EVIDENCE BASED PERIODONTICS

Contents

• Introduction.

• Need for Evidence Based Decision Making.

• Advantages of Evidence Based Approach.

• Process of Evidence Based Decision Making.

• Sources of Evidence.

• Appraising the Evidence, Evaluating the Outcomes, Assessing Evidence.

• Contradictory studies.

• Implementing Evidence Based Decisions in Clinical Practice.

• Change management

• References.

IntroductionEvidence based medicine was pioneered at Mc Master University, Ontario, Canada in 1980s. It was defiend by Sackett et. al. In 2000 as “the integration of the best research evidence with clinical expertise and patient values”

It has 3 new aspects:

Evidence obtained from randomised controlled trials. Systematic review and meta-analysis to synthesise and analyse the evidence. Electronic databases to access the evidence.

Evidence based dentistry has been defined by ADA in 2002 as “an approach to oral health care that requires judicious integration of systematic assessment of clinically relevant scientific evidence relating to the patients’ oral and medical conditions and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences.”

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Need for Evidence Based Decision Making

Variations in PracticeClinicians tend to practice the same as they were taught in dental schools. Thus, the longer they have been out of school, the greater the gap in their knowledge of up-to-date care.

Variations also occur because of a gap between the time that current research knowledge become available and its application to care. There is a delay in adopting useful procedures and in discontinuing ineffective or harmful ones.

Assimilating Evidence into PracticeAssimilating scientific evidence into practice requires keeping up-to-date through reading extensively, attending courses, and using the internet to search for published scientific articles. Keeping current with relevant research is challenging. Substantive advances made in the knowledge of clinical dentistry Periodontics have not been translated into practice or fully applied to allow patients to receive the total benefits.

Advantages of Evidence Based ApproachEvidence based approach is:

1. Objective2. Scientifically sound3. Patient focussed4. Incorporates clinical experience5. Stresses good judgement6. Is thorough and comprehensive7. Uses transparent methodology

Process of Evidence Based Decision Making1. Asking good questions – PILO Process2. Searching for and acquiring evidence

a. Levels of evidenceb. Sources of evidence – primary and secondary

3. Appraising the evidence4. Evaluating the outcome

Asking Good QuestionsThe first step in searching for relevant evidence is to frame the appropriate questions. A question should consist of 4 parts:

P: Population or patient problemI: InterventionC: ComparisonO: Outcome

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E.g., “Fro a patient with a 5 mm pocket *actisite* as compared to *atridox* greater gain in CAL? ”

P: (Problem) 5 mm pocketI: (Intervention) ActisiteC: (Comparison) AtridoxO: (Outcome) Gain in CAL

a. Focusing on the most important single issue or outcome.b. Facilitating computerised search by identifying the key terms used in the search.c. Identifying the problem, the result, and the outcomes related to the specific care provided

to that patient. This allows identification of the type of evidence required to solve the problem as well as considerations for measuring the effectiveness of the intervention.

Searching for and acquiring evidenceAll valid researches that answer a specific question is considered evidence.

a. Levels of Evidence.The highest level of evidence – “gold standard” – is the systemic review and meta-analysis using two or more RCT (Randomised Controlled Trials)

They are considered the gold standard because of their strict protocols to reduce bias. Systematic reviews provide a summary of multiple research studies that have investigated the same specific question. They use explicit criteria for retrieval, assessments and synthesis of evidence from RCTs.

Meta analysis is a statistical process often used with systematic reviews. It involves combining statistical analysis of several individual studies into one analysis.

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Meta Analysis &Systematic Review

RCTs

Cohort Studies

Case Control Studies

Case Reports

Ideas, Editorials, Opinions

Animal Research

In-vitro (test tube) Research

Levels of Clinical EvidencesLevels are based on the ability to control bias and to demonstrate cause and effect.

Progressing up the pyramid, the number of studies and correspondingly the amount of available literature decrease, while at the same time their relevance in answering clinical questions increases.

The level of evidence is related to the type of questions asked, such as those derived from issues of therapy or prevention, diagnosis, etiology and prognosis.

