Download THE ATTITUDES, AWARENESS, PERCEPTIONS AND BARRIERS

THE ATTITUDES, AWARENESS, PERCEPTIONS AND BARRIERS TOWARDS
EVIDENCE-BASED PRACTICE AMONG ORTHODONTISTS IN THE UNITED
STATES.
Asha Madhavji, D.M.D.
An Abstract Presented to the Faculty of the Graduate School
of Saint Louis University in Partial Fulfillment
of the Requirement for the Degree of
Master of Science in Dentistry
2010
Abstract
Purpose: This study evaluated the attitudes, awareness and
barriers to evidence-based practice among orthodontists in
the United States.
Methods: Two surveys consisting of 51
questions pertaining to evidence-based orthodontics were
sent to 8,455 AAO members in the United States. The
respondent’s age, attainment of a Master’s Degree and
whether or not they were currently involved with teaching,
was also ascertained. Results: A total of 1517 and 1047
surveys were received for the first and second surveys,
respectively. The majority of respondents had positive
attitudes towards, but a poor understanding of, evidencebased practice. The major barrier identified was ambiguous
and conflicting research. Most respondents felt that
guidelines would help increase evidence-based practice in
orthodontics. Younger orthodontists, as well as those
involved with teaching, were more positive, reported fewer
barriers and displayed better understanding of evidencebased practice than older orthodontists and those not
involved with teaching, respectively. Those without
Master’s Degrees reported more barriers than those with
degrees. Conclusion: Educational initiatives are needed to
help promote evidence-based practice in orthodontics.
1
THE ATTITUDES, AWARENESS, PERCEPTIONS AND BARRIERS TOWARDS
EVIDENCE-BASED PRACTICE AMONG ORTHODONTISTS IN THE UNITED
STATES.
Asha Madhavji, D.M.D.
A Thesis Presented to the Faculty of the Graduate School of
Saint Louis University in Partial Fulfillment
of the Requirement for the Degree of
Master of Science in Dentistry
2010
COMMITTEE IN CHARGE OF CANDIDACY:
Adjunct Professor Peter Buschang,
Chairperson and Advisor
Professor Eustaquio A. Araujo
Assistant Professor Ki Beom Kim
i
DEDICATION
I dedicate this project to my loving and supportive
family.
To Neel, my husband whose warm hugs, bright smile,
and calm demeanor make every day special. To my brother who
has always been one of my best friends. And, to my dear and
wonderful parents whose support and guidance have helped me
fulfill one of my greatest dreams… to become an
orthodontist.
ii
ACKNOWLEDGEMENTS
I would like to acknowledge the following individuals:
•
Dr. Buschang for guidance, insight, encouragement and
believing in this project from the start. Your support
and dedication has made this a truly enlightening
learning experience.
•
Dr. Araujo for being a mentor who has so generously
shared a wealth of orthodontic wisdom. Thank you for
your time and support in making this project happen.
•
Dr. Kim for being a great instructor who has provided
invaluable insights to improve this project. Thanks
for being so understanding and helpful throughout this
process.
•
Dr. Behrents for allowing this project to be approved
and funded.
•
The faculty (Dr. Oliver, Dr. McCray, Dr. Hayes and Dr.
Purcell) and residents of SLU who participated in the
development of this study.
•
The AAO for assisting in distribution of the surveys.
•
Survey Monkey for the wonderful online survey design.
iii
TABLE OF CONTENTS
List of Tables............................................vi
CHAPTER 1: INTRODUCTION....................................1
CHAPTER 2: REVIEW OF THE LITERATURE
History of the use of knowledge.......................4
Evidence-based medicine...............................7
Evidence-based approach...............................9
Problems with the tradition-based approach...........12
Evidence-based paradigm..............................17
Advantages of evidence-based practice................21
Barriers to evidence-based practice..................23
Evidence-based practice in medicine now..............30
Evidence-based practice in dentistry ................38
Evidence-based practice in orthodontics..............47
Barriers to evidence-based practice in orthodontics..51
Goals of this study..................................54
References...........................................56
CHAPTER 3: SURVEY 1 JOURNAL ARTICLE.......................63
Abstract.............................................63
Introduction.........................................64
Methods and materials................................66
Survey Design.....................................66
Demographic variables of interest.................67
Survey Validity...................................67
Survey Reliability................................68
Survey Distribution...............................68
Data collection and Analysis......................69
Results..............................................69
Attitudes, awareness and current practices........70
Barriers..........................................71
Understanding of terms............................72
Statements regarding orthodontic issues...........73
Primary reason for changing practice philosophy...74
Dealing with clinical uncertainties...............74
Discussion...........................................75
Conclusions and recommendations......................84
References...........................................85
iv
CHAPTER 4: SURVEY 2 JOURNAL ARTICLE......................108
Abstract............................................108
Introduction........................................109
Methods and materials...............................111
Survey Design...................................111
Demographic variables of interest...............112
Survey Validity.................................112
Survey Reliability..............................112
Survey Distribution.............................113
Data collection and Analysis....................113
Results.............................................114
Attitudes, awareness and current practices......114
Barriers........................................115
Understanding of evidence-based practice........116
Best method to increase evidence-based practice.117
Discussion..........................................118
Conclusions and recommendations.....................125
References..........................................126
Appendix A (Survey 1)....................................143
Appendix B (Frequency tables for Survey 1 questions).....148
Appendix C (Survey 2)....................................161
Appendix D (Frequency tables for Survey 2 questions).....164
Vita Auctoris............................................172
v
LIST OF TABLES
Table 1:
Evolution of the dental knowledge base...........5
Table 2:
Hierarchy of the levels of evidence.............18
Table 3:
Number of randomized control trials and
systematic reviews for each period ...........53
Table 4:
Survey 1 questions, abbreviated questions and
answer choices with assigned numerical values
used for data analysis .......................88
Table 5:
Comparison of the sample in Survey 1 with the
sample in Keim et al.’s 2008 study of
orthodontists in the United States ...........97
Table 6:
Percentage of respondents who selected each
answer choice for Survey 1 questions on
attitudes, awareness and current practices ...98
Table 7:
Survey 1 trends regarding attitudes, awareness
and current practices among the three
demographic variables ....................... 99
Table 8:
Percentage of respondents who selected each
answer choice for Survey 1 questions on
barriers ...................................100
Table 9:
Survey 1 trends regarding barriers among the
three demographic variables .................101
Table 10:
Percentage of respondents who selected each
answer choice for Survey 1 questions on
understanding of terms ......................102
Table 11:
Survey 1 trends regarding understanding of terms
among the three demographic variables .......103
Table 12:
Percentage of respondents who selected each
answer choice for Survey 1 statements regarding
major orthodontic controversies .............104
vi
Table 13:
Survey 1 trends regarding statements on major
orthodontic controversies among the three
demographic variables .......................105
Table 14:
Percentage of respondents who selected each
answer choice for the Survey 1 statement:
I change my practice philosophy primarily based
on ..........................................106
Table 15:
Percentage of respondents who selected each
answer choice for the Survey 1 statement: When
faced with clinical uncertainty I usually ...107
Table 16:
Survey 2 questions, abbreviated questions and
answer choices with assigned numerical values
used for data analysis ......................128
Table 17:
Comparison of the sample in Survey 2 with the
sample in Keim et al.’s 2008 survey of
orthodontists in the United States ..........134
Table 18:
Percentage of respondents who selected each
answer choice for Survey 2 questions on
attitudes, awareness and current practices ..135
Table 19:
Survey 2 trends regarding attitudes, awareness
and current practices among the three
demographic variables ...................... 137
Table 20:
Percentage of respondents who selected each
answer choice for Survey 2 questions on
barriers and understanding ..................138
Table 21:
Survey 2 trends regarding barriers among the
three demographic variables .................140
Table 22:
Percentage of respondents who selected each
answer choice for the Survey 2 statement: I
feel the best method to increase evidence-based
practice in orthodontics ....................142
Table B.1. Gender distribution of survey 1 respondents...148
Table B.2. Age distribution of survey 1 respondents......148
Table B.3. Distribution of responses to the question: Do
you have a Master's Degree? ................148
vii
Table B.4. Distribution of responses to the question: Are
you currently involved in research or teaching
at a university? ...........................148
Table B.5. Distribution of responses to the statement:
Research influences my daily work ...........149
Table B.6. Distribution of responses to the statement:
Peer-reviewed journals provide the best current
evidence for me to incorporate into my
practice.................................... 149
Table B.7. Distribution of responses to the statement: I
would be interested in more clinical practice
guidelines that help guide treatment decision
