clinical Practice. Chicago: American Medical Association Press; 2002.
  6. Schlosser RW. The role of systematic reviews in evidence-based practice, research, and development. Focus. 2006;15:1–3.
  7. University of South Dakota Library. What is Evidence Based Medicine? Available at: www.usd.edu/library/evidence-based-medicine-model.cfm. Accessed November 21, 2013.
  8. Mullen EJ, Streiner DL. The evidence for and against evidence-based practice. Brief Treatment and Crisis Intervention. 2004;4(2):111–121.