E.g.,

Highest level of evidence for questions on therapy: SRs of RCTs Highest level of evidence for questions on prognosis: SRs of inception cohort studies

Type of question related to type of method and level of evidence

Question Type Methodology of Choice Question FocusTherapy & prevention

SR of RCTsSR of cohort studies

Allows for comparison between intervention and control groups

Diagnosis SR of prospective cohort studies

Compare tests with a reference or gold standard test

Etiology, causation, harm

SR of prospective cohort studies

Compares a group exposed to a particular agent with an unexposed group

Prognosis SR of retrospective cohort studies

Follows progression of a group with a particular disease and compares with a group without the disease

Sources of EvidencePrimary: Original research publications.

Secondary: Systematic reviews, meta-analysis, evidence based article reviews and clinical guidelines synthesised from primary sources.

Primary SourcesBiomedical database such as Medline (MedPub) and EMBASE provide access to both primary and secondary research.

The PICO question provides the foundation for the search terms used in the database.

Secondary Sourcesa. Summaries of systematic reviews and research articles. Evidence based journals such

as Journal of Evidence Based Dental Practice and Evidence Based Dentistry provide concise and easy to read summaries of selected biomedical literature.

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b. Clinical practice guidelines and protocols. Guidelines defined by the Institution of Medicine in 2000 as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.”

c. AAP position papers, statements and parameters of care: the AAP regularly maintains treatments, products and concepts to ensure that they are still the best available and publish the results in their position papers.

Comparison of systematic review and literature review

Characteristic Systematic Review Literature ReviewFocus of review Specific or narrow focus Range of issues or broad focusWho conducts it Multi-disciplinary team IndividualSelection of studies to include

All the studies that meet pre-established criteria. Bias is minimised

Inherent personal bias with lack of criteria.

Reported findings

Description of study design, subjects, length of trial, outcome measures.

Description in nature, reporting the outcome of studies rather than their study designs.

Synthesis of selected studies

Results are statistically combined (meta-analysis)

Studies are reported without combining data.

Main results Summary of trials; total number of subjects, definitive statements about findings in relation to objectives and outcome measures

Summary of the findings by author in relation to purpose of literature review and specific objective.

Appraising the EvidenceIt is necessary to review the evidence to determine if the methods were conducted rigorously and appropriately. International evidence-based groups have made this easier by developing appraisal forms and check-lists that guide the user through a standard series of “Yes/No” questions to determine the validity of the individual study or systematic review.

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Guidelines that can be used for critical analysis

Guide PurposeCONSOERT statement (Consolidated Standards of Reporting Trials)

To improve the reporting and review of RCTs

QUOROM (Quality of Reporting of Meta-Analysis)

To improve the reporting and review of SRs

CASP (Critical Appraisal Skills Program) To review RCTs, SRs and other types of studies

Evaluating the OutcomesThe final steps in evidence based decision making are to evaluate the effectiveness of the intervention and clinical outcomes and to determine how effectively teh EBDM process was applied. This can be achieved through self evaluation, by questioning the effectiveness of each step.

Assessing EvidenceA large number of research articles are published every year. This makes it necessary to assess the evidence for their clinical relevance. This is done by using 12 different tools:

1. Scepticism2. Deductive reasoning3. Inductive reasoning4. Cause preceding effect5. No change in hypothesis6. Clinically relevant pre-trial hypothesis7. Size of association8. Contradictory studies9. Randomisation10. Non-randomised evidence11. Placebo effect12. Conflict of interest

ScepticismIn 1900, William Hunter developed the idea that microorganisms were responsible for a wide variety of systemic conditions. He believed that removal of the causative organisms through tooth extraction resulted in the improvement in the systemic health. Since this theory explained a wide range of diseases for which there was no explanation at that time, it became widely accepted and led to wholesale extraction of teeth.

The focal infection theory fell into disrepute in the 1940s and 1950s when widespread extraction failed to reduce or eliminate the systemic condition.

