ARTICLE 1

EVIDENCE-BASED HEALTH CARE
A Perspective for Oral Medicine
Author: Dr. Shailesh Lele MDS
Sr. Professor & Head
Department of Oral Medicine
and Radiology
Director
Centre for Evidence-Based
Dentistry & Informatics
A successful, professionally satisfying practice of health care delivery requires gathering and evaluation of relevant data in terms of causative factors, investigative procedures, therapeutic choices and prediction of outcome. This is clinical decision making system. Here are some of those situations that make us use the clinical decision making process:
ETIOLOGY
INVESTIGATION
THERAPY
PROGNOSIS

1. In a 49-year old post-menopausal female patient with untreated diabetes, what could be the cause of burning sensation in tongue?

2. Lesion of stomatitis nicotina

1. Is bitewing radiography superior to periapical in detection of secondary caries?

2. Is digital radiography significantly better in disease detection, to adopt it in routine practice?

1. Trigeminal neuralgia- use of carbamazepine

2. How beneficial is the use of corticosteroids in preventing post- herpetic neuralgia?

1. What is the risk of bacterial endocarditis during endodontics in a patient with valvular heart disease?

2. What is the probability of recurrence of aphthous following administration of levamisole?
Most of the times, we make decisions at subconscious level, not really aware of how and why we come to a particular decision! In the above cited examples, under each category there is a situation when one is not certain of the decision to make. In the other instance, under each category, one is quite certain of the decision to reach. Even then it is possible that your decision is challenged by the patient! Situations such as these make us sit back and ponder on the clinical decision making process. In the end, we face one of the two following questions.
How do you reach a clinical decision?
How do you defend your clinical decision?

The problem however does not end here! One has to further make sure that the clinical decision we may reach is valid, current and applicable to one’s patient?

Traditionally one would turn to a variety of external (other than information from patient history and examination, and one's own knowledge) sources to help us decide. You may turn for guidance to (former) teachers, textbooks, professional colleagues, product literature ('infommercial'), continuing education programmes or journal articles. Except the last mentioned source, all the others tend to be dogmatic, experience-bound, biased and mostly outdated. Even though the journals may not have these limitations, how to ascertain that the conclusions reached in the article are 'valid' and 'applicable to one's patient'? The way out of these is perhaps "Evidence-Based Health Care (EBHC)".
Evidence-Based Health Care


Definition: “a conscientious, explicit, and judicious use of current best evidence in conjunction with clinical experience to make decisions regarding patient care”. This needs some explanation. 'Conscientious' means purposeful and persevering approach. 'Explicit' means to follow a transparent protocol that can be repeated by others. 'Judicious' would mean that the evidence gathered should not be used blindly, but be used in conjunction with one's own experience and the expectations of the patient.

Contrary to common misbelief, EBHC does not advocate disregarding clinical experience. No doubt, practice of EBHC involves use of statistics. It is however wrong to feel that EBHC is shackled by it. However strong the statistical evidence is, it is one of the inputs that goes into making a clinical decision.

History: Unknowingly many must have been practicing such approaches in the delivery of health care. A conscious use of such practices can be traced to post-revolutionary Paris (around 1850s). [Some would like to take the origins further back to China in the period before Christ.]

The modern history of EBHC, however, dates back to the 1970s at McMaster University, Canada, (McMaster University Evidence Based Medicine Group) where a rigorous approach to gather evidence from the scientific literature was incorporated in the postgraduate curriculum of Medicine. It further came into vogue in the 1980s at University of Harvard, US. From medicine it became popular in other specialities like psychiatry, paediatrics, surgery, nursing; and lately in dentistry. The real boost to EBHC and its formal acceptance came in 1995 at Oxford, UK with the establishment of the Centre for Evidence-based Medicine. The Centre for Evidence-based Dentistry soon followed at Oxford which has been guiding the movement around the world.

Perceiving the need for a scientific approach in dentistry, and inspired by this global phenomenon, some of us at College of Dental Sciences, Davangere got together the first ever )in the Asian subcontinent) Centre for Evidence-Based Dentistry & Informatics on the 31st of March 2000.
Steps: Essentially there are 6 steps that need to be followed meticulously in the practice of EBHC. The first three steps give us a clinical decision that is valid, current and applicable to one's patients (that is what EBHC is all about!).
Formulating a relevant, focused, clinically important question that is likely to be answered.
Finding the evidence.
Appraising the evidence for validity and its applicability in your patient.
Applying the evidence in one’s own patients in conjunction with the patient's expectations and values, and also using one's own clinical judgement.
Assessing the outcome of applying the evidence in your patients.
Summarizing and storing records for future reference.

The first three steps need learning of certain new skills that are not taught in a dental curriculum. Realizing this lacuna, a national workshop (on-line information & registration) has been organized at College of Dental Sciences, Davangere to provide training in these skills.

Description of each of these steps deserves much more space than that can be given in a single article like this. In the coming months, I hope to update you on these steps through these pages and at http://www.cods.edu/cebd-i/.
Benefits & Limitations: Ironically, 'evidence' that EBHC works is limited. But the methodology is appealing and seems most likely to lead to clinical decisions that are beneficial to the patients.
B
E
N
E
F
I
T
S
 Defines the current acceptable standard of health care that has medico-legal, health insurance & health administration implications.
If the evidence is strong, one does not have to experiment (involving time, money, and a lot of ethical questions) and the results become immediately applicable clinically. The patients stand to benefit greatly by this.
One’s skills in acquisition and critical assessment of information are improved, not to mention the exciting part of searching for and appraising the evidence.

Educational value: EBHC can provide the most current and relevant scientific inputs to students. It can also prepare a cadre of clinical faculty capable of bridging the gap between basic research and clinical skills. And finally, it will provide a data base / electronic referral point to analyze research and data and provide ready reference.
Points out areas for further research.

L
I
M
I
T
A
T
I
O
N
S
 Authoritarian clinicians & teachers perceive it as a threat !!
Access to information is limited.
Suitable evidence (studies) may not be available.

Some of the tools of EBHC are time consuming and difficult to master.
Evidence-based practice may increase rather than decrease the cost of health care.
Why practice and teach EBHC? We must practice EBHC simply because we, as health care professionals, owe it to our patients to provide the currently best care available. At the same time we must teach EBHC to prepare our students with lifelong learning skills, so that they continue to evaluate and use information for the benefit of patients.

EBHC and OM: Oral Medicine is a ripe area for evidence-based practice. Etiology of most oral disease processes is uncertain. Many diagnostic tests are costly and need to be critically evaluated for their sensitivity, specificity and cost-benefit analysis. Most treatment protocols are opinion-based rather than evidence-based. Prognosis of many oral diseases is difficult to predict.

Practice of EBHC shall give a solid foundation, based on which clinical decisions in Oral Medicine can be made. An all out effort is imperative on the part of the profession to acquire the knowledge base and skills required for practice of this novel and potentially beneficial approach to the delivery of health care.

In the words of Will Durant “Every subject begins as a philosophy, an integration of a general body of truths, goes through science, dealing in exactitudes, ends as an art related to skill and beauty”.

Presently, Oral Medicine is perhaps hovering between being a philosophy and science. Let us lift it to the level of an art!

Your feedback shall be appreciated and posted on this web site for others to view. Your comments, criticism and suggestions, on this article and the web site, can be entered in our guestbook. Thank you for your time.

Top