Keeping Current: A Commitment to Patient Care Excellence through Evidence Based Practice ======================================================================================== * Jane L. Forrest * Pamela Overman ## Abstract The desire to improve the oral health of clients begins with the hygienist's commitment to keeping current with useful scientific knowledge. The challenge is mastering the skills to discriminate between the many claims and what actually has been shown to be effective. One approach is through evidence-based decision-making (EBDM), which helps practitioners find relevant clinical evidence when it is needed for treatment decisions and for answering client questions. The purpose of this article is to discuss EBDM and its use in practice, potential challenges, future developments and resources that will assist in keeping current. * Evidence-based Decision-Making * Evidence-based Practice * Cochrane * PubMed * pre-appraised evidence * Clinical Decision Support ![Figure1](http://jdh.adha.org/https://jdh.adha.org/content/jdenthyg/87/suppl_1/33/F1.medium.gif) [Figure1](http://jdh.adha.org/content/87/suppl_1/33/F1) ## Introduction The desire to improve the oral health of clients must start with the hygienist's commitment to keeping current with useful scientific knowledge. Most dental hygienists struggle with keeping up with the onslaught of information touting the latest innovations in oral health care. The challenge is separating the many claims from what actually has been shown to be effective in patient care. One approach is through evidence-based decision making (EBDM), which is specifically designed to help practitioners find relevant clinical evidence when it is needed to help make treatment decisions and to answer client questions. ### What is Evidence-Based Decision Making? EBDM is defined as “the integration of best research evidence with our clinical expertise and our patient's unique values and circumstances.”1 Thus, optimal decisions are made when all components are considered (Figure 1). EBDM is not unique to any specific health discipline and focuses on the decision-making process, which is why it is referred to here as EBDM or evidence-based practice (EBP) rather than evidence-based dentistry or evidence-based dental hygiene. ### Milestones in the Evolution of EBDM #### 1. The Birth of Evidence Based Medicine – McMaster University, Ontario Canada In 1981, David Sackett, along with a group of clinical epidemiologists at McMaster University, published articles advising clinicians how to read clinical journals.2 The group proposed the term “critical appraisal” and recognized its value in using the approach of identifying the best evidence to solve patient problems. This approach to medical care represented a fundamental change of practice and warranted a new term that would capture this difference. In 1990, Gordon Guyatt proposed the term “evidence-based medicine” (EBM).3 The approach took hold and began to spread to other health care disciplines. In 2007, the development of EBM by researchers at McMaster University was recognized as one of the 15 greatest medical breakthroughs since 1840.4 Table I provides a summary of the milestones in the evolution of EBDM. ![Figure 1:](http://jdh.adha.org/https://jdh.adha.org/content/jdenthyg/87/suppl_1/33/F2.medium.gif) [Figure 1:](http://jdh.adha.org/content/87/suppl_1/33/F2) Figure 1: Evidence-Based Decision Making View this table: [Table I:](http://jdh.adha.org/content/87/suppl_1/33/T1) Table I: The milestones in the evolution of EBDM #### 2. The Cochrane Collaboration – Advocacy for Using Evidence Concurrently, another approach contributing to EBP was developing in England based on the work of Archie Cochrane, a British epidemiologist, who advocated for the use of randomized controlled trials (RCTs) as a means of reliably informing health care practice.5 Later, after realizing that reading independent RCTs might provide conflicting information, he promoted organizing a database of RCTs and synthesizing their findings around specific health conditions.6 This eventually led to the development of the Cochrane Collaboration, a world-wide independent, not-for-profit organization comprised of 52 review groups, making it the largest organization committed to preparing systematic reviews to facilitate medical decision-making. These systematic reviews (and meta-analyses), known as Cochrane Reviews, are published online in The Cochrane Library. The Cochrane Oral Health Group is one of the 52 review groups. Since 1994, the Oral Health Group has published 132 systematic reviews and is investigating 66 new protocols.7 Many of the 132 reviews support the preventive and therapeutic care provided by dental hygienists, and therefore Cochrane Reviews are a very important resource for keeping current. Also, the impact of the Oral Health Group's publications puts it in the top 3 journals of dentistry, behind the Journal of Clinical Periodontology and the Journal of Dental Research.7 #### 3. Tools to Tame PubMed Since 1997, PubMed has provided free access to the MEDLINE, the largest scientific database, and the number of citations has steadily increased to over 22 million. As the peer reviewed literature has been digitally stored and made accessible, its growth has made it nearly impossible for practitioners in every field to keep current. Fortunately, PubMed has recognized this problem and has developed evidence-based short-cuts called filters to help retrieve different article types, such as those based on study designs. This, in turn, allows the user to be very efficient in searching for Systematic Reviews (SRs) and Meta-Analyses (MAs) and Practice Guidelines (PGs), the highest levels of evidence. In addition to doing a traditional PubMed search, a valuable feature for busy professionals is PubMed Clinical Queries, which directly uses evidence-based filters. For example, typing in the search terms on the Clinical Queries page automatically finds citations for SRs, MAs, reviews of clinical trials, evidence-based medicine, consensus development conferences and PGs. Thus, both PubMed search mechanisms allow for searching electronically across hundreds of journals at one time and being able to filter the results to the highest levels of clinically relevant evidence. In addition, PubMed has a mechanism that allows the user to receive email notifications when new articles are published on a specific topic of interest making it more convenient to stay current on that topic. #### 4. CODA Adopts EBP Accreditation Standards for Dental Hygiene Another evidence-based practice milestone is reflected in the CODA Accreditation Standards for Dental Hygiene Programs requiring students to master the skills required for EBDM.8 Graduating dental hygienists must be competent in providing patient-centered treatment and evidence-based care in a manner minimizing risk and optimizing oral health (Standard 2-17,).8 This has implications for both the curriculum and faculty development. EBDM will require much greater emphasis placed on research in an already jam-packed curriculum and