evidence based periodontology

EVIDENCE-BASED PERIODONTICS

PRESENTED BY:DR SWAPNIL P. BORKAR

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• INTRODUCTION • PRINCIPLE• WHAT IS TRADITIONAL CLINICAL PRACTICE• TRIAD OF EVIDENCE BASED PERIODONTOLOGY (EBP) • EVIDENCE BASED VS TRADITIONAL PERIODONTOLOGY • DEVELOPMENT• COMPONENTS • SOURCES OF EVIDENCE• SYSTEMATIC REVIEWS• META-ANALYSIS• CRITICAL APPRAISAL• BIAS• CONFOUNDING• CHANCE• INTERPRETATION• CONCLUSION

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WHAT IS EVIDENCE ?

NEED FOR EVIDENCE

WHAT IS EVIDENCE BASED PRACTICE ? “Evidence based practice involves integrating individual clinical

practice with the best available external clinical evidence from systematic research”. Sacketts et al

EVIDENCE BASED HEALTH CARE “An approach to decision making in which the clinician uses the best

available evidence , in consultation with the patient, to decide upon the option which suits the patient the best”. Muir Gray et al

EVIDENCE BASED MEDICINEThe integration of the best research evidence with clinical expertise and

patient values. (Sackett et al, 2000)3

EVIDENCE BASED DENTISTRY “ an approach to health care that requires the judicious integration of-

Systematic assessment of clinically relevant scientific evidence,relating to the patient’s oral and medical condition and history.

Dentist’s clinical expertise.

Patient’s treatment needs and preferences.”( According to the ADA-)

PRINCIPLES OF EVIDENCE BASED DENTISTRY

To define a clinically relevant and focussed question-

Getting the best information quickly

Assessing it’s quality

Deciding whether it is relevant

Best identified valid and relevant evidence used in the patient care

Evaluate the performance.4

HURDLES IN EVIDENCE BASED DENTISTRY

Amount of evidence

Quality of evidence

Authority rather than evidence

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ADVANTAGES OF EVIDENCE BASED DENTISTRY

objective scientifically sound Uses resources effectively patient focussed Incorporates clinical experience Stresses on good judgement Relies on evidence rather than authority Uses transparent methodology Enables practitioners to monitor and develop clinical performance

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• TRADITIONAL CLINICAL PRACTICE

• CLINICAL DECISIONS BASED ON PERSONAL BELIEFS AND EXPERIENCES

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EVIDENCE BASED PERIODONTOLOGY

WHAT IS EVIDENCE BASED PERIODONTOLOGY?

The application of evidence-based health care to periodontology.

It is a tool to support decision-making and integrating the best evidence available with clinical practice. Needleman,Moles,et al,Perio 2000

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TRIAD OF EVIDENCE BASED PERIODONTOLOGY (EBP)

GOAL OF EVIDENCE BASED PERIODONTOLOGY

To help the periodontist provide the best care for their patient

9How evidence-based periodontology fits into healthcare. Reproduced with permission from Clarkson, J, Harrison, JE, Ismail, AI, Needleman, IG, Worthington, H, eds. Evidence Based Dentistry for Effective

Practice. London: Martin Dunitz, 2003

EVIDENCE BASED VS TRADITIONAL PERIODONTOLOGY

SIMILARITIES:

High value of clinical skills and experience. Fundamental importance of integrating evidence with patient values.

Unclear basis of evidence.Unclear or absent appraisal of quality of evidence.More subjective,more opaque and biased process.Greater tendency to make black and white conclusions.

Uses the best evidence Systematic appraisal of quality of evidence.More objective,more transparent and less biased process.Greater acceptance of levels of uncertainty.

DIFFERENCES:

• EVIDENCE BASED PERIODONTOLOGY

• TRADITIONAL PERIODONTOLOGY

10Clarkson, J, Harrison, JE, Ismail, AI, Needleman, IG, Worthington, H, eds. Evidence Based Dentistry for EffectivePractice. London: Martin Dunitz, 2003

DEVELOPMENT OF EVIDENCE BASED PERIODONTOLOGY

coined by the clinical epidemiology group at Mc Master University.

