Introduction: the origins and aspirations of evidence-based dentistry

Widespread lack of understanding of the effects of healthcare was first clearly set out by Archie Cochrane in his book Effectiveness and efficiency: random reflections of health services, published in 1971.1 This publication set in motion a huge paradigm shift that underpinned perhaps the single most significant change in how clinical decisions are made that has occurred in modern times.

Effectiveness and efficiency pointed out that the NHS's 'cure' output was less than should be expected, given the economic input, and that scientific approaches to diagnosis and treatment would improve this situation. Most particularly Cochrane advocated the widespread use of randomised controlled trials. His assertion was that by doing this, the use of ineffective interventions would reduce and effective interventions would be utilised more efficiently (Table 1).

Table 1 Cochrane's applied research priorities (1971)

Recent refinement of the Cochrane concept has acknowledged that research evidence alone is not an adequate basis for clinical decision making. There has been increasing recognition that the clinician has a personal expertise to add into the decision equation and that the patient's concerns and preferences are also highly relevant to the achievement of positive outcomes. This more developed model of evidence-based practice was elegantly summarised in the 2003 Sicily Statement,2 which stated that evidence-based practice required that 'decisions about healthcare are based on the best available current valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of the available resources'. Figure 1 highlights the old and new philosophies of medical practice.3

Figure 1
figure 1

Paradigm shift: old and new philosophies of medical practice

The first Cochrane Centre, which organises and quality assures systematic reviews of healthcare randomised controlled trials, was launched in Oxford in 1992. Subsequently in 1995 The Cochrane Collaboration published a handbook of systematic reviewing, and since then multiple international specialist groups, including the Cochrane Oral Health Group have been set up. Online reference searching and retrieval software were created by the Collaboration and The Cochrane Database of Systematic Reviews and the Cochrane Trials Register and Cochrane Library followed. By May 2012, 5,044 reviews had been published and 2,183 protocols for systematic reviews had been established.

Barriers to the implementation of Evidence-Based Practice in dentistry

Various initiatives have attempted to reduce the obstacles practitioners face in adopting the evidence-based philosophy and applying it to the clinical care they give. Identification of these barriers is the first step towards making practice based on research evidence the norm rather than the exception (Table 2).

Table 2 Barriers to evidence-based dentistry

Research waste

A further barrier to evidence-based practice is 'research waste'. Failure of research to address the questions that matter to clinicians, and repetition of studies for which quality evidence already exists, are two of the greatest sources of research 'waste'.18 Therefore improving systems of research prioritisation so that the 'right' questions are funded is of great importance if practitioners are expected to treat patients according to research findings. Equally, to avoid the waste caused by repetition of studies, a system of examining the current state of evidence about a prioritised question would seem to be a fundamental pre-requisite to any research funding decision. Given that the funding for dental research is very limited in availability, avoidance of any research 'waste' in dentistry would seem to be of particular importance (Fig. 2).

Figure 2
figure 2

Stages of waste in clinician and patient-relevant research evidence18

While the notion of evidence-based practice is clearly a good one, at the level of the individual dental practitioner there is a huge challenge. The volume of research that can inform dental practice is enormous. For example in 2002 there were 460,000 dental articles available through MEDLINE and similar levels (423,500) at January 2014.19 It is therefore simply not possible for individual clinicians to read, make sense of, and translate all of current research into action in day to day work. Thus, sources of summarised reviews of treatment effectiveness are important in facilitating evidence-based practice. Pre-processed evidence that is relevant to everyday clinical work is comparatively rare, although the volume of it is growing. The size of the knowledge base is not, however, the only barrier to evidence-based practice and it is clear that having access to the evidence is insufficient in itself to change practice.20 Other barriers include a complete lack of relevant and robust research evidence in some parts of clinical dental practice.6

Research prioritisation

There is little consensus as to how best to determine the research agenda for dentistry. Table 3 illustrates approaches adopted by various organisations21 and in 2011, the Cochrane Collaboration established an Agenda and Priority Setting Methods Group to try to determine appropriate methodologies for deciding what research should be supported.22 Development of appropriate research priority setting methods would seem to be essential if the spending of research funds is to be aligned with real need for evidence.21 Uncertainties in practice or policy should drive the prioritisation of research topics, rather than it being the research interests of those carrying out the investigations, which dictate the research agenda.

