EBDM-Intro & formulating good clinical questions PDF

Brought to you by Continuing Education Evidence-based Decision Making: Introduction and Formulating Good Clinical Questions Course Author(s): Jane L. Forrest, EdD, BSDH, Lesley McGovern Kupiec, RDH, MSDH CE Credits: 2 hours Intended Audience: Dentists, Dental Hygienists, Dental...

Brought to you by Continuing Education Evidence-based Decision Making: Introduction and Formulating Good Clinical Questions Course Author(s): Jane L. Forrest, EdD, BSDH, Lesley McGovern Kupiec, RDH, MSDH CE Credits: 2 hours Intended Audience: Dentists, Dental Hygienists, Dental Students, Dental Hygiene Students Date Course Online: 03/01/2008 Last Revision Date: 02/01/2018 Course Expiration Date: 01/31/2021 Cost: Free Method: Self-instructional AGD Subject Code(s): 130 Online Course: www.dentalcare.com/en-us/professional-education/ce-courses/ce311 Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy. Introduction The primary learning objectives for this course are to: 1) increase your knowledge of evidence-based concepts, principles and skills, and 2) specifically how to formulate a good clinical question in order to find relevant evidence to answer that question. Conflict of Interest Disclosure Statement Jane Forrest has done consulting work for P&G. Lesley Kupiec works part-time as a dental hygiene educator for P&G. ADA CERP The Procter & Gamble Company is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at: http://www.ada.org/cerp Approved PACE Program Provider The Procter & Gamble Company is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and Membership Maintenance Credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 8/1/2017 to 7/31/2021. Provider ID# 211886 1 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals Course Contents Formulate a good question using the PICO Overview process. Learning Objectives Discuss the benefits of EBDM. Introduction - What is EBDM? Is Evidence-based Practice a New Term for Introduction - What is EBDM? an Old Concept? Evidence has always contributed to clinical Principles of EBDM decision-making; however, with the The Need for EBDM proliferation of clinical studies and journal Levels of Evidence publications, keeping current with relevant EBDM Skills and the 5-Step Process research is nearly impossible. Because we EBDM in Action rely on well-designed research studies to Applying the PICO Process demonstrate the efficacy and effectiveness Structuring the PICO Question of diagnostic tests, treatment strategies, Benefits of EBDM new materials, and products, knowing how Conclusion to find the scientific evidence is an essential Course Test component for clinical practice. References About the Authors Using evidence from the medical literature to answer questions, direct clinical action and Overview guide practice was pioneered at McMaster The Evidence-based Decision Making (EBDM) University, Ontario, Canada in the 1980’s. As process provides a mechanism for staying current clinical research and the publication of findings in practice by addressing gaps in knowledge increased, so did the need to use the medical so that the clinician can provide the best care literature to guide practice. The old clinical possible. To accomplish this, EBDM requires problem-solving model based on individual understanding new concepts and skills, the first experience or the use of information gained and often the most difficult is how to ask an by consulting authorities (colleagues or text answerable question. This question provides the books) gave way to a new methodology for basis for identifying the key terms for conducting practice and restructured the way in which an efficient search, the second step of the EBDM more effective clinical problem-solving should process. These two steps provide the basis for be conducted. This new methodology was the three that follow: critically appraising the termed Evidence-Based Medicine (EBM)1 and evidence, applying the results in clinical practice, its definition is currently stated as: and evaluating the outcome. The EBDM approach recognizes that clinicians can never be completely current with all conditions, medications, materials, The integration of the best research or available products, and provides a structured evidence with our clinical expertise and our approach to keeping current. patient’s unique values and circumstances.2 Learning Objectives Upon completion of this course, the dental Rather than refer to medicine, often this professional should be able to: definition has been broadened to mean Define EBP (Evidence-based Practice). ‘practice’ or ‘healthcare’ and is the definition we Define EBDM (Evidence-based Decision are using for Evidence-Based Practice (EBP). Making) and its purpose. Explain why EBP is not just a new term for an Several professions have adapted this old concept. definition to make it specific to their discipline. Identify two principles of EBDM. For example, the American Dental Association Discuss the need for EBDM. (ADA) defines “evidence-based dentistry” Identify the levels of evidence and premise (EBD) as: an approach to oral health care that upon which they are based. requires the judicious integration of systematic Describe