making ..................................... 149
Table B.8. Distribution of responses to the statement: I
read Scientific Peer-reviewed Journals ......150
Table B.9. Distribution of responses to the statement:
Please evaluate your awareness of the Cochrane
Collaboration... ............................150
Table B.10. Distribution of responses to the statement: I
have used PubMed/Medline in the past year to
answer a clinical question. .................150
Table B.11. Distribution of responses to the statement: The
practical demands of work make it difficult for
me to keep up-to-date with current best
evidence relating to practice .............. 151
Table B.12. Distribution of responses to the statement:
There are not enough clinical practice
guidelines in the literature ............... 151
Table B.13. Distribution of responses to the statement:
The literature is often conflicting and
ambiguous. ................................. 151
Table B.14. Distribution of responses to the statement: I
am satisfied with my current knowledge and
practice and feel it is sufficient ......... 152
viii
Table B.15. Distribution of responses to the statement: I
have the skills to undertake a comprehensive
literature review .......................... 152
Table B.16. Distribution of responses to the statement: I
feel comfortable performing a comprehensive
literature review .......................... 152
Table B.17. Distribution of responses to the statement: I
can obtain copies of published research papers
relating to my clinical practice. .......... 153
Table B.18. Distribution of responses to the statement: I
have no access to the internet. ............ 153
Table B.19. Distribution of responses to the statement: I
have access to the Internet at home ........ 153
Table B.20. Distribution of responses to the statement: I
have access to the internet at work. ....... 153
Table B.21. Distribution of responses regarding
comprehension of blinding ................. 154
Table B.22. Distribution of responses regarding
comprehension of systematic review ......... 154
Table B.23. Distribution of responses regarding
comprehension of meta-analysis ............ 154
Table B.24. Distribution of responses regarding
comprehension of randomized control trial .. 155
Table B.25. Distribution of responses regarding
comprehension of strength of evidence ...... 155
Table B.26. Distribution of responses regarding
comprehension of odds ratio ................ 155
Table B.27. Distribution of responses regarding
comprehension sample power ................. 156
ix
Table B.28. Distribution of responses regarding
comprehension of confidence interval ....... 156
Table B.29. Distribution of responses regarding
comprehension of specificity ............... 156
Table B.30. Distribution of responses regarding
comprehension of PICO questions ............ 157
Table B.31. Distribution of responses to the statement: Two
phase treatment of Class II Division 1
malocclusion is more efficient than one-phase
treatment in the permanent dentition ....... 157
Table B.32. Distribution of responses to the statement:
Occlusion is a primary etiologic factor in
TMD........................................ 157
Table B.33. Distribution of responses to the statement:
Third molars eruption causes lower incisor
crowding ................................... 158
Table B.34. Distribution of responses to the statement:
Frenectomy should be performed before
orthodontic treatment commences. ........... 158
Table B.35. Distribution of responses to the statement:
Premolar extraction smiles are rated as
significantly less esthetic than non-extraction
smiles. .................................... 158
Table B.36. Distribution of responses to the statement:
Extraction treatment causes TMD ............ 159
x
Table B.37. Distribution of responses to the statement: All
casts should be mounted to improve diagnosis
and treatment. ............................. 159
Table B.38. Distribution of responses to the statement: I
change my practice philosophy based primarily
on. ........................................ 159
Table B.39. Distribution of responses to the statement:
When faced with clinical uncertainties I
usually .................................... 160
Table D.1. Gender distribution of survey 2 respondents.. 164
Table D.2. Age distribution of Survey 2 respondents..... 164
Table D.3. Distribution of responses to the question: Do
you have a Master's Degree? ................ 164
Table D.4. Distribution of responses to the question: Are
you currently involved in research or teaching
at a university? ........................... 164
Table D.5. Distribution of responses to the statement: I
have previously heard or read about evidencebased orthodontics. ........................ 165
Table D.6. Distribution of responses to the statement: I
have participated in a course about evidencebased orthodontics. ........................ 165
Table D.7. Distribution of responses to the statement: The
attitudes of my colleagues to evidence-based
orthodontics. .............................. 165
xi
Table D.8. Distribution of responses to the statement:
Evidenced-based orthodontics in day-to-day
practice is. ............................... 166
Table D.9. Distribution of responses to the statement: An
evidence-based approach to practice improves
patient care ............................... 166
Table D.10. Distribution of responses to the statement:
Evidence-based orthodontics is more appropriate
for research settings not the clinical practice
of orthodontics ............................ 166
Table D.11. Distribution of responses to the statement:
Evidence-based orthodontics sounds good in
theory but is not practically useful. ...... 167
Table D.12. Distribution of responses to the statement:
Evidence-based orthodontics is best suited for
the next, younger, generation of
orthodontists. ............................ 167
Table D.13. Distribution of responses to the statement: I
can practice evidence-based orthodontics
through careful observation of what does and
does not work in my practice ............... 167
Table D.14. Distribution of responses to the statement: The
benefit of evidence-based orthodontics to
patient treatment is questionable. ......... 168
Table D.15. Distribution of responses to the statement:
There is no financial gain to practicing
evidenced-based orthodontics. .............. 168
Table D.16. Distribution of responses to the statement:
Evidence-based orthodontics is a threat to
clinician’s autonomy and experience. ....... 168
xii
Table D.17. Distribution of responses to the statement: I
am not interested in evidence-based
orthodontics. .............................. 169
Table D.18. Distribution of responses to the statement: I
have very little knowledge of evidence-based
orthodontics. .............................. 169
Table D.19. Distribution of responses to the statement:
Please indicate the relative level of evidence
of the case control study design. .......... 169
Table D.20. Distribution of responses to the statement:
Please indicate the relative level of evidence
of the case series study design. ........... 170
Table D.21. Distribution of responses to the statement:
Please indicate the relative level of evidence
of the case series study design. ........... 170
Table D.22. Distribution of responses to the statement:
Please indicate the relative level of evidence
of the randomized control trial study
design...................................... 170
Table D.23. Distribution of responses to the statement:
Randomized clinical trials are the only good
sources of evidence in literature. ......... 171
Table D.24. Distribution of responses to the statement:
Please identify the best method to increase
evidence-based practice in orthodontics. ... 171
xiii
CHAPTER 1: INTRODUCTION
Evidence-based practice is an approach that emphasizes
finding and using the best, current research evidence,
along with clinical experience and patient preferences to
help make health-care decisions.1 The goal of evidence-based
practice is to provide patients with up-to-date treatment
that research has shown to be safe, effective and
efficient. Ultimately, the goal of evidence-based practice
is to continuously improve patient care based on new
research developments.2
The concept of evidence-based practice is well
established in medicine. The Institute of Medicine has
designated evidence-based medicine as a key feature of
high-quality health care.3 There is a wealth of information
regarding evidence-based medicine including evidence-based
medical journals, evidence-based summaries and evidencebased practice guidelines.4 The Agency for Healthcare
Research has 12 Evidence-based Practice Centers located in
universities in the United States and Canada that conduct
evidence-based medical research.5 In dentistry, evidencebased practice is less developed but quickly gaining
momentum. The American Dental Association has made a
concerted effort to incorporate evidence-based practice
into the dental field in the United States; its website has
1
an entire section devoted to Evidence-Based Dentistry.6
Dental schools are introducing evidence-based courses into
their curriculums, there are journals focusing on evidencebased dentistry, two centers for evidence-based dentistry
have been established, and the Cochrane Collaboration has
included an Oral Health database.7
In orthodontics,
evidence-based practice is still in its infancy stages.
Studies on evidence-based practice in medicine found
that most physicians welcome evidence-based practice and
feel that it improves patient care.8-11 Barriers to evidencebased practice include the lack of time, an overwhelming
amount of literature, and difficulties incorporating
evidence into practice. Physicians felt that the best way
to increase evidence-based practice was by using evidencebased guidelines developed by colleagues. Dentists have
also expressed positive attitudes and awareness of
evidence-based practice.12,13 However, their understanding of
evidence-based concepts were poor. The major barriers
dentists reported were lack of time, lack of knowledge
about evidence-based practice and financial constraints.12,13
Dentists felt that the development of practical guidelines,
journal clubs and peer review sessions would help increase
evidence-based practice in dentistry.14 There is currently
no information about the attitudes and awareness,
2
perceptions and barriers to evidence-based practice in
orthodontics.