1994: Alexia et al challenged the methods and quality of the periodontal clinical research in the mid-1980s.; Set up an Oral Health Group as part of the Cochrane Collaboration in Boston, USA.

1996: WWP held by the AAP included elements of evidence-based health care, supported by Michael Newman at the University of California, Los Angeles.

1997: The Editorial Base of the Oral Health Group moved to Manchester University , with Bill Shaw and Helen as the co-ordinating editors.

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2001: The first Cochrane Systematic review in periodontology was published and researched the effect of GTR for the intrabony defects.

2002: The EWP became the first international workshop to use rigorous Systematic Reviews to inform the consensus.

2003: Similar approach by the AAP for Contemporary Science Workshop.

12Evidence-based periodontology, systematic reviews and research quality IAN NEEDLEMAN et al perio 2000, vol 37 , 2005

COMPONENTS OF EVIDENCE BASED PERIODONTOLOGY

13The steps of evidence-based periodontology. Reproduced with permission from Clarkson, J, Harrison, JE, Ismail, AI, Needleman, IG, Worthington, H, eds. Evidence Based Dentistry for Effective Practice. London: Martin Dunitz, 2003

SOURCES OF EVIDENCEPRIMARY SOURCES:

The primary sources are original research publications that have not been filtered or synthesized .

SECONDARY SOURCES:

Secondary sources are synthesized publications of the primary literature.

These resources include:- Summaries of Systematic Reviews

Individual research articles

Clinical practice guidelines and protocols


DATABASES FOR SEARCH

MEDLINE ( PUBMED)

EMBASE

HEALTH STAR

CINALH ( Cumulative Index To Nursing and Allied Health)

The COCHRANE COLLABORATION LIBRARY

Pub Med is designed to provide access to both primary and secondary research from the biomedical literature.

Pub Med provides access to MEDLINE which contains-

o Bibliographic citations

o Authors’ abstracts from more than 4800 biomedical journals published in the US and 70 other countries.

The database contains over 12 millon citations dating back to 1966, and it adds more than 5,20,000 new citations each year.

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SYSTEMATIC REVIEWS

A systematic review is a literature review focused on a single question that tries to identify, appraise, select and synthesize all the high quality research evidence relevant to that question.

Systematic reviews of high quality RCT are crucial to EBP

An understanding of systematic reviews and how to implement them in practice is becoming mandatory for all professionals involved in the delivery of health.

“ In patients with chronic periodontitis,what is the effect of smoking or smoking cessation on the response to non-surgical periodontal therapy in terms of clinical and patient-centered outcomes?” ( Labriola et al. )

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OBJECTIVES OF SYSTEMATIC REVIEWS To provide a comprehensive and contemporary appraisal of research using

transparent methods while aiming to minimize the bias.

To aid in clinical decision making.

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WHAT A HIGH QUALITY SR CAN DO

• Find and summarize all the available studies.

• Provide an assessment of the quality of the research and in particular the degree of protection from bias within the original studies.

• Estimate research effects across the multiple studies with meta-analysis.

• It is possible to generalize the results if the effect is consistent across multiple studies.

CANNOT DO

• Cannot be used in isolation to dictate clinical practice.

• Can only be used in context with clinical judgment and patient preference.

• Cannot give strong conclusions if the research base is weak in quality.

• Cannot overcome limitations of narrowly designed clinical research.

• Cannot exclude irrelevant studies. 18Evidence-based periodontology, systematic reviews and research quality IAN NEEDLEMAN et al perio 2000, vol 37 , 2005

COCHRANE COLLABORATION

Many health care journals now published systematic reviews, but the best known source isThe Cochrane Collaboration, a group of over15,000 specialists in health care who systematically review randomized trials of the effects of treatments, and when appropriate, the results of other research.

Cochrane reviews are published in The Cochrane Database Of Systematic Reviews section of The Cochrane Library, which upto January 2009 contained 3,625 complete reviews and 1,921 protocols for additional reviews being conducted.

