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This interview is the continuation of the TWO part series about Evidence based Dentistry, EBD. Please see the second and the last part about EBD below. (It gets a little more technical here, but very important)

Hello Ms Hope, lets continue about Evidence Based Dentistry.
MedA: We were talking about SR and CS and I feel our readers are not aware of that.  So could you elaborate more on this SR and CS thingi?

Hope: There are different kinds of study designs that provide different strengths of evidence. For example, an expert panel might convene to offer advice about a clinical question. This evidence would not be as strong a design as a randomized controlled trial (RCT). And systematic reviews (SR) provide the highest level of evidence because their authors search for all the evidence they can about a particular clinical question and then analyze all of the relevant studies together, often with a meta-analysis, to give the best overall assessment of the current state of the evidence on that topic. That is why only systematic reviews are collected at the ADA EBD website – they put the highest level of evidence at user’s fingertips.

The systematic reviews are arranged by topic and subtopics. Clicking on any SR takes you to its abstract in PubMed. There is often a link there to the full article, which may or may not be freely accessible in full. Because there are so many different professional journals and most dentists do not have subscriptions to many, a wonderful feature of the EBD website is the posting of critical summaries for a growing number of SRs. If you find a critical summary right beside the SR listing, you can read that 600-800 word document and you will get a summary of the results of the review, the authors’ conclusions and a critique of the strengths and weaknesses of the way the review was conducted and of the strengths and weaknesses of the evidence itself. The critical summary (CS) ends with a description of the clinical implications.

In March 2010, I attended an ADA training to learn to write critical summaries (CS) of systematic reviews (SR) posted at the ADA’s EBD website: http://ebd.ada.com  The critical summaries are intended to help clinicians more quickly access the evidence from the systematic reviews collected at the site. A CS is written in a concise, easy to understand manner. This is a very structured, time-consuming, and demanding process. I can assure you that before a CS appears at the web-site, it has been scrutinized by several experts who look at every word. So far, two of the CS’s I authored have been posted to the website.

MedA: can any one write the CSs? How can I be a part of these CSs?  Could you please elaborate this !!
Hope: Anyone who is interested in writing critical summaries for the ADA can apply at the EBD website. It is a volunteer activity and to be eligible you need to have a “dental degree.” I was eligible as a dental hygienist and I am sure it helped that I had attended the EBD course at Forsyth. Accepted applicants will attend a 2-day training. Per the ADA: “Learn how to put evidence-based information to practical use and contribute your knowledge to the dental profession! Here is a unique opportunity... for educational and professional development under EBD experts, continuing education credit, for publication acknowledgement, and to help colleagues use current evidence in decision-making.” My obligation, after the training, is to write at least 10 critical summaries over the course of 2 years. So far, I have finished two and a third is almost through the process.

MedA: How did you end up with your first CSs?
Hope: I was very excited when the first one was posted – but I really know very few people who could share my excitement. The first one, I co-authored with Ahmed El-Kadem, a dentist and faculty member at Cairo University. We both attended the EBD course last year and then a training to be ADA evidence reviewers. We collaborated online to write our first CS. One of the great benefits of being a reviewer is being assigned an expert mentor. He  worked closely with us to prepare a CS that we could submit to a Critical Review Panel for the next step in the process. Additionally, each issue of the Journal of the American Dental Association now contains one CS.

You can find our critical summary at the ADA’s EBD website: http://ebd.ada.org . Clink on the lower left picture for Systematic Reviews. Ours is under Endodontics, subheading: Outcomes. You will see a list with 3 columns: Systematic Reviews, Critical Summary, Plain Language Summary. Currently, ours is the second SR in this section that has a critical summary. Soon it will also have a plain language summary that will be easily accessible to the public. The title of the Systematic Review we wrote about is:
Single versus multiple visits for endodontic treatment of permanent teeth: a Cochrane systematic review 
Figini L, Lodi G, Gorni F, Gagliani M. Journal of Endodontics. 2008;34(9):1041-7

If you click on that title, you will be taken to the CONCHRANE review. You will notice that to the right of the SR title is “Critical Summary”. Click on that and you will be able to read our critical summary.

MedA What do you think is the future of EBD with respect to students, new dentists and practicing dentists?

Attendees of the March 2010 ADA Evidence Reviewer Workshop at NYU.

 Hope: Dental schools will all soon be making EBD an essential part of dental education so that future dentists will be life-long learners who can find and appraise evidence and keep up with our constantly evolving understanding of dental science. An accreditation standard that will be in effect by July 2013, states “Graduates [of dental schools] must be competent to access, critically appraise, apply, and communicate scientific and lay literature as it relates to providing evidence-based patient care.” Another accreditation standard for US dental schools will be, “Patient care must be evidenced-based, integrating the best research evidence and patient values.”

So dental students in the future, and in some dental schools for students right now, the future will absolutely involve a strong understanding of EBD. For those who have already graduated and for many graduating soon, the decision to practice with an evidence-based approach will be their own. A great effort is being made by the ADA and other organizations to teach EBD and make easily accessed evidence-based resources available. I suspect that online tools will develop to meet the tremendous need for excellent, evidence-based information that can be used by dentists who have never received EBD training. Of course, there are also many wonderful resources available online that anyone can use to teach themselves the basics of EBD – if they are sufficiently motivated to spend the necessary time.

As a caution, the term evidence-based is often used by individuals to indicate something that has some kind of evidence. What we require is the best evidence – much of which is now limited and non-existent.  An increase in demand for more and better evidence will hopefully improve the situation!


MedA: Is EBD actually like a cook book type dentistry? I mean, for every situation, you gotta do this then that followed by that!!
Hope: I attended the very popular EBD Champions Conference in Chicago put on by the ADA. The goal is to give dental professionals from across the US an overview of EBD and teach them how to return to their states and share what they’ve learned with their colleagues. I learned there that there are many dentists who are very uncomfortable with EBD seeing it as a threat to the ability of dentists to provide their patients with personalized, individual care. Many fear that it will lead to practice requirements that every dentist must provide for each patient – cookbook dentistry, as you said. I guess that because I took the EBD course before I became a Champion, I was surprised because I knew that EBD is actually just the opposite. To begin with, the needs of patients will always be extremely individual. Right now, the science of dentistry has little really strong, good evidence. And that evidence applies to the population studied – not all people. Fortunately, the evidence will improve and grow providing more and better evidence to inform the clinical decisions that dentists make. It is, however, only a piece of the decision-making process that clinicians use along with their expertise and experience to meet the needs and preferences of their patients.

You can find a wonderful description of how one dentist used EBD to provide an individual patient the best treatment possible in The Journal of Evidence-based Dental Practice, September 2010 at www.jebdp.com. The feature article, titled Use of evidence-based decision making in private practice for emergency treatment of dental trauma: EB case report  was written by Syrene A. Miller and Greg Miller and appears on pages 135-146. I am sure it will provide you and your readers with a good appreciation for what EBD is and how it could be used in practice.



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