The purpose of this study was to determine the
attitudes and awareness of evidence-based practice among
orthodontists in the United States. In order to determine
the initiatives that might be needed, barriers to evidencebased practice were also examined. It was hoped that this
study would identify obstacles and solutions to
incorporating an evidence-based approach in orthodontics.
3
CHAPTER 2: REVIEW OF LITERATURE
History of the Use of Knowledge
The history of dental knowledge has gone through four
major eras or stages. The first era of knowledge was called
the Age of the Expert, then came the Age of
Professionalism, the Age of Science and now we are in the
Age of Evidence (Table 1).15
The dental knowledge base initially developed during
the “Age of the Expert.” Dentistry emerged as a society of
“barber surgeons” and knowledge creation was experiencebased.15 There was little in the form of systematic
observation. Knowledge dissemination was limited to a
master-apprentice relationship.15
During the 18th century, the second era of dental
knowledge emerged, the “Age of Professionalization.”15
Fauchard published his comprehensive dental textbook and
this stimulated the production of many other dental texts.15
Knowledge dissemination was further enhanced with the
creation of dental schools and the first dental society
journals in the 1840s.15
The dental knowledge base entered the third era, the
“Age of Science,” at the start of the twentieth century.15
4
Table 1. Evolution of the dental knowledge base15
Principal Method for Knowledge Base
Process
Knowledge
Knowledge
Knowledge
Creation
Synthesis
Dissemination
Era
ExperienceAge of the Expert
Experimental Apprenticeship
based
Texts,
ExperienceAge of
based
Shared
societies,
Professionalization
Limited
experimental
journals,
observational
schools
Texts,
Traditional
Limited
Age of Science
journals,
literature
observational
schools,
review
formal CE
Texts,
journals,
schools,
Systematic
Systematic
observation
review
Age of Evidence
CE,
guidelines,
evidence
summaries
5
There was a shift in dental education from proprietary
settings to university-based institutions.15 Systematic
experimentation increased. Knowledge synthesis evolved from
expert's experience toward evaluation of the available
literature.15 This resulted in the traditional literature
review.15 However, literature reviews are still subject to
bias.15 The expert conducting the literature review is a key
element of the review.15 This individual selects the studies
to be included and excluded and presents a subjective
interpretation of the literature.15 Therefore, the
literature review is open to both intentional and
unintentional biases.15
The dental knowledge base is now entering a fourth
era: the “Age of Evidence.” Knowledge creation in this era
places an emphasis on randomized clinical trials, although
observational study designs continue to be utilised.15 The
traditional literature review has been surpassed by the
systematic review. Systematic reviews represent a
substantial change by minimizing the role of the expert,
and minimizing bias through strict protocols.15 Evidencebased clinical guidelines and evidence summaries are
becoming increasingly prominent in knowledge dissemination.
Furthermore, the most significant change in the
6
dissemination of the dental knowledge is that access to the
majority of the knowledge base is via the Internet.15 Thus,
while the twentieth century was deemed the age of science,
the twenty-first century has been referred to as the age of
evidence.16 With that, there has been an increasing interest
in evidence-based practice in healthcare.
Evidence-based Medicine
Evidence-based practice has its roots in the medical
field. In the early 1980s, the Department of Clinical
Epidemiology and Biostatistics at McMaster University
developed practical methods for using evidence to answer
clinical questions.17 The goal was to give students and
clinicians the skills to facilitate life-long learning.18
The term “evidence-based medicine” was first introduced in
the published literature by Guyatt in 1991. However, an
article published in 1992 by the Evidence-Based Medicine
Working Group really brought the concept to the attention
of the medical community at large.19 The article focused on
the role of evidence in medical education and suggested a
new paradigm for medical teaching and practice. This new
paradigm was evidence-based medicine.
Evidence-based medicine is defined as “the
conscientious, explicit and judicious use of current best
7
evidence in making decisions about the care of individual
patients.”1 The practice of evidence-based medicine means
integrating individual clinical expertise with the best
available external clinical evidence from systematic
research.20 The goal of evidence-based care is for
clinicians to provide the best care to patients.2 The
evidence-based approach is intended to be a practical
approach to clinical decision making in the face of
uncertainty.21
In dentistry, the evidence-based approach is defined
as “an approach to oral health care that requires the
judicious integration of systematic assessments of
clinically relevant scientific evidence, relating to the
patient's oral and medical condition and history, with the
dentist's clinical expertise and the patient's treatment
needs and preferences”.20 Evidence-based dentistry closes
the gap between research and the real world of clinical
practice, providing dentists with powerful tools to
evaluate and apply the best, current research.22 The
electronic revolution that has come about due to the
internet has made evidence readily accessible.22 Now,
evidence-based dental practice is not only a possibility
but a very likely reality.
8
Evidence-based Approach
Evidence-based care augments the tradition-based
approach in some very important ways. Firstly, traditionbased care places a high value on a clinician’s accumulated
personal knowledge.18 The tradition-based care approach
stresses following long-held practices.18 In other words,
doing what was typically done in the past, even if these
practices are not based on scientific evidence. There is an
emphasis on
knowledge, experience and intuition in making
good clinical judgments.18 The tradition-based approach was
based on a number of assumptions about the knowledge needed
to guide clinical treatment. Firstly, unsystematic
observations from clinical experience were considered a
valid way of developing clinical judgment. Secondly, the
study of basic mechanisms of disease and pathophysiologic
principles were considered an adequate guide for clinical
practice. Thirdly, traditional formal-training and common
sense were thought to be sufficient for evaluating new
tests and treatments. Lastly, content expertise and
clinical experience were considered adequate for developing
valid guidelines for practice.19
In facing clinical problems with a tradition-based
approach, clinicians may reflect on clinical experience,
9
reflect on underlying biological principles, refer to
textbooks or ask a local expert.19 Additionally, focusing on
the introduction and discussion of a paper was thought to
be an appropriate way to identify the relevant information
in a new article. A high priority was placed on traditional
scientific authority, adherence to standard approaches,
direct contact with local experts, or reference to
literature of experts.19
The evidence-based approach, in contrast, favors
integration of good judgment with the best available
evidence and patient’s values in clinical decisionmaking.1,18 Evidence-based practice de-emphasizes intuition,
unsystematic clinical experience, and pathophysiologic
rationale in making clinical decisions.19
Instead, the
focus is on using evidence from clinical research to guide
decision making in patient care.
The assumptions of the evidence-based paradigm are
quite different from those of the tradition-based approach.
Firstly, clinical experience and instincts are assumed to
be a necessary part of being a competent clinician for both
approaches. However, systematic observation and recording
of clinical treatments in a reproducible and unbiased
manner has been shown to increase the accuracy of
10
conclusions drawn from such observations. Without
systematic observations, interpretations of information
from clinical experience and intuition may be misleading
and must therefore be viewed with caution.19 Secondly, the
study of basic mechanisms of disease is considered
necessary but insufficient for clinical practice by the
evidence-based approach. Rationale for treatment and
diagnosis based solely on basic pathophysiologic principles
may be misleading. Thirdly, understanding the rules of
evidence is required to correctly interpret scientific
literature and is fundamental to the evidence-based
approach. Therefore, the evidence-based approach puts a
lower value on authority.19 Instead, the evidence-based
approach empowers clinicians with skills to make
independent assessments of evidence and the credibility of
expert opinions. The most important assumption of this
approach is that those clinicians whose practice is based
on an understanding of the underlying scientific evidence
will provide better patient care.19
11
Problems with the Tradition-based Approach
The evidence-based approach was developed in response
to problems and pitfalls with the tradition-based approach.
One of the potential problems of a tradition-based approach
is that the quality of patient care can be negatively
affected in some circumstances. There is a saying that
“good judgment comes from experience, and experience comes
from bad judgment.”18 Therefore, a student may progress from
being a competent novice to a masterful clinician at the
expense of patients on which this experience was garnered.18
Another problem with the tradition-based approach is
the incorporation of research innovations into clinical
practice when there is an inconsistency between new and old
ideas. New research can contradict the long-standing data
upon which clinicians have based traditional treatment. For
example, the concept of “extension for prevention” as
advocated by G.V. Black is now being challenged by clinical
data on more conservative restorations.23 According to G.V.
