evidence-based dental practice developing guidelines or clinical recommendations

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KORNBERG SCHOOL OF DENTISTRY1

Evidence-based Dental Practice

Developing guidelines or clinical recommendations

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Outline

• The practice of EBD at a community health center– Define clinical questions – Locate and critique systematic reviews– If no reviews are available, locate and critique primary

research– Develop clinical protocols– Implement the protocols in practice

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What is EBD practice?

• [EBD] is a set of principles and methods intended to ensure that, to the greatest extent possible, medical [dental] decisions, guidelines, and other types of policies are based on and consistent with good evidence of effectiveness and benefit.

Eddy M. Health Affairs 2005:24:9-17

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EBD Practice at a Community Health Center

Step 1:

Identify procedures that require standardization or reduction in variability– Review of procedures provided, “word-of-

mouth”– Review of cost variation– Review of charts– Determine the benefits and harms of different

approaches

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Step 2:

Share the data with the practitioners (dentists and dental hygienists) and decide on the need for developing clinical protocols (guidelines), or standards– Guidelines are statements that should be followed,

but can be adapted based on patients’ needs and conditions.

– Clinical protocols define in steps how guidelines are implemented in clinical care.

– Standards: are statements and policies that must be followed without modification.

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Step 2:• Form a committee to steer the process

– Representatives from different groups (dentists, hygienists, medical and allied health)

– Content consultants from dental schools – Other consultants

• Methods• Search for evidence• EBD experts

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Step 3:

Decide on the clinical question(s) which, if answered, can resolve the clinical issue defined in the first step.

Use a modified PICO standard:

1. Population

2. Intervention

3. Conditions or disease state

4. Outcomes

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Step 4: • Using PICO, define inclusion and exclusion criteria for guidelines or

standards• Conduct a systematic review of all guidelines or standards relevant to the

question• Retrieve and review the documents using the inclusion and exclusion

criteria• Select a preliminary set for analysis• Prepare a summary table of standards or guidelines using the PICO

format


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Step 4: • Rate the quality of the guidelines using the GRADE system

– Guyatt GH, Oxman AD, Vist G, Kunz R, Falck-Ytter Y, Alonso-Coello P,

Schünemann HJ, for the GRADE Working Group.

Rating quality of evidence and strength of recommendations GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ


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The Grade System

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The GRADE system

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Step 6:• Decide whether the current guidelines or standards

are adequate for your institution or you need to revise them

• The only change that can be made is not in the evidence, but rather in the conditions which dictate implementation of the guidelines (The C in PICO)– E.g. Your organization may decide to apply topical fluorides based

on the risk status of adult patients, if the original evidence supporting the application is based on expert opinion.


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Step 6:• Disseminate the guideline• Train the practitioners to apply the guidelines• Conduct calibration exercises using case

summaries or patients• Monitor the implementation using reviews and

chart audits• Review and disseminate the findings


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Step 4 Revised:• If no standards or guidelines are available to

answer your PICO question, then search for systematic reviews or the most appropriate evidence to answer the question

• This process is more time consuming (i.e. more costly) and requires the help of experienced reviewers


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Step 5 Revised:• Select systematic reviews or primary studies for

consideration for further analysis• Agree (committee decision) on which studies or

reviews will be included in the development of guidelines

• Summarize the evidence using the PICO format• Rate the quality of each bit of evidence using the

tools in the ADA EBD website


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Appraisal Tools in the EBD Website

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• While each study should be critiqued for its strengths and weaknesses, decisions on best practices should rely on the best available evidence.

• In addition to the GRADE system, there are several other classification systems– The most applicable to community health centers,

in my opinion, is the one used in the UK National Health Service.

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UK National Health Service• Level A: Consistent randomized controlled clinical trial, cohort

trial, cohort study, … clinical decision rule validated in different populations.

• Level B: Consistent Retrospective Cohort, Exploratory Cohort, Ecological Study, Outcomes Research, case-control study or extrapolations from level A studies.

• Level C: Case-series study or extrapolations from level B studies.

• Level D: Expert opinion without explicit critical appraisal, or based on physiology (or microbiology, biology), bench research....

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Step 6• After summarizing and grading the evidence, the

panel should decide on how to answer the PICO question:– State the guidance by population group or specific targets– State what are the key points (what, when, and how) for

each intervention– Identify conditions when the guidance should be applied

(risk factors, patient factors, operator factors)– Define the anticipated outcomes that should be collected,

analyzed and followed

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Step 7• Disseminate the guidelines, seek comments, and edit the text to

clarify it• Prepare training of staff to implement the guidelines• Define targets for follow-up in implementation• Calibrate the providers• Assess process and final outcomes• Be vigilant for new evidence and modify the guidelines, if

necessary• Review the application and usability of the guidelines at least

once year

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EBD Practice as an Individual Dentist or Dental Hygienist

• Clinical question• Has your institution developed EBD guidelines to answer the

question?– If no, search for published guidelines and relevant evidence

• Critique the evidence using the tools referenced in the previous slides

• Make a decision on how best to answer the clinical question and strength of evidence supporting your decision

• Communicate all information: evidence for/against, risks and benefits to the patient

• Training and calibration of the providers • Quality assurance

evidence-based dental practice developing guidelines or clinical recommendations

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