the 5 steps and skills necessary for assessments of clinically relevant scientific EBDM. evidence, relating to patient’s oral and medical 2 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals condition and history, with the dentists’ clinical Is Evidence-based Practice a New Term expertise and the patient’s treatment needs for an Old Concept? and preferences.3 The use of evidence in practice is not new. What is new is the nature of the clinical evidence Inherent in these definitions is the recognition itself in terms of the methods for gathering it that research evidence is a valued component [randomized controlled trials and other well- of the clinical decision-making process, and the designed methods], the statistical tools for intent is that the use of current best evidence synthesizing and analyzing it [systematic reviews does not replace clinical skills, judgment, or and meta-analysis], and the ways for accessing experience but provides another dimension [electronic databases] and applying it [evidence- to the decision-making process that also based decision-making and practice guidelines].5 considers the patient’s preferences (Figure 1).2 It is this decision-making process that we In other words, evidence-based practice is not refer to as Evidence-Based Decision Making just a new term for an old concept and as a (EBDM) and is defined as:4 result of advances, practitioners need: 1. more efficient and effective online searching The formalized process of using the skills for skills to find relevant evidence, and identifying, searching for and interpreting 2. critical appraisal skills to rapidly evaluate and the results of the best scientific evidence, sort out what is valid and useful, and what is not. which is considered in conjunction with the clinician’s experience and judgment, the EBDM is the formalized process and structure for patient’s preferences and values, and the learning these skills with the purpose of closing clinical/patient circumstances when making the gap between what is known and what is patient care decisions. practiced in order to improve patient care based on informed decision-making. Again, EBDM is not unique to medicine or any Principles of EBDM specific health discipline, but represents a Evidence-based decision-making is about solving concise way of referring to the application of clinical problems and involves two fundamental evidence to clinical decision-making. principles:5 Figure 1. EBDM Process. ©2002 Forrest, NCDHR 3 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals 1. Evidence alone is never sufficient to make The Need for EBDM a clinical decision. As EBP has evolved, so An evidence-based approach emerged in has the realization that the evidence from response to the need for improving the quality clinical research is only one key component of health care, keeping up with the evidence as it of the decision making process and does changes with new research, and demonstrating not tell a practitioner what to do. the best use of limited resources. Forces driving 2. A hierarchy of evidence exists to guide clinical the need to improve the quality of care include: decision-making. EBDM is a structured process which incorporates a formal set of 1. variations in practice, rules for interpreting the results of clinical 2. slow translation and assimilation of the research and places a lower value on scientific evidence into practice, authority or custom. In contrast to EBDM, 3. managing the information overload, and traditional decision-making, relies more on 4. changing educational competencies that intuition, unsystematic clinical experience require students to have the skills for lifelong and pathophysiologic rationale. learning. Table 1. The Need For EBDM. 4 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals Levels of Evidence Although each level may contribute to the total Sources regarded as strong evidence include body of knowledge, “...not all levels are equally clinical practice guidelines, systematic reviews useful for making patient care decisions.”13 with meta-analyses, systematic reviews alone, As you progress up the pyramid, the number individual randomized controlled trials (RCT), of studies and correspondingly, the amount and well-designed non-randomized control of available literature decreases, while at the studies (Figure 2). The hierarchy of evidence for same time their relevance to answering clinical treatment questions is based on the notion of questions increases (Figure 3).13 causation and the need to control bias.13 Figure 2. Hierarchy of Study Types and Levels of Clinical Evidence. 2016 Modified Evidence Pyramid. Copyright permission granted by SUNY Downstate Medical Center, Medical Research Library at Brooklyn Figure 3. Available Literature and its Relevance. 