Black, cavity preparation should involve removal of all
demineralized dentin, unsupported enamel rods, as well as,
extension of the cavity into pits and fissures to prevent
these areas from developing carious lesions in the future.23
However, this aggressive tooth cavity preparation results
12
in removal of large amounts of healthy tooth structure.23
Mertz-Fairhurst et al. have shown that advances in adhesive
technology challenge the concept of extension for
prevention.23 Their study compared three different carious
lesion treatment modalities over 10 years.23 One treatment
group had the traditional extension for prevention cavity
preparation and the placement of an unsealed amalgam
restoration.23 The second treatment group had a conservative
cavity preparation and the placement of a sealed amalgam
restoration.23 The last treatment group had a bonded and
sealed composite placed over a cavitated lesion that
extended into dentin.23 The cavitated lesion was not
prepared and therefore active caries remained in the
restoration. The results of their study defied conventional
logic. The conservative preparation restored with a sealed
amalgam and the cavitated lesion restored with composite
restoration performed better over 10 years than the
traditional unsealed amalgam restoration placed in the
extension-for-prevention cavity preparation.23 Additionally,
the bonded and sealed composite restoration that was placed
over the cavitated lesion with active caries, arrested the
lesion’s progress over the 10 year study period.23 The
authors concluded that the sealed restorations performed
better than the unsealed restorations with regards to
13
conserving tooth structure, protecting restoration margins,
preventing recurrent caries and prolonging the survival of
the restorations.23 Clearly, there is a need for clinicians
to continue to evolve their training and treatments in
light of new research findings. While this may seem to be a
natural part of continued professional learning, there are
many examples of how clinicians fail to use the current
best evidence in clinical decisions. Examples of this
include the slow growth in the use of dental sealants and
the routine removal of asymptomatic third molars.24,25 Both
the medical and dental literature suggest that traditional
methods used to change clinical behavior, such as
continuing education requirements, are not fully
effective.26-28 Evidence-based practice makes research
findings more accessible to clinicians and more applicable
to practice.24 Importantly, a study by Choudhry et al.
suggests that physicians who have been in practice longer
may be providing lower-quality care.29 This is in contrast
to the common sense notion that physicians with more
experience have accumulated more knowledge and skills
during years in practice and deliver higher quality care
than beginning physicians.29
14
Variation between practitioners has also been
highlighted as a problem with the traditional-based
approach. This variation can be the result of differences
in training, personal experiences, and the type of new
information incorporated into practice. The result is large
differences in prognosis, diagnosis, treatment, outcomes,
and cost of care for patients with similar disease
entities.18 In Wennberg and Gittelsohn’s landmark studies on
incidence of tonsillectomies, the treatment performed for
similar patients with similar clinical problems differed as
much as 12-fold (i.e. 13 per 10,000 to 151 per 10,000).30
Their findings suggested that the type of care the patient
received depended more on the clinician than on the actual
clinical problem.18,30 Similarly, a study by Weinfeld et al.
evaluated the methods and timing of treatment for cleft
patients.31 The goal was to evaluate international trends in
cleft lip and palate surgery and care.31 A survey was mailed
to 224 cleft lip and palate centers in the United States,
and 34 international cleft lip and palate centers.31 The
results of the survey showed very little uniformity in the
management, timing and type of treatment rendered to cleft
lip and palate patients among the different clinical
centers.31 Bader and Shugars have also shown significant
variations in dental care provided by different
15
practitioners including large differences in diagnosis,
prognosis, treatment, and cost.32 William Ecenbarger visited
50 dentists in 28 states for a dental assessment and
treatment plan. The treatment plans varied greatly ranging
in cost from $500 to $30,000. This sort of variability is
not well regarded by the general public and undermines
trust in the health care system.33
Another problem with the traditional approach is that
unsystematic observations can be misleading due to biases
being unknowingly incorporated into the process.34
Unsystematic observations based on recalled experiences and
memory of established clinicians may overestimate the
efficacy of treatment.35 Also, favorable treatments are more
likely to be recalled by clinicians when patients comply
with treatment regimens. Therefore good patient compliance
may be a marker of better outcomes even if the treatment is
not effective.36 Additionally, due to the universal tendency
for regression to the mean, a therapy reassessed after a
period of time may appear effective even if it is not.37
Importantly, day-to-day practice is not conducted with
blinding. Therefore, both the clinician and the patient are
aware when treatment is being performed. Lastly, the
16
placebo effect and the desire for a positive outcome could
lead to inaccurate estimates of treatment effectiveness.21
Evidence-based Paradigm
In order to address the concerns associated with the
tradition-based approach, the evidence-based approach was
developed. Due to large differences between the two
approaches, the evidence-based approach is considered a new
paradigm. Evidence-based practice requires new skills to be
learned and applied by clinicians. These include defining
the clinical problem and formulating a clear clinical
question, learning to conduct an efficient literature
search, selection of the best relevant studies, determining
the validity of the selected studies, and implementing
useful findings in practice.38 This process is referred to
as critical appraisal and is the cornerstone of evidencebased practice.19
The evidence-based approach recognizes a hierarchy of
evidence. The strength of the evidence graded from greatest
to least is as follows: systematic reviews of randomized
controlled clinical trials, randomized controlled clinical
trials, systematic reviews of cohort studies, cohort
studies, systematic reviews of case-control studies, case-
17
control studies, case series and consensus opinion of
experts (Table 2).39
The gold standard of evidence-based practice is the
randomized controlled clinical trial. This is because the
randomized trial and the systematic review of several
randomized trials have the least potential for bias.
Table 2. Hierarchy of the levels of evidence
Level of
Evidence
Study Type
Systematic Review of Randomized Control
1a
Trials
1b
Individual Randomized Control Trial
2a
Systematic Review of Cohort Studies
2b
Individual Cohort Study
Systematic Review of Case-control
3a
Studies
3b
Case-control Study
4
Case-series
5
Expert opinion
18
These studies are much more likely to provide valid
information and much less likely to be misleading than the
other study types.1 The randomized clinical trial is the
“gold standard” for determining whether or not a treatment
does more good than harm.1 However, this does not mean that
randomized control trials are the only source of usable
clinical information. Often, it is not practical or even
possible to conduct a randomized control trial for some
clinical problems. Well-designed, planned, and analyzed
retrospective studies aimed at minimizing biases may
provide valuable information for clinical practice.2
Clinical questions about diagnosis are often best addressed
with cohort studies. Questions about prognosis and harm are
best addressed by cohort or case-control studies. Clinical
questions about a treatment intervention and prevention are
best addressed by randomized control clinical trials.40 It
is important, when possible, to base firm recommendations
on rigorously controlled studies and to be more cautious
when basing recommendations on the results of uncontrolled
clinical observations.41 It is useful to remember that
evidence-based practice involves identifying the best
available current evidence with which to solve a clinical
problem.1
19
An important tool in the evidence-based approach is
the systematic review. The goal is to provide an objective
and comprehensive review of the research literature.42
Systematic reviews are considered the best source of
evidence.2 Systematic reviews use explicit methods to
search, collect, and appraise the evidence. The methodology
is documented and reproducible and is intended to minimize
bias and subjectivity.22 A systematic review that utilizes
quantitative methods to summarize results is called a metaanalysis.40 Meta-analysis provides a method of combining the
results of similar small trials that the lacked power
necessary to demonstrate treatment effects. Despite the
benefits of these studies, not all systematic reviews and
meta-analyses are equal.2,40 To assume that systematic
reviews and randomized clinical trials do not have
limitations is naive and incorrect.2 As is the case with
primary research, the clinician must critically evaluate
and interpret the results of systematic reviews. This is
very different from the traditional literature review.