Table 3 Research priority-setting approaches21

support for evidence-based dentistry

The Shirley-Glasstone Hughes (SGH) Foundation is one of the very few organisations offering funding exclusively to dentally related research projects and it has done so since 1990. Forty-one projects costing a total of £678,000 were funded between 1991 and 2005. An evaluation of the research output from this funding23 offered seven recommendations, including an indication that, in order to ensure relevance to 'real-world' dentistry, the SGH Fund should continue to ensure that dentists out-with academic institutions have access to the funding, and that SGH should focus on funding research themes of direct relevance to primary dental care.

In order to adopt these recommendations, the mechanisms by which research commissioning activity could be better informed by the day to day information needs of primary dental care practitioners were explored. An attempt was made to create a process that would encourage as many UK dental practitioners as possible to voice their opinion on what they need to know from research.

A new process (Fig. 3) that allowed dentists to influence the research agenda was launched at the British Dental Association (BDA) annual conference in May 2009. Rapid reviewing of specific topics' available evidence that was integral to the new process was implemented in September 2009. The new process was advertised in this Journal, on the BDA website and at BDA regional meetings.

Figure 3
figure 3

Process for dental practitioners to influence EBD through research

Practitioner engagement in research agenda setting

Unfortunately, very few practitioners took up the opportunity to direct the SGH research agenda using the online approach. Therefore, to try to increase participation, an online topic voting system was introduced. This gave dental practitioners the opportunity to prioritise nominated research topics. The most voted for topic in any voting period (one month duration) became the subject of a rapid evidence review. This involved a researcher undertaking a narrative appraisal of the available evidence relating to the practitioner-prioritised topic. Once a review was complete, an 'evidence statement' or summary was published online and in the BDJ. These jargon-free summaries of the critically-appraised evidence were produced and published24,25,26,27,28,29,30,31,32 in a form whereby the 'pre-digested' evidence could be easily used by a practitioner. Figure 4 describes the full research agenda-setting process as a series of information exchanges.

Figure 4
figure 4

Information exchange: a research agenda-setting process

So how can we ensure that dentistry becomes more evidence-based?

The first step towards promoting evidence-based practice in dentistry is to ensure that evaluation and synthesis of evidence skills are comprehensively embedded in dental training. This will ensure that practitioners with the capability, if not the capacity, to understand and apply research evidence to day to day practice are entering the workforce.

Secondly, in order to overcome the lack of quality evidence which is relevant to the day to day world of a general dental practitioner, it is essential that practitioners put forward to funding bodies the issues and dilemmas they face with their patients, and ask for relevant research to be prioritised and funded. If dentistry is to remain a science, as well as an art, we need to have appropriate evidence on which to base, and defend, our activities. If practitioners lack a voice in the science underpinning their profession, formulaic guideline/pathway driven dentistry may result.

Furthermore, wider availability of easily accessible pre-processed evidence syntheses on relevant topics, such as the short reviews published in the series by Fox24,25,26,27,28,29,30,31,32,33 can and should promote interest in, and hopefully the growth of, the application of research evidence in practice. Such short, jargon-free précis of the research evidence have been shown to be appreciated by practitioners34 because the average dentist does not have the time to read, digest and synthesise all the evidence on a given topic, and unless evidence review is comprehensive there is always a danger that bias and incorrect conclusions are drawn. While Cochrane reviews meet this 'comprehensiveness' requirement, the bulk of them are impractical for use by practitioners. Thus, the production of research 'synopses' seem to offer a very positive way forward in support of evidence-based dentistry and the BDA/SGH continues to provide these.

Information about the current rapid reviewing provided by the British Dental Association/Shirley Glasstone Hughes Trust is available at Curious About: http://www.bda.org/dentists/education/sgh/about_sgh.aspx

This paper has described a strategy through which practitioners and the BDA can support evidence-based practice, provide useful answers and resources for dentists who wish to involve themselves in research and help set the priorities in dental research.

The next paper in this series will describe the implementation and evaluation of the online system of research prioritisation for dentistry.