5 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals Knowing which segment of the literature is to Research Methods - The Evidence Pyramid: appropriate for clinical decision-making and http://library.downstate.edu/EBM2/2100.htm. how to quickly retrieve this information is important to evidence-based practice. For EBDM Skills and the 5-Step Process example, the study methodology and level The principles of EBDM methodology are based of evidence will differ based on the type of on the abilities to find, critically appraise, and question asked, such as those derived from correctly apply current evidence from relevant issues of therapy/prevention, diagnosis, research to decisions made in practice so that etiology, and prognosis. Table 2 reviews the what is known is reflected in the care provided. type of question and the highest levels of The EBDM skills and 5-step process are evidence based on the study methodology. For outlined in Table 3. example, for questions associated with therapy and prevention, the highest level of evidence The following procedures provide an overview will be from meta-analyses or systematic of the five steps and skills involved in reviews of randomized controlled trials (RCTs), establishing an evidence-based practice. since the objective of these studies is to test interventions demonstrating cause and effect 1. Converting information needs/problems and to select treatments that improve the into clinical questions so they can be condition/disease and avoid adverse events.5 answered – the PICO process. Asking the right question is a difficult skill Correctly identifying the type of study to answer to learn, yet it is fundamental to evidence- the question is an important skill to develop to based practice. The process almost always access the appropriate evidence when searching begins with a patient question or problem. the healthcare literature. For example, identifying A “well-built” question should include four the best implant technique for replacing a single parts, referred to as PICO that identify the maxillary molar is a treatment question. Ideally, a Patient Problem or Population (P), Intervention meta-analysis or systematic review of RCTs would (I), Comparison (C), and Outcome(s) (O).2 be available on the treatment being considered. These parts, or components provide the key If one were not available, then the next best terms for step two. evidence would be from a well-conducted individual RCT. However, when the focus of the 2. Conducting a computerized search with question is on long-term outcomes of treatment, maximum efficiency for accessing the then it is a question of prognosis where the best external evidence with which to highest level of evidence would be provided by answer the question. a systematic review of inception cohort studies, This type of search requires a shift in which are studies that follows patients from when thinking. Finding relevant evidence requires a disease or condition first manifests itself clinically. conducting a focused search of the peer- And again, if a meta-analysis or systematic review reviewed professional literature based were not available, the next highest level would on the appropriate methodology. Online be an individual inception cohort study, and so databases and software that enable quick on down the hierarchy (Table 2). Two important access to the literature have made it easier concepts to keep in mind are that: 1) for any type to locate relevant clinical evidence. of question, having a well-conducted meta-analysis or systematic review typically provides stronger Knowing what constitutes the highest levels evidence than a single study, and 2) a meta- of evidence and how to apply evidence- analysis or systematic review is only as good as the based filters and limits will let you search individual studies that comprise it. the literature with maximum efficiency. It is the combination of technology and An excellent website that graphically displays the good evidence that allows healthcare different types of research methods and designs professionals to apply the benefits from can be found at the SUNY Downstate Medical clinical research to patient care. Center, Evidence Based Medicine Course, Guide 6 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals Table 2. Type of Question Related to Levels of Evidence and Study Methodology. 7 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals  Table 3. Skills needed to apply the EBDM Process.2 To assist professionals in keeping up with of interest, i.e., your patient problem or the literature and in making it possible to question. Understanding how to present quickly find needed information without statistical information to patients in a clear leaving your location, online access to and unambiguous manner will help in making MEDLINE via PubMed, good patient care decisions. Differences http://www.ncbi.nlm.nih.gov/pubmed, is between groups in clinical trials are generally provided by the National Library of Medicine straight forward when expressed in terms (NLM). See the dentalcare.com course, of the mean values; whereas, results Strategies for Searching the Literature Using presented as proportions, such as relative PubMed, for step-by-step guidance. risk reduction, absolute risk reduction, odds ratio and numbers needed to treat (NNT), 3. Critically appraising the evidence for are more challenging to understand. Also, its validity and usefulness (clinical understanding the difference between applicability). statistical and clinical significance will help you Once you have found the most current in translating and determining if the findings evidence, the next