Traditional literature reviews are broad in scope, written
by experts and often reflect the author’s subjective views
and biases. This means that the conclusions may not always
be accurate.22
20
Advantages of Evidence-based Practice
Evidence-based practice is advantageous for the
practicing clinician. For one thing, using an evidencebased approach allows clinicians to monitor and improve
clinical performance and routinely upgrade their knowledge
base.38,43 Physicians are not always informed about new
practices and procedures and often do not incorporate
advances in the medical field into their practices.44,45 A
study by Ramsey et al. showed that internists knowledge
base declined greatly within 15 years of graduation.44 Their
study found that there was an inverse relationship between
the scores achieved on an exam testing general medical
knowledge and the number of years that had elapsed since
certification. A study by Shin et al. showed that graduates
of a problem-based learning curriculum are more up-to-date
on the management of hypertension than the graduates of a
traditional curriculum.45 They also found that graduates of
traditional medical programs tend to progressively decline
in their knowledge of appropriate clinical practice as time
since graduation increases.45 However, graduates of
evidence-based curriculum programs that teach selfdirected, life-long, evidence-based medicine tend to be upto-date for as long as 15 years after graduation.38,45 In
addition, an improved
understanding of research
21
methodology allows clinicians to be more critical in
applying research data.38 For example, members of a journal
club can utilize an evidence-based approach to transform a
passive summary of assigned articles into an active inquiry
to solve clinical problems.38 Clinicians can use real-life
patient situations to direct literature searches, appraise
relevant evidence and maintain an up-to-date standard of
practice.38 An evidence-based approach empowers clinicians
to effectively utilize research resources through learning
effective methods of accessing and appraising the best
current evidence.22 Computer literacy and data retrieval
techniques and reading habits may also improve.38 The
educational and training process will also benefit from an
evidence-based approach because it gives teams a framework
for problem solving and teaching.38 By making an expert’s
implicit clinical reasoning explicit, students can
substitute mimicry with understanding and minimize the need
for years of experience as the only method of developing
clinical judgment.21 An evidence-based approach allows
junior members on a team a chance to contribute positively
to the team effort. It has been shown that the evidencebase approach can be learned by clinicians of different
backgrounds and at any stage of their careers.38 Also, an
evidence-based approach will enable better communication
22
with patients regarding the reasons for treatment
decisions.38 Evidence-based practice has the potential to
improve continuity and uniformity of care through common
approaches developed by clinicians. Research studies have
shown that patients receiving evidence-based treatment
routinely have better outcomes than patients who do not.46
For example, as a result of randomized control trials of
carotid endarterectomy (CEA) surgeries the percentage of
inappropriate surgeries among elderly dropped from 32% to
9%.46 The percentage of appropriate CEA surgeries rose from
35% before the randomized clinical trials to 87% after the
randomized clinical trials.46 Another benefit of evidencebased practice is that it may help minimize litigation
issues by facilitating justification of treatment
decisions.47 Therapeutic procedures stemming from evidencebased treatment principles with appropriate informed
consent may help to minimize legal disputes and regain
public trust.48
Barriers to Evidence-based Practice
There are barriers to practicing with an evidencebased approach. Firstly, as with all change, there is the
threat of something new, different, and unknown. Since
different skills are required, established clinicians with
23
rudimentary critical appraisal skills may feel threatened
by fear of inadequacy.19 Also, clinicians with limited
computer literacy might find the computer skills required
to perform effective searches quite daunting.38 Overcoming
this barrier will require dissemination of knowledge and
understanding of the concepts of evidence-based practice.
There is also the potential threat of established
clinicians’ ideas and practices being exposed as obsolete,
ineffective, or unsound.38 Others feel that evidence-based
practice threatens clinician autonomy. The concern is that
evidence-based practice will result in clinicians being
inappropriately told what to do by external sources or that
a self-appointed group of experts will dictate a single
“right” way of practice.49
However, evidence-based practice
is about utilizing the current, best evidence to make
treatment decisions that maximally enhance patient care.
The evidence-based approach is not intended to dictate
clinical practice.49
Secondly, time and effort are necessary to perform a
critical appraisal. This may be viewed as inefficient and
unnecessary. Concerns about evidence-based medicine, among
surveyed physicians, were that evidence-based practice is
time-consuming and ignores clinical experience.22 A
24
potential solution to such a problem would be education on
how to conduct effective literature searches and evaluate
evidence as well as explaining the basis of evidence-based
practice.
Thirdly, high quality evidence is lacking for many
clinical questions, which may make the process seem futile.
However, an evidence-based approach provides an objective
way to determine the current level of evidence.18 There is
also the advantage of highlighting gaps in the literature
and providing a scaffold for conducting new, well-designed
studies.38
Fourthly, some are skeptical about the concept of
evidence-based practice and argue that evidence-based
practice is neither new, nor effective.19 Testing the
effectiveness of this approach compared to the traditional
approach is difficult. However the results of short-term
studies are promising. Short-term studies have shown that
the skills of evidence-based practice can be taught.50 A
study by Kitchens and Pfeifer compared the difference
between a literature-based curriculum to a modifiedcurriculum in an internal medicine residency. The modifiedcurriculum was based on the traditional literature-based
curriculum but it was modified to encourage resident
25
participation and emphasized important clinical questions.50
A total of 83 residents participated in the study and were
divided into two groups: a control group and an
experimental group. The literature-based curriculum group
formed the control group and the modified-curriculum group
formed the experimental group. The study was divided into
two phases. At the end of each phase, the residents were
given a test on clinical epidemiology. A literature-based
curriculum in critical appraisal was the subject of a
weekly pre-clinic conference for the control group in Phase
I. The experimental group had a weekly conference on topics
in ambulatory care medicine during Phase I. At the end of
Phase I, both groups were given a test of basic knowledge
of clinical epidemiology. The curriculum was then modified
with the addition of written questions to emphasize
important educational points and to stimulate resident
participation. The modified curriculum became the subject
of the pre-clinic conference the experimental group, while
the control group changed to topics in ambulatory medicine.
At the end of Phase II both groups were again tested on
basic knowledge of clinical epidemiology. The residents in
the modified-curriculum group performed better on the Phase
II test than the literature-based curriculum group.50 The
experimental group performed significantly better on the
26
second test than on the first, 68.5% vs. 63.3%. The control
group did not improve significantly; their scores changed
from 64.5% to 65.9%. The modified-curriculum group also
showed greater improvement over the 8 weeks than the
literature-based curriculum group.50 The differences in test
scores for Test II minus Test I were +5.17% in experimental
group and -1.44% in control group. Twenty-one percent of
the experimental group residents vs. 5% of control group
residents improved their scores by 18% or more. The
residency period is a very important time to teach critical
appraisal skills. Educational curriculums need to be
critically evaluated to stimulate the development of more
effective educational programs.
Short-term trials have also shown that better, more
informed clinical decisions are made following even a brief
critical appraisal training.51 A study by Bennett et al.
evaluated the teaching of critical appraisal of literature
among final-year clinical clerks.51 The experimental group
received a short-course in critical appraisal of clinical
articles.51 The control group did not receive a special
intervention.51
Clerks in the experimental group had scores
that improved 37% on a diagnostic test exercise and 8% on a
treatment exercise.51 In contrast, clerks in the control
27
group has scores that decreased for both the diagnostic
test exercise and the treatment exercise.51 Furthermore, a
study comparing graduates of a program that operates under
the evidence-based paradigm versus the traditional approach
found that the graduates from the program with an evidencebased curriculum were more knowledgeable about current
guidelines in treatment.52 The argument that “everyone is
already doing it”, is contradicted by evidence showing
large variations in integration of patient values into
clinical treatment and great variation in the frequency
that treatment interventions are rendered to patients.1,53
Also, evidence-based practice has financial
implications. The implementation of infrastructure for
practicing with an evidence-based approach can be costly
because it requires computer hardware and software and
journal subscriptions.38 However, if evidence-based practice
improves the health of patients, then the extra costs may
be offset by savings due to decreased use of expensive
acute care and more efficient and effective delivery of
care.54 For example, in the absence of research from the
cardiovascular field from 1982 to the 2007, the cost of
treatment for patients with cardiovascular problems was
estimated to have been 35% more.49 Also, the research and
28
development in treating AIDS has cost $30 billion since
1981. Without this research, potentially more than 50% of
hospital beds in the United States would be used by AIDS
patients at an estimated cost of $1.4 trillion.49
Lastly, evidence-based practice has been misunderstood
as an approach that ignores clinical expertise gained
through years of experience. However, clinical expertise
and external evidence are not mutually exclusive in
evidence-based practice. Instead, both clinical expertise
and the best available external evidence are necessary to
deliver optimal patient care. Neither alone is sufficient.
Without clinical expertise, even excellent external
evidence may be used inappropriately. Without the current
best evidence, a practice may provide patient care that is
outdated or to the detriment of the patient.1
There are also many misconceptions about evidencebased practice. It is erroneously believed that evidencebased practice is not possible without randomized clinical
trials. However, evidence-based practice is intended to be
a practical method of solving clinical problems.55 The
process involves finding the best available evidence,
assessing the validity of the evidence and grading the
strength of evidence. Randomized clinical trials are the
29
“gold standard” for evaluating therapy interventions.
