The Need for EBDM

An evidence-based approach has emerged in response to the need to improve the quality of health care and to demonstrate the best use of limited resources.4,13 Forces driving the need to improve the quality of care include:

  1. variations in practice,
  2. slow translation and assimilation of the scientific evidence into practice,4,14-16
  3. managing the information overload, and
  4. changing educational competencies that require students to have the skills for lifelong learning.6
  1. Variations in Practice Patterns

    Substantial advances have been made in our knowledge of effective disease prevention measures and of new therapies, diagnostic tests, materials, techniques and delivery systems, and yet the translation of this knowledge into practice has not been fully applied. Variations in practices among dental clinicians are well documented, whether it involves diagnostic procedures, treatment planning17,18 and treatment,19 or prescribing antibiotics, such as was found among endodontists20 and general practitioners.21
  2. Slow Translation and Assimilation of Research Findings into Practice

    Far too often variations in practice occur due to a gap between the time current research knowledge becomes available and its application to care. Consequently, there is a delay in adopting useful procedures and in discontinuing ineffective or harmful ones.22-25 One example has been the use, or lack of use, of dental sealants.24 Although their effectiveness have been well documented over the past 3 decades, only 18.5% of US children and youth ages 5-17 have one or more sealed permanent teeth (1988-1991 data)26 and goals for Healthy People 2020 have been retained, but modified to increase the proportion since the 2010 goals were only set at 50%.27

    Assimilating scientific evidence into practice requires that clinicians keep up to date by reading extensively, attending courses and taking advantage of the Internet and electronic databases to search for published scientific articles. However, colleagues and personal journal collections tend to be the primary information sources for treatment decisions, rather than the scientific literature.28-30 Treatment decisions tend to reflect the knowledge, skills and attitudes learned as a student,8,25,31 and trends indicating that the longer clinicians are out of school, the bigger the gap in their knowledge of up-to-date care,31-32 as demonstrated by the knowledge, opinions and practices of dentists and dental hygienists in providing oral cancer examinations.33,34 This reinforces the need to learn evidence-based information seeking behaviors and critical analysis skills while still in school.
  3. Managing the Information Overload

    In addition to influencing variations in practice and the slow translation and assimilation of scientific evidence into practice, it is physically impossible to keep up to date with the increasing number published articles. With the number of good clinical trials and meta-analyses increasing at a rate of 10% per year35 and located in over 700 dental journals world-wide, knowing which journals to subscribe to that have the relevant articles related to an individual’s practice is nearly impossible. To stay current in general dentistry, one would have to identify, obtain, read and appraise 6 articles per week, 52 weeks per year.35

    A similar situation applies to keeping current with research studies related to clinical dental hygiene practice. A substantial number of articles, 112 meta-analyses (reviews and statistical analysis of already conducted research that address the same question) and 1707 RCTs, published between 1990 and 2003 were identified when searching MEDLINE36 (Table 1).
Table 1. Research Supporting Clinical Dental Hygiene Practice34
table01
©2006 Forrest, NCDHR
    In this case, 50% of the 112 meta-analyses were located in 7 journals and the Cochrane Library with the remaining half found in 33 other journals. Of the 1700 RCTs, 70% were located in 32 journals with the remaining 30% in 174 journals.36

    Again, the challenge is to find relevant clinical evidence when it’s needed in order to help make well-informed decisions. Evidence-based practice is now possible due to increased access to relevant clinical findings via development of online databases and computers that enable quick access to the scientific literature. Being able to search electronically across hundreds of journals for specific answers to patient questions or problems solves this problem.
  1. Changing Educational Requirements

    Another need for EBDM is reflected in educational requirements and competencies for both dental and dental hygiene students. The ADA Accreditation Standards for Dental Education Programs37 now expect dental schools to develop specific competencies that are reflective of an evidence-based definition of general dentistry.37 In addition to the ADA, the American Dental Education Association’s Competencies for the New Dentist identifies general skills that reflect an evidence-based approach.38 These include being able to continuously analyze the outcomes of patient treatment to improve that treatment, evaluate scientific literature and other sources of information to make decisions about dental treatment, and manage oral health based on an application of scientific principles.

    Similar competencies for dental hygienists are incorporated in the ADEA Dental Hygiene Curriculum Guidelines.39 For example, "The process of care requires defined problem solving and critical thinking skills and supports evidenced-based decision-making." Further support for EBDM is found in the curriculum guidelines under Research for Dental and Dental Hygiene Education (pp. 123-128)39 in that their aims are to provide both dentists and dental hygienists with the skills and knowledge to be able to access the most recent and relevant scientific evidence, critically appraise it, and determine if it is applicable to the problem being addressed. The clear intent of the accreditation standards and competencies contained within these documents is the focus on the importance of comprehensive patient-centered care and the need for adding evidence-based decision-making to the traditional experienced-based approach. Table 2 highlights the four forces driving the need for EBDM.
Table 2. The Need For EBDM
Forces Driving the
Need for EBDM
ProblemResult of using EBDM
Variations in PracticeTranslation of research for use in practice is not fully applied so that patients receive the best possible care.Enhances consistency of practice.

Increases standards of practice and practice guidelines based on scientific evidence.
Slow Translation and Assimilation of Research into PracticePatients do not receive the best possible care as soon as it is available and ineffective care is not discontinued.Allows clinicians to stay current in order to close the gap between what is known and what is practiced.
Managing the Information OverloadAbility to keep up with the increasing publication of clinical research studies in multiple journals and databases. Also, quick access to health information, new products and procedures is now available, however not all sources are accurate and can be misleading or not appropriate. Access to computers and online databases, i.e., PubMed, allow clinicians to quickly find research evidence to accurately answer questions and provide patient-centered care that is based on an evaluation of the most recent scientific findings.
Changing Educational RequirementsADA Accreditation Standards and ADEA Competencies for the New Dentist and for Dental Hygienists have been updated and now require programs to integrate an evidence-based approach in clinical decision making. This is a change rather than a problem.Greater emphasis is placed on the importance of comprehensive patient-centered care and the need for adding evidence-based decision-making to the traditional experienced-based decision-making approach.
©2007 Forrest and Miller, NCDHR