step in the EBDM process apply to your patient. is to understand what you have and its relevance to your patient and the PICO 5. Assessing the process and your question. Resources are available to help you performance critically appraise individual research studies The final step in EBDM is evaluation of the and meta-analyses or systematic reviews. effectiveness of the process. Mastering They consist of a worksheet with a structured the skills of evidence based decision- series of questions that can help you making takes practice and reflection and determine the strengths and weaknesses of a clinician who is new to the steps should how a study was conducted and how useful not be discouraged by early difficulties and applicable the evidence is to the specific encountered. Evaluating the process of patient problem or question being asked.17-19 EBDM may include a range of activities such as examining outcomes related to the 4. Applying the results of the appraisal, or health/function of the patient and patient evidence, in clinical practice. satisfaction. Self-evaluation of developing Once the methods are determined to be valid, skills is a most critical aspect in mastery of the fourth step is to determine if the results EBDM. With an understanding of how to (potential benefits or harms) are important. effectively use EBDM, you can quickly and This is achieved by looking at whether there conveniently stay current with scientific is an association between specific treatments findings on topics that are important to you and outcomes or exposures, the strength and your patients. of that association, and the condition 8 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals EBDM in Action As summarized by White et al, “Erosive tooth wear (ETW) is an umbrella term that includes The PICO Process (Skill/Step 1) dental erosion, abfraction, attrition and abrasion, The formality of using PICO to frame the alone or in combination.”21 From Nathan’s question forces the questioner to focus on assessments, we know that he has a moderate what the patient believes is the most important amount of ETW due to multiple risk factors problem and the desired outcome. Doing this including his: diet and dietary habits, oral health facilitates selecting language or key terms regimen, and his competitive swimming. Unlike for conducting the computerized search, the dental caries, which begins by demineralization second step in the process. Next, it allows and is a subsurface, reversible disease process you to determine the type of evidence and in early stages, dental erosion is characterized information required to solve the problem and by irreversible surface and near surface the outcome measures that will be used to damage to the tooth structure.22 Due to the determine the effectiveness of the intervention. permanent loss of hard tissue by ETW, it is very important that dental professionals assess, One of the greatest difficulties in developing recognize and intervene to protect enamel from each aspect of the PICO question is providing further destruction when signs exist. However, an adequate amount of information without management of ETW may be challenging due to being too detailed. Each component of the PICO the multifactorial nature of the disease process.22 question should be stated as a concise short phrase as illustrated in the following case example. After discussing each of Nathan’s risk factors, he realizes that some of his habits are contributing Case Example to his oral health problem. He had always Your new patient, Mr. Nathan Baker, is a 20-year thought being a vegetarian was healthy and that old student-athlete who has been swimming it was good to brush right after meals. He did competitively sine he was 12 years-old. His chief not know that his diet was acidic and eating too complaint is about the smooth, yellow areas near frequently could contribute to erosion.23,24 Nor did his gum line that he recently noticed. He wants he realize that he should wait 1-2 hours before to know what might be causing this and if there brushing his teeth after an acid exposure,21 or is anything he can do to fix and/or prevent it that as a competitive swimmer, if he is training in from getting worse. When reviewing his health water with a pH lower than the optimal (7.2-8.0) history and behaviors, you learn that Nathan is he may be subject to further erosion.25 a vegetarian, frequently snacking throughout the day on healthy fruits and vegetables. He also You both agree on changes that he can make consumes sports drinks and an occasional energy with his eating and oral care habits but realize drink with his hectic student/athlete schedule. there are some things that aren’t going to change – like the fact he is a competitive swimmer and Nathan currently uses a manual toothbrush plans to remain a vegetarian. He then asks you right after every meal, flosses nightly, and uses about the toothpaste he should be using. He whatever fluoride toothpaste is on sale when asks you about Sensodyne Pronamel® (a sodium he goes to buy one. He was apologetic for not fluoride toothpaste with potassium nitrate), since getting in for his hygiene visits at all last year. he recently heard a TV commercial stating