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REQUIREMENTS FOR SRThe Cochrane group provides a handbook for systematic reviewers of intervention ,

where they suggest that each systematic review should contain the following main sections:-

Background Objectives Methods of the review Results Conclusion and discussion

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STEPS FOR PREPARING AND MAINTAINING A SYSTEMATIC REVIEW

Formulating a problem

Locating and selecting studies

Critical appraisal of studies

Collecting data

Analyzing and presenting results

Interpreting results

Improving and updating reviews 21

QUALITY ASSESSMENT CHECKLIST FOR SR IN DENTISTRY

Did the review address a focused question? Did authors look for appropriate papers? Do you think authors attempted to identify all the relevant studies? Search for published and unpublished literature? Were the inclusion criteria carried out by atleast 2 reviewers? Are the results clearly displayed? Was an assessment of heterogeneity made and reasons for variation discussed? Were the results of the review applicable?

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COMPARISON OF CHARACTERISTICS OF SYSTEMATIC REVIEWS AND TRADITIONAL LITERATURE REVIEWS

CHARACTERISTIC SYSTEMATIC REVIEW LITERATURE REVIEW

Focus of review Specific problem : Narrow focus.Eg : Effectiveness of Periostat as an adjunct to scaling and root planing for the treatment of adult periodontitis.

Range of issues on a topic:Broad focus.Eg : Effectiveness of adjunctive antimicrobial agents for treating periodontitis.

Who conducts Multidisciplinary team Individual Selection of studies to include

Pre-established criteria based on validity of the study design and specific problem;All studies that meet the criteria are included.

Criteria not pre-established or reported in the methods;search on range of issues.may include or exclude studies based on personal bias or support for the hypothesis,if one is stated.

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CHARACTERISTIC SYSTEMATIC REVIEW LITERATURE REVIEWReported findings Search strategy: databases

searched.

Number of studies that met or did not meet the criteria: why certain studies were excluded.

Description of study design, subjects, length of trial,state of health / disease,outcome measures.

Literature presentation format crafted by the individual author.

Search strategy,databases and total number of studies(pros and cons)are rarely identified.

Descriptive in nature, reporting the outcomes of studies rather than their study design.

Synthesis of selected studies

Critical analysis of the included studies.Determination of the results could be statistically combined.

Reporting of studies that support a procedure or position and those that do not;rather than combining data or conducting a statistical analysis.

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CHARACTERISTIC SYSTEMATIC REVIEW LITERATURE REVIEW

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 the authors in relation to the purpose of literature review and specific objectives.

Conclusions or comments

Discussion of key findings with the interpretation of the results, including potential biases and recommendations for future trials.

Discussion of key findings with the interpretation of the results, including recommendations and limitations for future trials.

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META-ANALYSISDEFINITION: by Huque

“ A statistical analysis that combines or integrates the results of several independent clinical trials considered by the analyst to be ‘combinable’.

“ statistical overview”, “quantitative synthesis” , “pooling” and “weighted averaging” .

HISTORY

• The term coined in 1976 by the psychologist Glass .

• The first meta-analysis has been identified as the 1940 book-length publication “Extra- Sensory Perception after 60 years”, J.G.Pratt et al

• The meta-analysis of a medical treatment was first published in 1955.

• In oral health care, the first meta-analysis indexed in the MEDLINE database was published in 1989 . 26

TYPES OF META-ANALYSISPOOLED ( QUANTITATIVE ) ANALYSIS :

• The analysts pool the observations of many studies and then calculate parameters such as risk ratios or odds ratios from the pooled data. ( Grebarg and Horowitz,1988 )

• Pooled analysis should report both relative risk and reductions and absolute risk and risk reductions.

METHODOLOGIC (QUALITATIVE ) ANALYSIS:

• The quality of the research concerning the intervention is scored according to a list of objective criteria.

• The analyst then examines the methodological superior studies to determine whether or not the question of benefits is answered correctly by them.

• termed methodological analysis ( Grebarg and Horowitz, 1988 ) or ‘ quality scores analysis’ (Greenland, 1994 ).

• In some cases, the methodologically strongest studies agree with one another and disagree with the weaker studies, which may or may not be consistent with one another.