However, they are not the only source of useful evidence.55
Additionally, evidence-based practice is not intended
solely for individuals in academics.55
Rather, the goal is
to help clinicians identify solutions to clinical problems
that are valid and efficient. Lastly, evidence-based
practice is not “old-hat,” common sense knowledge used by
everybody in daily practice.55 It is the process of
identifying and incorporating the best available evidence
to assist in clinical decision-making. The end-goal is to
provide high-quality, effective health care.1
Evidence-based Practice in Medicine Now
The medical community has embraced the evidence-based
approach for quite some time. This can be witnessed in a
variety of ways. Many articles in medical journals have
been published on how to access, evaluate, and interpret
the literature. Major medical journals have adopted a more
informative structure for their abstract formats. Journals
that publish articles of high relevance and methodological
rigor have been launched. Textbooks with rigorous reviews
of the evidence also have become available. Practice
guidelines based on rigorous review of available evidence
are more common. A growing demand has arisen for courses on
30
effective use of the medical literature in day-to-day
patient care.19 Also, the Institute of Medicine designated
“evidence-based patient-centered health care delivery as a
key feature of high-quality medical care.”3
A study in 1998 by McColl et al. evaluated general
practitioner’s perceptions of evidence-based medicine in
England.9 Twenty-five percent of all general practitioners
in the area were randomly selected. The response rate was
67% (i.e. 302 out of 452). The study evaluated respondent
attitudes towards evidence based medicine, the ability to
access and evaluate evidence, barriers to practicing
evidence based medicine, and the best method of encouraging
evidence-based practice in medicine. The results of the
study showed that most respondents welcomed evidence-based
medicine and felt that it improves patient care. The level
of awareness of extracting journals, review publications
and databases was low. Even among those who were aware of
the research resources, most did not use them. The biggest
barrier perceived to practicing evidence-based medicine was
a lack of time. The physicians felt that the best way to
move towards evidence-based practice was by using evidencebased guidelines developed by colleagues.
31
A 2001 study by Coleman and Nicholl examined the
influence of evidence-based guidance on health care
decisions. The study evaluated the use of seven different
sources of evidence-based guidance among senior health
professionals in England.8 The health care officials were
from three health settings: health authorities, community
hospitals and primary care groups. There were a total of
566 subjects in the sample and the survey was conducted
through the postal system.8 The sample consisted of 95
health authorities, 375 community hospital consultants or
directors, and 96 lead general practitioners.8 The study
evaluated the subject’s knowledge of evidence-based
guidance, usage of evidence-based guidance, subject’s
belief in the quality and usefulness of evidence-based
guidance, and the perceived influence of evidence-based
signed studies.
ADDIN EN.CITE
.CITE
<EndNote><Cite><Author>Coleman</Author><Year>2001</Year><Re
cNum>204</RecNum><record><rec-number>204</recnumber><foreign-keys><key app="EN" dbid="papa0atxmtrdthepsttpzapied52tf02zt2r">204</key></foreig
n-keys><ref-type name="Journal Article">17</reftype><contributors><authors><author>Coleman,
P</author><author>Nicholl,
J</author></authors></contributors><titles><title>Influence
32
of evidence-based guidance on health policy and clinical
practice in England</title><secondary-title>Brit Med
primary care general practitioners.8 The average number of
different guidelines ever consulted by the health
authorities was 4.3.8 The source of evidence-based
guidelines used most often by health authorities was
Effective Health Care Bulletins which is produced in York.8
The average number of different guidelines ever consulted
by the hospital consultants was 1.9.8 The source of
evidence-based guidelines used most often by hospital
consultants was the Cochrane Collaboration.8 The average
number of different guidelines ever consulted by the
primary care general practitioners was 1.8.8 The source of
evidence-based guidelines used most often by general
practitioners was Bandolier.8 All health-care professionals
believed that the evidence-based guidance was of good
quality.8 However, the health authorities were significantly
more likely than either hospital consultants or the general
practitioners to perceive that the evidence-based guidance
had influenced or changed practice. The percentage of
health authorities which felt that evidence-based guidance
had influenced practice was 87%.8 In comparison, only 52% of
the hospital consultants and 57% of general practitioners
felt that evidence-based guidance had influenced practice.8
For all three groups, the least utilized portal for
accessing evidence-based guidance was the Internet.8 The
33
most frequently used method of access to evidence-based
guidelines was direct mailing. Direct mailing was used by
57% of all respondents and comprised 41% of the total
access type.8 The internet was used by 29% of respondents,
but accounted for only 12% of the total access type.8 The
proportion of total access type for libraries was also 12%.8
The evidence-based guidance was significantly more likely
to have contributed to the decisions made by public health
authorities than the decisions made by consultants in
hospitals or primary care general practitioners.8 The health
care professionals have adopted a passive role in accessing
evidence-based guidelines by relying on direct mailings.8
The authors concluded that a more proactive approach of
seeking information through the internet needs to be
adopted by health care professionals.8 A system of
increasing information support and access in order to
promote increased awareness and use of evidence-based
guidance needs to be developed.8
A study by O’Donnell in 2004 evaluated attitudes and
knowledge of primary care professionals toward evidencebased practice in Scotland.10 A survey was sent to 437
individuals. These individuals were chairs, general
managers, clinical governance leads, lead nurses, lead
34
pharmacists, and public health practitioners. There were
289 responses received to yield a response rate of 66%. All
of the professional groups supported evidence-based
practice with 94% of public health practitioners agreeing
that it was a welcome development.
However, about 34% of public health practitioners felt
that it was impossible to keep updated with current
evidence. About 80% of public health practitioners felt
that they had the skills to undertake a comprehensive
literature review. However, among public health
practitioners understanding of terms associated with
evidence-based practice ranged from 32% of respondents for
the term “intention-to-treat analysis” to 77% for the term
“randomization.” Access to the internet and electronic
databases was readily available for all groups. Public
health practitioners were the least likely group to view
guidelines developed by others as the best source of
evidence-based information. The major barrier to
implementing evidence-based practice was time. Respondents
perceived that potential solutions include providing
increased financial and staff resources and increasing
training in evidence-based practice.
35
A 2006 study by De Smedt et al. aimed to evaluate
primary care professionals' self-reported attitudes towards
evidence-based practice. The study also evaluated the
awareness of information sources, perceptions of the
barriers to evidence-based practice and strategies to
improve insight into evidence-based practice and patient
care.11 An Internet-based survey was administered to Belgian
medical doctors, nurses and paramedics.11 The paramedic
category included emergency medical technicians, firemen
and medical volunteers.11 The final sample size consisted or
112 doctors, 158 nurses and 121 paramedics. In general,
respondents were supportive towards evidence-based practice
and felt that evidence-based practice improves patient
care.11 However, medical doctors claimed that only 50% of
their practice was evidence-based. The nurses devoted 59%
of their time on evidence-based practice.11 The paramedics
devoted 54% of their time on evidence-based practice.11
Doctors depend mostly on official clinical guidelines, the
Internet and textbooks to make clinical decisions in face
of uncertainty.11 Nurses preferred conferences and protocols
to make decisions when faced with clinical problems.11 The
paramedics relied primarily on courses and their own
judgment to make decisions when faced with uncertainty.11
PubMed was consulted by 67% of the doctors, 32% of nurses
36
and 7% of paramedics. All respondents strongly relied on
experimental knowledge gained through interaction with
colleagues, and the majority reported that their colleagues
are often not supportive of evidence-based practice.11 Lack
of time, the overwhelming amount of literature and
difficulties with incorporating evidence into practice were
the most common barriers cited by respondents.11 Nurses also
felt that a lack of critical appraisal skills was a barrier
to evidence based practice.11 The paramedics cited
difficulties understanding research and limited access to
computer facilities in their working environment as
additional barriers to evidence-based practice.11 Nurses and
paramedics were more willing to adopt the opinion of senior
colleagues and individual feedback than medical doctors.11
There were many obstacles that need to be overcome to
transition from an experience-based practice to an
evidence-based practice.11 The most appropriate method for
implementation of evidence-based practice was deemed to be
provision of summaries of evidence, easily understandable
protocols and web-based databases accessible from the
working environment.11 Also, it was deemed that supervisors
and educators need to evolve from an experience-based to
evidence-based practice.11 Adopting an evidence-based
37
teaching curriculum would help stimulate students to adopt
an evidence-based approach in practice.11
Evidence-based Practice in Dentistry
In dentistry, the evidence-based approach has lagged
behind medicine, but it is growing. Evidence-based
dentistry is an important development and its impact on
clinical decision making is expected to increase.56
Chiappelli distinguishes between the evidence-based
approach and the traditional approach as follows: dentistry
based on evidence is “bits and pieces of conveniently
selected evidence”, while evidence-based dentistry is “the
collection of the best available research evidence.”57
However, evidence-based dentistry is an emerging concept
and there are relatively few randomized clinical trials and
other outcome-oriented studies in dentistry that have
evaluated clinical interventions.32 Outcome studies on
important aspects of dentistry such as the management of
caries, periodontal disease and facial pain are lacking.24
Perceptions of experts still dominate various aspects of
decision making in patient dental care. For example, the
prognosis of teeth adjacent to a single missing posterior
tooth has not been examined.