translating classroom learning into application on the clinic floor. ### Using Evidence in Practice The EBDM movement has come very far in a relatively short time, however, the challenge for all health care practitioners, including dental hygienists, is to integrate EBDM into clinical practice. For example, how would one respond to a client who questions how adequate an oral cancer screening was performed since neither of the adjunctive devices that she saw on a popular daytime TV show were used? Or, how would one respond to clients who refuse to have radiographs taken because a report on the evening news discussed a possible association between dental x-rays and Meningiomas? Finally, how does one respond to a client who has always taken an antibiotic prior to treatment and now questions why he no longer needs to be premedicated? Knowing how to answer these questions requires skills in: 1. Efficiently finding the most current scientific information 2. Understanding the research design, the data/findings, and the level of evidence that was obtained 3. Knowing how to present this information in a way that the client understands it and can make an informed decision While EBDM is now incorporated into dental hygiene education, this is a fairly recent occurrence. Many will still be unfamiliar with the skills to practice EBDM. View this table: [Table II:](http://jdh.adha.org/content/87/suppl_1/33/T2) Table II: Pre-Appraised Evidence Resources View this table: [Table III:](http://jdh.adha.org/content/87/suppl_1/33/T3) Table III: Skills and Abilities Needed to Apply an Evidence-Based Decision-Making Process1 View this table: [Table IV:](http://jdh.adha.org/content/87/suppl_1/33/T4) Table IV: Strategies for Getting Started on Integrating Evidence Based Decision Making Mastering the skills of EBDM can help dental hygienists identify the best evidence to solve patient problems. However, other challenges may be encountered. Even when a search yields a citation that seems perfect to answer a clinical question, much of the scientific literature is not available for free. Partnering with an academic institution may assist with access to full text. Once the best evidence is found, translating the findings into clinical practice is another potential barrier. One of our human traits is to hold cognitive biases. When new evidence goes against current beliefs, we find ways to discount that evidence. When there is conflicting evidence or uncertainty, we tend to stick with what we have always done. Academic institutions are wrestling with these barriers as they work to make their educational programs models of evidence based practice. EBDM is evolving and improving to help clinicians overcome these barriers. ### Future Developments to Support Clinical Decision Making A recent development in EBDM is clinical decision support (CDS). CDS systems have their greatest potential at the point-of-care, i.e., chairside, using an electronic dental record integrated with a large patient database and algorithms that help sort and present evidence-based recommendations. These types of systems are more advanced in medicine, where as patient-specific information is entered, individual patient characteristics are automatically linked to the current best evidence that matches his or her specific circumstances. This can assist the clinician by suggesting appropriate care or warning about adverse effects.9 CDS systems provide clinicians with knowledge and person-specific information (such as computerized alerts and reminders) rather than general guidelines.10 “The goal of CDS is to provide the right information, to the right person, in the right format, through the right channel, at the right point in workflow to improve health and health care decisions and outcomes.”11 In dental hygiene, the best CDS are drug databases, which can be accessed chairside over the internet by computer and mobile devices. By linking to one of several drug database websites, detailed information about a particular drug and drug interactions can be obtained. As with all patient information, one must be careful when using personal/mobile devices so that confidentiality is maintained to prevent any HIPAA violations of protected patient information. The infrastructure to support EBDM at the point of care is evolving. However, until electronic patient records are fully integrated with a CDS system, evidence resources can be accessed via the internet. Table II presents examples of resources that support CDS. Levels 2 through 6 provide access to pre-appraised evidence, which means that the research evidence has undergone a filtering process to include only those studies that are of higher quality, and they are regularly updated so that the evidence accessed through these resources is current.12 ### Getting Started Recognizing that clinicians have time constraints and yet want to provide the best possible care to their patients, an evidence-based approach provides an effective strategy for keeping current. It also requires understanding new concepts and developing new skills (Table III). Many of the resources listed in Table IV can assist in learning these concepts and skills, and are free. For example, the PubMed tutorial presents information on its key features in short segments, some of which are YouTube videos. The online CE course on “Strategies for Searching the Literature Using PubMed” walks the user step-by-step through how to conduct a traditional and Clinical Queries search. For those who have not had a research design course or who need a refresher, the Guide to Research Methods, the Evidence Pyramid provides a graphical display and explanation of research designs and levels of evidence. Understanding evidence-based methodology and distinctions between different types of research allows clinicians to better judge the validity and relevance of reported findings. Being able to search electronically across hundreds of journals at the same time using PubMed overcomes the challenge of finding relevant evidence when it is needed to make a well-informed decision. Ideally, accessing new research that is valid, easy to read and pre-appraised will make keeping current the norm for practice, and in the future, further development of CDS will help clinicians implement EBDM in real time by linking electronic patient records with evidence based resources. ## Footnotes * *Jane Forrest, RDH, EdD, is the Section Chair of Behavioral Science and Practice Management, and the Director of the National Center for Dental Hygiene Research & Practice, Ostrow School of Dentistry of the University of Southern California. Pamela R. Overman, BSDH, MS, EdD, is the associate dean for academic affairs and professor of dentistry at the University of Missouri-Kansas City School of Dentistry.* * Copyright © 2013 The American Dental Hygienists’ Association ## References 1. Straus SE, Glasziou P, Richardson WS, Haynes RB. Evidence-Based Medicine: How to Practice and Teach It, 4th Ed. London, England: Churchill Livingstone Elsevier. 2011. 2. Sackett DL. 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