that Since you suspect his chief complaint is due to it helps with erosion. You typically recommend erosion, you perform the Basic Erosive Wear a stannous fluoride toothpaste, like Crest Pro- Examination (BEWE),20 an easy to use scoring Health, but are not sure which one will be more system to measure erosive wear, recording the effective in preventing the initiation and further most severely affected tooth in each sextant. [See progression dental erosion. TABLES 1 and 2 for the criteria for grading erosive tooth wear and risk levels as a guide to clinical To answer Mr. Baker’s question you investigate management.]20 Nathan’s cumulative BEWE score the two options so each of you are fully of 10 alerts you that he is at medium risk for informed about the pros and cons before erosive wear, confirming your initial thought. selecting a treatment. With the increased 9 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals  Table 4. PICO Worksheet for Mr. Baker’s Case. ©2016 SA Miller and JL Forrest, PICO Worksheet, National Center for Dental Hygiene Research & Practice. 10 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals incidence of tooth erosion and the vast number may not be an alternative, however when there of toothpaste options, this information will be is one, it should be used. In our case, we have a valuable addition to your evidence-based selected the stannous fluoride toothpaste, Crest “library” that you are creating in your office. Pro-Health, as the main alternative. To find the answer, you must define Nathan’s The final aspect of the PICO question is the question so it facilitates an efficient search of outcome [O]. This specifies the result(s) of what the literature. To guide this process, the PICO you plan to accomplish, improve, or affect. It Worksheet and Search Strategy form can assist should be measurable and directly solve the you (Table 4). problem. Examples of outcomes are more, or as effective in relieving or eliminating specific Applying the PICO Process symptoms, improving or maintaining function, The first step in developing a well-built question is and enhancing esthetics. In Nathan’s case, to identify the patient problem or population [P] you are seeking evidence that demonstrates by describing either the patient’s chief complaint the effectiveness of Sensodyne Pronamel® or by generalizing the patient’s condition to a toothpaste under a given set of conditions, i.e., larger population. The problem is further shaped effective in preventing tooth erosion. Outcomes or refined by the most important characteristics yield better search results when defining that might influence the results such as: them in specific terms and they should solve the specific problem. “More effective or just as Level of disease or health status effective” are not acceptable outcomes unless Age, race, gender, previous conditions, past they describe how the intervention is more and current medications effective or just as effective as the Comparison. For our example, more effective in preventing In Nathan Baker’s case, we know the chief tooth erosion is the desired outcome. complaint or the Problem is erosive tooth wear and that his home care, diet, and possibly Structuring the PICO Question swimming are contributing factors. After understanding the elements of PICO and identifying each PICO component, you are Identifying the Intervention [I] is the second now ready to structure the PICO question for step in the PICO process. It is important to Nathan’s case. The same exact terms/wording identify what new treatment option is being used for each PICO component, is used to considered or what the patient is asking about, construct the PICO question. The formula for which keeps the process patient-centered. This writing the Question is: may include the use of a specific diagnostic test, treatment, adjunctive therapy, medication, For a patient with ______(P)_______, will ______ or the recommendation to the patient to use a (I)______ as compared to ____(C)______ increase/ product or procedure. The Intervention is the decrease be as or more effective in _______ new consideration for that patient.4 In Nathan’s (O)______? case, the intervention being considered is the Sensodyne Pronamel® (a sodium fluoride The PICO question for Nathan is then written toothpaste with potassium nitrate). as: The third phase of the well-built question is the “For a patient with erosive tooth wear (P), will Comparison [C], which is the main alternative Sensodyne Pronamel® (a sodium fluoride (intervention) you are considering.2 It should be toothpaste with potassium nitrate) (I), as specific and limited to one alternative choice, compared to Crest Pro Health (a stannous as is the Intervention. The C is typically the fluoride toothpaste) (C), be more effective in accepted procedure you perform, or the gold preventing erosive tooth wear (O)?” standard. Having specified just one “I” and one “C” facilitates an effective computerized Following the PICO Worksheet (Table 5), you search. The Comparison is the only optional would then identify the type of question and component in the PICO question since there study, and then list any additional terms or 11 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals  Table 5. PICO Worksheet for Mr. Baker’s Case. ©2016 SA Miller, JL Forrest, PICO Worksheet, National Center for Dental Hygiene Research & Practice. 