32
However, expert opinion
states that treatment is needed to prevent arch collapse.
38
Therefore, routine dental treatment is recommended to
replace single missing posterior teeth despite being
unsupported by evidence.24
Nonetheless, evidence-based dentistry is making
inroads. A series of articles have been written to provide
dental clinicians with different paradigms for making
clinical decisions and using critical appraisal.22,55,58,59
Journals focusing on evidence based dentistry such as
Evidence-Based Dentistry have arisen. Courses on evidencebased dentistry are being introduced.18 Additionally the
number of systematic reviews in the dental literature has
increased steadily since the early 1990s. Currently, there
are over 1200 systematic reviews in the American Dental
Association’s evidence-based dentistry database.6
A search on MEDLINE and the Cochrane databases of
systematic reviews was conducted by Bader et al. to survey
the dental literature.60 They also included reviews that
were known to the authors but not found in the searches.60
Systematic reviews that were included in the survey stated
the intention to identify all relevant articles within
predefined limits, applied defined exclusion and inclusion
criteria, and presented data from included studies.60 The
literature survey identified 131 systematic reviews and 96
39
of these had direct clinical relevance.60 Over that last
decade, clinically relevant systematic reviews have been
published with increasing frequency.60 These reviews vary in
the types of studies and the appraisal of those studies.60
The results of the reviews also varied.60 About 17% found
the evidence was found to be insufficient to answer the key
question.60 About 50% hedged in answering the key question
and stated that the evidence was weak in quality or limited
in quantity.60 The number of systematic reviews that address
clinical topics in dentistry is small but it is growing.60
However, a large proportion of these reviews state that the
evidence available to answer the key question was weak.60 It
was also concluded that the importance of systematic
reviews is not fully appreciated by practicing dentists.60
As systematic reviews continue to grow, dentistry will
become better informed about the scientific evidence
supporting clinical practice.60 Recent studies have
evaluated the extent to which evidence-based practice is
embraced by the dental community. These studies have
utilized postal surveys to examine dentists’ attitudes and
awareness of evidence-based practice in dentistry.
Rabe et al. studied the attitudes, awareness and
perceptions on evidence-based dentistry among dental
40
professionals in Halland, Sweden.13 These professionals
consisted of the following five groups: dental hygienists,
general dentists and specialist dentists in public dental
services, and dental hygienists and general dentists in
private practice. A questionnaire survey was sent to 290
dental professionals in Sweden. Two hundred and twenty
replies were received yielding a response rate of 76%. The
replies were from 67 dental hygienists, 137 general
dentists, and 16 dental specialists. Of these replies, 22
were retired and were removed from the sample. Thus, the
sample consisted of 198 questionnaire replies. Time spent
on self study was reported to be between 0 to 1 hours per
week for a majority of dental hygienists and general
dentists. The specialists reported spending between 1 and 3
hours per week on self-studies. A majority of the
respondents had a positive attitude towards evidence-based
practice, except for general dentists in private practice.
Respondents all perceived their colleagues attitudes as
less positive towards evidence-based practice than their
own attitudes. All respondents considered evidence-based
practice at least partly useful in daily practice. In
addition, the vast majority of dental professionals, except
for general dentists, felt that evidence-based practice
would improve care of their patients in private practice.
41
For general dentists in private practice, 50% felt
evidence-based practice would improve patient care and 50%
felt it would not change patient care. The median
percentage range of evidence-based practice was between 6180% for dental hygienists. For general dentists and
specialist dentists the median percentage range of
evidence-based practice was 41-60%. A majority of
respondents were aware of evidence-based practice. This
ranged from 59% of dental hygienists in public dental
services to 100% of specialist dentists in public dental
services. In contrast to dental hygienists and general
dentists, a majority of specialist dentists conducted
searches on Medline database and were aware of the Cochrane
Collaboration. The terms of evidence-based dentistry was
understood to some extent by a majority of respondents. In
addition, when the term was not understood a majority would
like to learn more to understand it. The major barrier to
evidence-based practice among dental hygienists and general
dentists was a lack of time. For specialist dentists, the
major barrier to evidence-based practice was poor
availability and information about the scientific evidence.
Interestingly, more than 66% of public dental services
specialist dentists perceived no barriers to practicing
evidence-based dentistry.
42
A study by Zamros et al. evaluated evidence-based
practice among a group of Malaysian dental practitioners.12
The survey was sent to 384 dentists and 193 replied for a
response rate of 50.3%. About 70% of the respondents (i.e.
135 individuals) had heard of evidence-based practice.
While 80% of these individuals reported understanding the
term “evidence-based practice”, only 62% of these
individuals understood the term “critical appraisal.” In
this study, about 43% of the respondents who were aware of
evidence-based dentistry were not aware of the strengths
and types of evidence in the literature and incorrectly
assumed that all evidence from scientific journals were
appropriate for evidence-based practice. The lack of the
familiarity with important evidence-based concepts suggests
an inconsistency between the respondents’ perceived and
actual understanding of evidence-based practice. Of those
who were aware of evidence-based practice, most felt that
it improved their knowledge and skills (98%) and treatment
quality (98%). When faced with clinical uncertainty, 91% of
respondents referred to colleagues, 89% made referrals, 83%
consulted textbooks, and 67% referred to an electronic
database. Forty-two percent of respondents felt that the
best and quickest way of finding evidence was by asking
experienced colleagues or referring to textbooks. About 45%
43
of the 135 individuals stated that, in cases of clinical
uncertainty, they would continue treatment based on their
judgment and experience without conducting an evidence
search.
In terms of reading scientific articles, 47% read
articles less than once a month, 31% read articles at least
once a month, 20% read articles at least once a week and 2%
never read articles at all.
Of those 135 respondents who
were aware of evidence-based dentistry, 44% felt that it
was very important, 43% felt that it was important and 98%
were interested in learning more about it. The main
barriers to practicing evidence-based dentistry were lack
of time (64% of respondents), financial constraints (40% of
respondents) and lack of knowledge of evidence-based
practice (28% of respondents). Other barriers were poor
English skills (2%), lack of skill to appraise scientific
journals (22%), satisfaction with current knowledge and
practice (24%), limited access to computers and the
internet (17%), and lack of interest in evidence-based
practice (10%). Though the majority of dentists had a
positive attitude towards evidence-based practice, due to
the above-mentioned barriers, most used sources other than
electronic databases to solve clinical problems. The
authors suggest that journal clubs and peer review sessions
can be useful ways to develop and improve critical
44
appraisal skills. The authors also suggest that the
respondents’ positive attitudes toward evidence-based
practice are encouraging. Such attitudes provide an
opportunity for dental educators to promote understanding
and changes in solving clinical questions. Courses on
evidence-based practice may be one of the ways to instigate
this. Additionally, providing financial and other
incentives to attend these seminars could help dentists
offset the financial constraints of developing evidencedbased approaches in their practices.
Allison and Bedos evaluated Canadian dentists’
perception of the utility and accessibility of dental
research.14 Questionnaires were sent out to all 17,648
registered Canadian dentists.14 There were 2,797 completed
and returned questionnaires.14 The response rate was 15.8%.14
The sample was broadly representative of Canadian dentists
in terms of geographic location, gender and the type of
practice.14 There were 2,595 clinicians in the sample and
this formed 92.8% of the sample.14 There were 101 academic
individuals and this constituted 3.6% of the sample.14 There
were 2,329 general practitioners which formed 90% of the
sample.14 There were 260 specialist dentists in the sample
and this formed 10% of the sample.14 Research was reported
45
as easily available by 64.3% of the sample and 88.8% of the
sample reported research as useful.14 There were differences
noted between general dentists and specialists.14 Fewer
general dentists found research results to be easily
available to them.14 Similarly, differences were noted
between clinicians and those in an academic setting.