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Many of the precepts of the focal infection theory are being reviewed today. However, in order for the hypothesis not to fall into disrepute again, the theories should be viewed with scepticism and there must be no unsubstantiated attributions, no theories without evidence.

Evidence on how to cure, manage, or prevent chronic diseases is notoriously contradictory, inconsistent and unreliable. Three reasons why most studies on Periodontics are inaccurate:

1. Identifying a successful treatment for chronic diseases is challenging. It is estimated that less than 0.1% of tall treatments are effective, thus the most so called effective treatments identified in clinical trials turn out to be ineffective or even harmful.

2. Most chronic diseases are complex and include both environmental and genetic causes. Incomplete and mistaken understandings of chronic disease etiology can lead to a cascade of wrong turns in the exploration of possible diagnosis, prognosis and treatment.

3. Poor scientific methodology employed by researchers leads to inaccurate results.

Deductive reasoningCausal chain thinking which implies: if A causes B and B causes C than A causes C.

This system of deductive reasoning or application of logic was developed by the Greeks and is appropriate in mathematics – not in medicine or dentistry.

Loe, in a classic study in 1965 on experimental gingivitis, showed that plaque is the etiologic factor responsible for gingivitis. It is also well known that Periodontics is always preceded by gingivitis. But, saying that plaque leads to gingivitis would be over-simplifying the pathogenesis of the disease.

Another example of why logic is not ** in our field is: Antibiotics are used to treat bacterial infections. Periodontitis is a bacterial infection. Having said this, indiscriminate use of antibiotics in treating periodontitis is not justified. Increased use of antibiotics when not required has led to development of resistance on a global scale.

Inductive reasoningRational thought or inductive reasoning is based on systematic experiments. Galileo is typically credited with the start of systematic experimentation in physics. Three systematic experiments used in clinical research:

1. Core control study2. Cohort study3. Randomised control trial

In order to understand the study designs, we must first understand the terms ‘exposure’ and ‘end point.’

‘Exposure’ refers to a suspected etiologic factor or an intervention such as treatment or a diagnostic test.

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‘End point’ refers to the outcome of disease, quality of life measures, or nay type of condition that may be of interest tin clinical studies.

Randomised Controlled TrialsIndividuals are randomly assigned to different exposures and monitored longitudinally for the end point of interest. If the end points frequency differs between the exposure groups, an association between the exposure and the end point is present.

An example is a 3 years study conducted by Greene et.al. in 1971on 1248 general telephone workers in California. The study was carried to determine whether progression of gingival inflammation is reduced in an oral environment in which high levels of hygiene are maintained. Subjects were given a series of oral prophylaxis treatments combined with oral hygiene instructions (first exposure group.) Subjects in the control group received no attention from the study team except for annual examinations instructions (second exposure group.)

After 3 years, increase in plaque and debris in the control group was 4 times that of experimental group (end point.) Hence there is a difference in end point frequency (4 times) between the exposure groups, an association between oral prophylaxis + OHI (exposure) and (end point) decrease in plaque and calculus is present.

RCT is the gold standard design in clinical research. It is level 1 or the best level of evidence.

Cohort StudyExposed individuals are compared to non-exposed individuals and monitored longitudinally for end point occurrence. If the end point differs between the exposed and non exposed individuals, an association between exposure and end point is present.

Loe et.al. conducted a longitudinal investigation to study the natural development and progression of periodontal disease. The first study group, established in Oslo, Norway, in 1969, consisted of 565 healthy male non-dental students and academicians between 17 and 40 years of age. This population had experienced maximum exposure to conventional dental care throughout their lives (exposed individuals.)

A second study group, established in Sri Lanka, in 1970, consisted of 480 male tea labourers between 15 and 40 years of age. The workers had never been exposed to any program relateive to prevention or treatment of dental diseases (non-exposed individuals.)

The results of this study are interesting. The Norwegian group, as the members approached 40 years, had a mean individual loss of attachment of slightly above 1.5 mm while that for the Sri Lankan group was 4.5 (end point.)