12 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals phrases related to the already identified and strengthened by current research findings, P, I, C, and O. By generating these words, helping to close the gap between what is known alternative key terms are identified that (research evidence) and what is practiced. facilitate finding evidence to answer your question, Step 2, conducting a computerized EBDM is not about knowing all the answers, search with maximum efficiency. For example, but rather about knowing how to structure key terms that could be used in the search are: good questions to be able to find relevant erosive tooth wear, tooth erosion, stannous information to better inform your decision fluoride, sodium fluoride with potassium making, and how and when to integrate new nitrate, Sensodyne Pronamel® toothpaste thinking and action into everyday practice. or dentifrice, Crest Pro Health toothpaste or dentifrice. An example of a completed PICO Conclusion Worksheet for Nathan Baker’s case is shown in Recognizing that clinicians have time Table 5. constraints and yet want to provide the best possible care to their patients, an Benefits of EBDM evidence-based approach offers clinicians EBDM provides a strategy for improving the a convenient method for finding current efficiency of integrating new evidence into research to support clinical decisions, answer patient care more rapidly by helping you patient questions, and explore alternative manage an increasing amount of information. treatments, procedures, or materials. With an EBDM assists you in developing treatment plans understanding of how to effectively use EBDM, and providing treatment and advice that are practitioners can quickly and conveniently stay scientifically defensible. In addition, it helps current with scientific findings on topics that ensure that your practice is continually informed are important to them and their patients. 13 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals Course Test Preview To receive Continuing Education credit for this course, you must complete the online test. Please go to: www.dentalcare.com/en-us/professional-education/ce-courses/ce311/start-test 1. The following components define evidence-based practice: a. Clinical expertise b. Patient values c. Scientific research d. Clinical conditions e. All of the above. 2. The purpose of EBDM is to: a. emphasize new research findings b. close the gap between research and practice c. defer to patients’ wishes d. use expert opinions e. None of the above. 3. EBDM is just a new term for clinical decision-making. a. True b. False 4. EBDM requires online searching skills and understanding research methods. a. True b. False 5. Evidence can change over time as new research studies are conducted. a. True b. False 6. The highest level of evidence is the same for treatment and prognosis questions. a. True b. False 7. Which of the following provides the highest level of evidence for treatment questions? a. Case Control Study b. Cohort Study c. Systematic Review of RCTs d. Randomized Controlled Trial e. Case Report 8. Systematic reviews typically provide a higher level of evidence than a single study. a. True b. False 9. As you progress up the levels of evidence, the amount of available literature also increases. a. True b. False 14 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals 10. As you progress up the levels of evidence, the literature becomes more relevant for answering therapy related questions. a. True b. False 11. The first step in the EBDM process is: a. finding the best evidence b. applying the results to patient care c. asking a good clinical question d. evaluating the results e. critically appraising the evidence 12. Which of the following characteristics describes the Intervention in the PICO process? a. New treatment option being considered. b. Main concern or chief complaint. c. Measurable result. d. Alternative. 13. The only optional component of the PICO question is: a. P b. I c. C d. O e. NA, there is no optional component. 14. The purpose of defining the PICO question is to: a. identify a clearly focused clinical question b. consider what the patient/client believes is important c. provide key search terms d. determine the type of evidence required to solve the problem e. All of the above. 