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WEAKNESSES OF META-ANALYSIS

A good meta-analysis of badly designed studies will result in bad statistics.

Another weakness of the method is the heavy reliance on published studies, which may increase the effect as it is very hard to publish studies that show no significant results.

This publication bias or “ file-drawer effect” should be seriously considered when interpreting the outcomes of a meta-analysis.

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STUDY DESIGNS Effectiveness of a treatment option is best answered by Randomized Controlled Trial

(RCT). Systematic Review of RCTs is the GOLD STANDARD . However for questions on etiology and prognosis cohort studies are more

appropriate.

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STUDY DESIGN AND THE TYPE OF QUESTIONS THEY ADDRESSD E F I N I T I O N O F S T U D Y

D E S I G N

EXPERIMENTAL STUDIES:

1.Randomized controlled trial:

2.Randomized controlled trial: split-mouth design

3. Non-randomized controlled trial:

U S E D F O R

Evaluating the effectiveness of an intervention.

RCT comparing the effectiveness of surgical therapy and non-surgical therapy.

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:

1.Cohort studies:.

2. Case-control studies.

3. Cross-sectional studies: a study or a survey undertaken on a defined population at a single point in time( snap-shot ).

Measuring the incidence of a disease; Looking at the cause of disease; determining the prognosis.

Identifying the potential risk factors for a disease; Looking at the possible causes of disease.

Measuring the prevalence of a disease or risk factor in a defined population at a specific time.

OBSERVATIONAL STUDIES


CRITICAL APPRAISALEvidence needs to be critically appraised.

Quality of evidence may vary according to the study design. The publication of the results in a high ranking journal is not an absolute guarantee of

quality.

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BIAS• Bias is any systematic error in design, conduct or analysis of a study which leads to an

erroneous conclusion ( Soben Peter )

• Bias leads to an incorrect estimate of the effect of a risk factor or exposure on the development of a disease or outcome.

• The observed effect will be either above or below the true value.

TYPES OF BIAS

1. SELECTION BIAS ( How the subjects were selected for inclusion in the study?)2. PERFORMANCE BIAS ( Provision of care )3. DETECTION / MEASUREMENT BIAS (Assessment of outcomes)4. PUBLICATION BIAS

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CONFOUNDING• Term that describes the situation where an estimate of the association between an exposure and

the disease is mixed up with the real effect of another exposure on the same disease, the two exposures being correlated.

Coffee drinking

Poor treatment response

Smoking habits

(confounder)

Risk factorAssociation


Confounding can be dealt with at the design stage of the investigation by:-

1. RANDOMIZATION

2. RESTRICTION

3. MATCHING

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CHANCE

• Chance is a random sampling error.

• The extent to which the sample results reflect the likely result in the population is assessed by performing statistical significance tests , and more importantly, by calculating the confidence intervals.

INTERPRETATION

• The authors may also fail to interpret their experimental results correctly. So, even if the study has been well conducted and appropriately analyzed , there is still the potential to draw incorrect conclusions from the results

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• Personal oral hygiene and chronic periodontitis

• Does oral health promotion improve oral hygiene and gingival health?

• How effective is surgical therapy compared with nonsurgical debridement?

• Which reconstructive procedures are effective for treating the periodontal intraosseous defect?

• Systematic review of the effect of smoking on nonsurgical periodontal therapy

37Evidence-based periodontology, systematic reviews and research quality perio 2000, vol 37 , 2005

CONCLUSION• The principles of evidence-based healthcare provide structure and guidance to

facilitate the highest levels of patient care.

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

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REFERENCES1. Carranza’s Clinical Periodontology, 10th edition, 2006.

2. Ian Needleman, David R.Moles, Helen Worthington; Evidence-based Periodontology; Systematic Reviews and Research Quality; Periodontology 2000; vol.37;2005;12-28.

3. Soben Peter , 3rd edition.

4. Newman MG, Caton JG, Gunsolly JC; The use of Evidence-based Approach in a Periodontal Therapy; Contemporary Science Workshop; Ann Periodontology 2003;8; 1-11.

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