Thus, the end point frequency differs between the exposed (1.5) and the unexposed (4.5) individuals and an association between exposure (preventive dental programs) and end point (reduced attachment loss) exists.

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A cohort design study is the optimal study design in non-experimental clinical research or is level-2 evidence.

Case Control StudyCases (individuals with the end point interest) are compared with controls (individuals without the end point of interest) with respect to the prevalence of the exposure. If the prevalence of exposure differs between cases and controls, an association between the exposure and the end point is present.

This is the most challenging study design to use and is called level 3 evidence.

An example would be if patients with oral Sub-mucus Fibrosis (cases) are compared with patients without OSMF (controls) with respect to the prevalence of areca nut chewing (exposure.) Unlike deductive reasoning, where associations are either true or false, such absolute truths cannot be achieved with systematic experiments. Conclusions based on controlled study designs are always surrounded by a degree of uncertainty.

Cause preceding effectThis refers to the typical dilemma of whether the egg came first or the chicken did.

Temporality or the cause has preceded the effect is necessary to claim causality.

Walter Loesche in 1979 gave the specific plaque hypothesis which states that only certain plaque is pathogenic and its pathogenicity depends on the pressure or increase in specific micro organisms. This concept predicts that plaque harbouring specific bacteria pathogens results in a periodontal disease because these organisms produce substances that mediate the destruction of the host tissues.

According to the ecological theory given by PD March, aerobic organisms are harboured in a healthy gingival sulcus. As the pocket deepens, the sub-gingival environment changes and favours the growth of anaerobes. According to this theory, the formation of a pocket is necessary for the growth of anaerobes and not the other way round.

Hence, it is hard to say with certainty which is the cause and which the effect is.

No change in hypothesisA well defined hypothesis should be established at the start of the study and this should be adhered to for the rest of the study. No changes can be made in the hypothesis once the study is started.

a. Modifying study sample definition: once the study sample is decided, this sample population should not be tampered with. E.g., if a certain periodontal treatment is evaluated, the results should be evaluated even on the teeth which are lost eventually, the original sample considered should not be altered for any reason. Results of improper subgroup analysis are meaningless when establishing causality.

b. Modifying exposure definition: exposure defined in the hypothesis should not be changed during the study. E.g., if the efficacy of a new mouth wash be tested against

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the gold standard, chlorhexidine and a pseudo cannot be changed from saline to water assuming it does not make too much a difference. Exposure decided in the original study design must not be changed.

c. Modifying end point definition: almost all major trials specify one primary end point in the pre-trial hypothesis. Any modification of this end point during or after the trial is a cause for concern. E.g., if the original study is checking the effect of SRP on decreased pocket depth, the end point cannot be changed to decrease in gingival index scores if no change in pocket depth is found.

Deviating from the pre-trial hypothesis is called “data torturing.” Manipulating the data to take only the values which prove our point is called “procrustean data torturing.” Just as the Greek Procrusteus fitted guests perfectly to his guest bed either through bodily stretching or chopping of the legs to ensure the body height and the bed length correspond.

Clinically relevant pre-trial hypothesisTrials on clinically relevant questions dramatically change clinical practice. Usually, clinically relevant questions share 4 important characteristics of the pre-trial hypotheses:

1. A clinically relevant end point (outcome in PICO question)2. Relevant exposure comparisons (intervention and control in PICO question)3. A study sample representative of real world clinical patients (patient defined in PICO

question)4. Small error rates

A clinically relevant end pointTwo clinically relevant end points are recognised.

True End Points: Tangible outcomes that directly measure how a patient feels, functions or survives like tooth loss which affects quality of life and ain which can be felt.

Surrogate End Points: Intangible outcomes used as a substitute for a true end point. E.g., reduction of pocket depth or gain in clinical attachment level.

The first requirement for a clinically relevant study is the pre-trial specification of a true end point.

Relevant exposure comparisonsA clinically relevant exposure comparison implies:

- Absence of contrived control groups- Use of a placebo control group when appropriate

An example for irrelevant exposure comparison would be comparing 0.12% chlorhexidine with 0.05% chlorhexidine mouth wash when it is known that 0.05% mouthwash is ineffective.