15. Select the PICO component that is missing or incomplete from this question: Will an antimicrobial therapy (minocycline HCl) in conjunction with scaling and root planing as compared to scaling and root planing alone, be more effective in preventing further attachment and bone loss? a. P b. I c. C d. O 16. Benefits of the EBDM process include: a. Provides a strategy for improving the efficiency of integrating new research evidence into patient care more rapidly by helping you manage an increasing amount of information. b. Assists in developing treatment plans and providing treatment and advice that are scientifically defensible. c. Helps insure that practice is continually informed and strengthened by current research findings. d. All of the above. e. A and C 15 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals 17. Read the following scenario and identify the Problem (P): Mrs. Sanchez is a 58-year-old women who is concerned about getting root surface cavities due to her receding gums. Her children receive fluoride treatments to prevent cavities on their teeth and asks you if she should be getting professionally applied fluoride treatments. Having recently read an article on chlorhexidine varnish (CHx- V) for the prevention of root caries you want to reread it to see if a CHx-V or Fluoride Varnish, which you normally provide, will be more effective. a. Fluoride varnish b. Receding gums c. Chlorhexidine varnish d. Root caries 18. For the scenario in Question #17, identify the Intervention (I): a. Fluoride varnish b. Receding gums c. Chlorhexidine varnish d. Root caries 19. Identify the Problem in the following scenario: Kevin is a 26-year-old man who talks to you about e-cigarettes and wants to know if they can help him permanently stop smoking. He has smoked since he was 16 and has never tried to quit before, but recently he has noticed his gums are bleeding and thinks it is due to his smoking. He also asks if e-cigarettes are better than nicotine gum. a. E-cigarettes b. Permanently quit smoking c. Bleeding gums d. Nicotine gum 20. Select the most appropriate PICO question for the following scenario: Kevin is a 26-year-old man who talks to you about e-cigarettes and wants to know if they can help him permanently stop smoking. He has smoked since he was 16 and has never tried to quit before, but recently he has noticed his gums are bleeding and thinks it is due to his smoking. He also asks if e-cigarettes are better than nicotine gum. a. Are e-cigarettes better than nicotine gum? b. For a patient with bleeding gums, are e-cigarettes as compared to nicotine gum better? c. For a patient who wants to permanently quit smoking, will e-cigarettes as compared to nicotine gum be more effective in permanently quitting smoking? d. 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Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs. Clin Oral Investig. 2008 Mar;12 Suppl 1:S65-8. doi: 10.1007/s00784- 007-0181-5. Epub 2008 Jan 29. 21. White DJ, Noble WH, West N. Managing Dental Erosion: Current Understanding and Future Directions. Accessed December 29, 2017. 22. Lussi A, Carvalho TS. Erosive Tooth Wear: A Multifactorial Condition of Growing Concern and Increasing Knowledge. In: Lussi A, Ganss C, ed. Erosive Tooth Wear. Monogr Oral Sci. Basel, Karger, 2014;25:1-15. 23. Barbour ME, Lussi A. Erosion in Relation to Nutrition and the Environment. In: Lussi A, Ganss C, ed. Erosive Tooth Wear. Monogr Oral Sci. Basel, Karger, 2014;25:143-154. 24. Staufenbiel I, Adam K, Deac A, et al. Influence of fruit consumption and fluoride application on the prevalence of caries and erosion in vegetarians--a controlled clinical trial. Eur J Clin Nutr. 2015 Oct;69(10):1156-60. doi: 10.1038/ejcn.2015.20. Epub 2015 Mar 18. 25. Buczkowska-Radlińska J, Łagocka R, Kaczmarek W, et al. Prevalence of dental erosion in adolescent competitive swimmers exposed to gas-chlorinated swimming pool water. Clin Oral Investig. 2013 Mar;17(2):579-83. doi: 10.1007/s00784-012-0720-6. Epub 2012 Apr 3. 17 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals About the Authors Jane L. Forrest, EdD, BSDH Dr. Forrest is a Professor of Clinical Dentistry and Chair of the Behavioral Science Section in the Division of Dental Public Health & Pediatric Dentistry, at the Ostrow School of Dentistry of USC, Los Angeles, CA. She also is the Director of the National Center for Dental Hygiene Research and Practice. Dr. Forrest is an internationally recognized author and presenter on Evidence-Based Decision Making (EBDM), receiving the 2017ADA/AADR EBD Accomplished Faculty Award. Dr. Forrest is the lead co-author on the book, EBDM in Action: Developing Competence in EB Practice and its companion, the Faculty Toolkit. She also has co-authored chapters on EBDM in Clinical Periodontology and Dental Hygiene Theory and Practice. Dr. Forrest has received federal funding for several grants including one to prepare faculty on how to integrate an evidence-based approach into curriculum. Email: [email protected] Lesley McGovern Kupiec, RDH, MSDH Lesley has over 8 years of experience in private clinical practice, in addition to part-time work with dental sales and education since 2011. She completed her undergraduate education in Massachusetts at both UMass, Amherst (BS, Sport Management) and Middlesex Community College (AS, Dental Hygiene). In 2014, Lesley graduated from the University of Southern California’s with her MSDH. It was here she combined her previous sports management background with her current passion for prevention in oral health resulting in publishing her graduate school research in the all sports edition of the AGD’s peer reviewed journal, General Dentistry. Lesley is active in the Los Angeles Dental Hygienists’ Society and the Academy for Sports Dentistry. She has also volunteered with the Special Olympics Special Smiles program. Email: [email protected] 18 Crest® + Oral-B® at dentalcare.com | The trusted resource for dental professionals