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Moreover, a conclusion drawn for one particular type of exposure connot be translasted to that of apparently closely related exposures. E.g., if a study determines the effect of doxycycline on sub antimicrobial doses, it cannot be assumed that a related drug like microcycline would have to same effect.

Representative Study SampleThe larger discrepancy between the study sample and the patient one seeks to treat, the more questionable the applicability of the study’s conclusion becomes. Studies done on population similar to the patients we treat are considered relevant.

E.g., most of the studies implicating Herpes Simplex Virus in the pathogenesis of periodontitis have been conducted on HIV patients. Hence, there is a controversy regarding HSV as an etiologic factor in periodontitis.

Small error ratesType-1 error rate: Likelihood concluding that there is an effect when in truth there is no effect; 1% or 5%.

Type-2 error rate: Likelihood of concluding that there is no effect when in truth there is an effect; 10% or 20%

Size of associationThe larger the association, the less likely it is causal; like 80% bone fill after the use of DFDBA would leave no doubt as to the association between DFDBA and bone fill whereas gain in CAL by 0.1 mm after local drug delivery would imply a doubtful association.

Size of association can be calculated by calculating the odds ratio – the probability that the event happens divided by the probability that the event does not happen.

End PointFailure Success

Exposure Experimental A BControl C D

Odd ratio = ad / bc

The size of odds ration ranges between 0 and infinity. An odds ratio larger than 1 (experimental failure X success of control is greater ad) indicates a harmful effect.

An odds ratio smaller than 1 (experimental success X control failure – bc is greater) means a protective effect.

Contradictory studiesStudies disproving a hypothesis have greater value than those which accept it. E.g., for many years root conditioning with citric acid and tetracycline were considered to prevent epithelial migration, favour fibroblast adhesion and thus help in regeneration. Marrioti et. al. in 2003

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published a position paper refuting the fact that these agents aid in regeneration and said that the only use of these agents could be in removing the smear layer on the root surface.

Another reason for many studies establishing an association is not present is because of the presence of confounding factors. E.g., smoking and diabetes mellitus are confounding factors for periodontitis.

In randomised studies confounding is not an issue because randomisation balances known and unknown confounders cross the compared groups with a high degree of certainty. E.g., if there are equal number of smokers in the experimental and the control group there is no bias.

In non-randomised studies, the following questions concerning confounding arise:

1. Whether all the confounders have been included: multiple confounders need to be included in statistical analysis. An association unadjusted for any potential confounders is called a crude association. When the crude association is adjusted for potential confounders, it is called an adjusted association.

2. Whether confounders can be accurately measured: potential confounders like smoking and life style could be difficult to measure as discrepancies between what is measured and the truth could lead to incomplete removal bias. The remaining bias is called residual confounding.

Randomisation Creates heterogeneity. Takes over treatment assignment away from the physician. Leads to a situation in which patients are randomly assigned to treatments and if they

refuse treatment, they are still analysed as if they have received treatment.

Randomisation includes the following steps:

1. Subjects are enrolled into a study prior to randomisation; important baseline disease characteristics are recorded and provided to an independent person or organisation. This step ensures that baseline information is available for every patient who will be randomised.

2. An independent person or organisation randomly assigns subjects to a treatment and informs the clinician regarding the treatment assignment. The concealment of the randomisation process ensures that clinicians cannot crack the code and that they will enrol only those patients they think are suited for the treatment that will be assigned.

3. The outcome in the subject is available regardless of the follow up time or compliance and according to the treatment assigned – not the treatment received. Factors related to compliance and unrelated to the treatment under investigation have a powerful influence on the outcome measured. Deleting such non-compliant patients might lead to biases.

Non-randomised evidenceEthical principles dictate that proposed interventions do more good than harm, that the populations in whom the study will be conducted will benefit from the findings and that an

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informed consent is obtained from enrolled subjects. E.g., studies on gene therapy using viral vectors and studies on human subjects are difficult due to safety concerns. Sample size considerations may prevent conduct of RCTs. The smaller the rates at which end points occur in an RCT, the larger the required sample size will be. For rare events such as bacterial endocarditis subsequent to a dental procedure or HIV conversion after exposure to an HIV contaminated dental needle, RCTs may never be possible because the required sample sizes are in the 100 thousands or millions of subjects.

Placebo effectPlacebo effect should be considered while evaluating studies to use as scientific evidence.

Placebo effects are the beneficial effects some patients experience by simply participating i a study, by patient-physician interaction, by patients anticipation for improvement, or by the patient’s desire to please the physician. A small controlled study in 11 patients showed that placebo effects can cause changes in brain function, providing plausibility to the argument that placebo effects may have biological effects. Due to such placebo effects, without mock surgeries it would be impossible to tell whether the improvements observed in clinical trials are caused by the placebo effects associated with the surgical procedures or by the hypothesised active ingredients of the surgery itself.

Overall, sufficient evidence is available to suggest that placebo effects can be real and measurable and that the magnitude of the effect may depend on the treatment under study and the type of outcome evaluated.

Conflict of interestConflict of interest has been defined as “a set of conditions in which professional judgement concerning a primary interest such as patient’s welfare or validity of research, tends to be unduly influenced by a secondary interest.” Secondary interests may be financial, religious or scientific beliefs, ideological or political beliefs, or academic interests. E.g., industry sponsored studies 3.6 times as likely to have pro-industry conclusions as non-industry sponsored studies.

Implementing Evidence Based Decisions in Clinical PracticeEvidence based practice has been defined as improving treatment outcomes by using research evidence along with clinical experience and patient preferences in making decisions about individual patients.

Implementing evidence based decisions in clinical practice includes the following steps:

1. Managing uncertainty2. Incorporating evidence into practice3. Linking outcomes with diagnosis and treatment4. Implementing evidence based decisions5. Change management

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Managing uncertaintyDecision making is an important skill in clinical practice. This could be complicated in Periodontics as establishing a prognosis is inherently imprecise.

There are psychological issues in making decisions, especially while facing clinical uncertainties. Simply repeating old behaviour patterns is generally more comfortable than the insightfulness needed to question one’s own actions and embrace change.

Another reason for our indecisiveness is that our classic elementary education has trained us not to make decisions on our own, but to follow a prescribed set of rules. Most of us have been educated under a pedagogical system of learning. In this system, the dominant teacher disseminates known facts to the submissive students. Motivation is external, learning is not generally applied and students are not encouraged to think and question but blindly accept what is taught to them.

Andragogical theory is an adult form of learning and encourages students to apply their mind. Andragogical theory states that adults learn best by internal motivation and have an urgency to solve problems by drawing on existing knowledge. Adult learning is about discovering what is known, accepting uncertainty, yet being able to apply new found knowledge immediately.

Traditional dental education has generally been pedagogical in nature. A linear approach to clinical decision making is followed.

Condition treatment outcome

Dentists including periodontists typically identify a presenting dental condition. E.g., periodontists conventionally believed that all cases with reduced width of gingiva require gingival augmentation. But, Dorfman et.al. in 1980 showed that experimental sites which had been grafted (FGG) and showed an increase of 4 mm of attached gingival showed no difference in GI, PI and CAL as compared to control sites in whom periodontal care was given every 3 months.

Thus, the linear or cook book approach to dental treatment could lead to successful outcomes such as an increased width of the attached gingiva, but it raises the question of over treatment. Traditional approaches which adhere to rules such as every patient with decreased gingival width need to be treated need to be replaced with evidence from newer research which employs a wait and watch policy. Only case with persisting inflammation or increasing recession are in need of treatment.

Incorporating evidence into practicePublication of research advances allowed practitioners to incorporate this evidence into clinical practice. This process is known as science transfer.

Dental practitioners, including periodontists, may bve aware of the current best evidence in dentistry due to the sheer number of dental journals and the rate at which studies are being

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published. This problem has been partly alleviated by the development of evidence based journals or systematic reviews.

Searching for and critically appraising evidence are significant barriers facing dental practitioners. When reading a scientific investigation, the dental professional should keep in mind the following 3 questions:

1. What are the results?2. Are the results valid?3. Are the findings relevant to my patient population?

These questions form the basis of critical appraisal, the ability to access a study for clarity, validity and generalisability. This skill has also been made easier by using critical appraisal work sheets that can be downloaded from various website. These worksheets act as a guide to help readers in the decision to use or discard evidence.

The effectiveness of the method used to disseminate evidence is also fo importance. Passive diffusion of information and C&E lectures are less effective than small, interactive grop work, problem-based learning, and practice-specific interventions,.

Linking outcomes with diagnosis and treatmenta. Outcome:

Dentistry is a treatment oriented profession and interventions are considered superior to “watchful waiting.” This often leads to over-estimation of a patient’s risk of disease progression and often leads to over-treatment.

Though periodontal disease may cause a significant morbidity and alter the quality of life by causing mobility, abscess formation, pain, loss of teeth and difficulty in mastication. Therefore, it is upto the astute clinician to decide when intervening becomes crucial and when it is preferable to wait and watch.

b. Diagnosis:Periodontal disease tends to be over-diagnosed by the novice practitioner, yet its subtleties allow it to be under-diagnosed by experienced practitioners. Diagnosis has been facilitated by assessing a patient’s susceptibility to dental disease. Scientific evidence has now identified risks factors for both periodontal disease. Assessment of susceptibility facilitates both diagnosis and prognosis. Treating before establishing a diagnosis or with a misdiagnosis usually leads to poor decisions and ultimately unfavourable outcomes. Unfortunately diagnosis has been under-emphasised in favor of technical skill development at the undergraduate level.

c. Treatment:Patients and dentists usually view dentistry as a treatment oriented profession that tends to discount the diagnostic phase of dental care. Another form of bias, financial bias, occurs when the compensation from more lucrative types of procedures unduly influence the decision making process. In Periodontics, surgical procedures are compensated at a higher rate than non-surgical therapies and clinicians have a built-in incentive to provide

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more costly services. This vulnerability is inherent in all the clinicians and they must keep this in mind when making decisions about individual patients.

Ideally the phases that should be followed when a patient visits a dental clinic are:Presenting condition Assess disease Establish diagnosis Establish prognosis Evaluate need / level of intervention.

Implementing evidence based decisionsDecisions to intervene are critical and should be the third step in a four step process. A diagnosis should be established prior to deciding to intervene. If diagnosis established, one might decide to intervene depending on the evidence based pattern of decision making described as follows:

Change managementThree main challenges lie ahead with the implementation of evidence based decisions:

a. Individual changesb. Organisational changesc. Allowing research findings to guide the decision making process

Change can be implemented by

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Condition

Diagnosis

Treatment

Outcome

No Treatment

No Diagnosis

Treatment No Treatment

Outcome

Recognising the need for change

Performing an organisational analysis and indentifying all the stakeholders

Including all the stakeholders in the process

Monitor and evaluate to ensure lasting change

Change managementAn evidence based method closes the gap between clinical research and the realities of practice by pro9vidign dental practitioners with the skills to find, efficiently filter, interpret, and apply research findings so that what is known is reflected in the care provided. This approach assists clinicians in keeping current with the conditions that a patient may have by providing a mechanism for addressing gaps in knowledge to provide the best care possible.

Conclusions • The principles of evidence-based healthcare provide

structure and guidance to facilitate the highest levels of patient care.

• Evidence-based healthcare is not an easier approach to patient management, but should provide both clinicians and patients with greater confidence and trust in their mutual relationship

References

• Textbook of Periodontics ,10th edition Carranza.• Textbook of Periodontics, 2nd edition Lindhe.• Textbook of Community dentistry, Dr. Soben Peter• Evidence based periodontics :A review. Ian needleman Perio 2000 vol 37 Feb 2005:

12-28.• Evidence based periodontics systematic reviews and research quality David R. Moles

et al Perio 2000 vol 37 Feb 2005: 12-28.

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