Clinicians were less likely to state that research results
were easily available to them.14 In terms of the perceived
utility of research, there were no differences between
general dentists and specialists.14 There were also no
differences between clinicians and academic dentists in
terms of perceived utility of research.14
Additionally,
82.1% of the sample reported that they would like
information to be more easily available.14 Of the
individuals who wanted improved accessibility to research,
59.2% wanted increased access through journals, 50.4%
through the internet, 47.1% wanted increased access through
continuing education.14 In terms of principle sources of
information, general dentists were most likely to use
continuing education, local dental societies, the JCDA,
general dental journals other than the JCDA, and company
representatives.14 Specialist dentists’ principle sources of
information were professional meetings, specialist
journals, and the Internet.14 In terms of the preferred
46
format of research, 50% prefer articles that translate
research findings into practical guidelines.14 Additionally
50% prefer a commentary on a series of abstracts and 28%
prefer a systematic review.14 About 39.4% prefer abstracts.14
Only about 19% prefer conventional research reports.14 About
96% of the sample stated that they have used the results of
research to change a clinical practice.14 Research was
especially useful in the area of treatment with 89% of the
sample altering the use of material or treatment technique
as a result of a research finding.61 However, only 46% had
altered an educational message and only 32% had an altered
a management strategy.61 Overall, a large majority (over
80%) of individuals felt research has a big or very big
impact on dental and general health of Canadians.61
Evidence-based Practice in Orthodontics
Evidence-based practice is a new and developing
phenomenon in orthodontics and enthusiasm for evidencebased practice in orthodontics is building.16,62 Proponents
of evidence-based approach to orthodontics realize its
potential for improving the care rendered to patients.
Additionally, practicing without using the current and best
evidence risks providing out-dated treatment or even worse,
treatment that is not in the best interest of patients.63
47
Ackermann states that “the challenge facing orthodontists
in the 21st century is the need to integrate the accrued
scientific evidence into clinical orthodontic practice.64
Until this occurs, orthodontists will not be able to
present a forthright and accurate cost/benefit analysis to
the patient and therefore, not obtain truly informed
consent.”64 The implications of this statement reiterate the
potentially crucial role evidence-based practice could have
in orthodontics. Practicing with an evidence-based approach
in orthodontics will require clinical judgment, an
integration of clinical experience and systematic
assessment of relevant evidence with respect to the
patient’s condition, treatment need and preference.64
The evidence-based approach in orthodontics has begun
to shed light on some major orthodontic controversies and
unsubstantiated practices.16,65 Rinchuse et al. state that
many past and present notions and ideas in orthodontics
which have been and are promoted as facts have been shown
to be incorrect by scientific inquiry.65 For example, the
long-held belief that the eruptive force of third molars
causes late mandibular crowding has been refuted by
scientific evidence even though it makes intuitive sense.6567
Randomized clinical trials helped resolve the Class II
48
early or late treatment dilemma when they showed no
difference between early two-stage treatment and late onestage treatment. In fact, contrary to popular opinion, onestage treatment was overall more efficient than two-stage
treatment.68,69 A parallel, randomized trial was conducted to
compare early, preadolescent treatment versus later,
adolescent treatment for children with Class II
malocclusions with more than seven millimeters of overjet.
The first phase consisted of either headgear or functional
appliance treatment for the early treatment group. The
control group received no treatment during the first phase.
In 75% of the early-treatment individuals who started
treatment at least a year before their peak pubertal
growth, favorable growth changes were observed with either
a headgear or a functional appliance compared to the
control untreated group. The second phase consisted of
full-fixed appliances for both the early treatment group
and the control untreated group. After the second phase of
fixed appliance treatment the skeletal change, alignment,
occlusion of the teeth, length and complexity of treatment
were evaluated between the two groups. The differences
created between the treated children and untreated control
group by phase 1 treatment before adolescence was not
evident after both groups received comprehensive fixed
49
appliance treatment during adolescence. The early-treatment
phase had only a minor effect on the overall treatment
outcome. The results suggest that 2-phase treatment started
before adolescence in the mixed dentition is not more
effective than 1-phase treatment started during
adolescence. Early treatment appears less efficient as
there was no reduction in the average time the individual
was in fixed appliances. Additionally, early treatment did
not decrease the proportion of treatments involving
extractions or orthognathic surgery.
The relationship between orthodontics and periodontal
health has also been examined recently. Though many
patients seek orthodontic treatment for esthetic
improvement, the effect of orthodontic treatment on
periodontal health was unclear. Orthodontic treatment has
been suggested to result in an improved periodontal status
through mechanisms such as increased ease of oral hygiene
and reduced occlusal trauma.70 Bollen et al. conducted a
systematic review to evaluate the effect of orthodontic
treatment on periodontal health.70 The objective of the
systematic review was to compare orthodontic treatment with
no intervention in terms of periodontal outcomes measured
post-treatment.70 The authors searched eight electronic
50
databases (1980–2006) and hand searched six dental journals
(1980–2006).70 Weak evidence from one randomized study and
11 non-randomized studies suggested that orthodontic
treatment was associated with 0.03 millimeters of gingival
recession, 0.13 mm of alveolar bone loss and 0.23 mm of
increased pocket depth when compared with no orthodontic
treatment.70 The effect of orthodontic treatment on
gingivitis and attachment loss was inconsistent across
studies.70
The review also found an absence of reliable
evidence on the effects of orthodontic treatment on
periodontal health.70 The existing low-quality of evidence
suggests that orthodontic therapy resulted in small
detrimental effects to the periodontium.70 This contrasts
the notion that orthodontic treatment improves periodontal
health.70 The author concludes that the results of the
review do not warrant the recommendation for orthodontic
treatment to prevent future periodontal problems, except
for specific unusual malocclusions.70
Barriers to Evidence-based Practice in Orthodontics
Despite the trend to evidence-based care in medicine
and dentistry, some people question an evidenced based
approach in orthodontics. They feel that, because many
orthodontic procedures are based on unquestionable data an
51
evidence-based practice has limited utility.71 However, due
to the dynamic nature of orthodontics, questions and
uncertainties associated with innovations in techniques and
procedures will continue to arise. A PubMed-Medline search
was conducted for randomized control trials in orthodontics
involving humans published in the English language in the
following journals: JADA, AJODO, Evidence Based Dentistry
Journal, Angle Orthodontist (Table 3). Between 1990 and
1994 there were only 21 randomized control trial studies
that were published. Between 1995 and 1999 there were 71
articles published. Between 2000 and 2004 there were 89
articles published. Between 2005 and 2009 there were 139
randomized control trial studies that were published.
52
Table 3. Number of randomized control trials and systematic
reviews for each period
Number of
Randomized Control
Number of Systematic
Year
Trial Articles
Reviews
1990-1994
21
2
1995-1999
71
3
2000-2004
89
17
2005-2009
139
48
1990-2009
320
70
Additionally, the American Dental Association compiled
systematic reviews according to various specialties on the
Evidence-Based Dentistry section of the ADA website.6 In the
orthodontic category there are currently 70 systematic
reviews spanning the period from 1990 to present.6 Two
systematic reviews were published between 1990 and 1994.6
Three systematic reviews were published between 1995 and
1999.6 Between 2000 and 2004, 17 of the 70 systematic
reviews were published.6 Between 2005 and 2009, 48 of the 70
systematic reviews were published.6 Evidently, the number of
randomized control trials and systematic reviews in the
orthodontic literature is limited but increasing.
53
Others feel that it is too early to use evidence-based
methods and suggest waiting until a larger database is
established.72 However, embracing evidence based practice
does not require a large database of high-quality evidence.
An evidence-based approach can be adopted even with a lack
of currently available research.72 The process of evidencebased practice requires that the best, current evidence be
utilized in making clinical decisions. Thus, even in
situations of limited current research, a clinician can
still conduct a critical appraisal of the literature and
select the best, relevant evidence. As new studies come to
light, the clinician can critically appraise the new
literature and in this process, maintain the most current
and best, standard of practice. Indeed, adopting an
evidence base approach in orthodontics will likely serve as
a catalyst for developing more quality research in
deficient areas. The evidence-based approach will provide
the basis for identifying areas of orthodontics that
require further evaluation and research efforts.
Goals of This Study
As part of the health care field, widespread evidencebased practice in orthodontics is presumably inevitable.
There are currently no studies in the literature that
54
evaluate the current climate of evidence-based practice in
orthodontics. This study will examine the tools which are
utilized to solve clinical orthodontic problems and
evaluate how orthodontists use evidence in their daily
practices. The goal is to assess the current understanding,
attitudes and perceptions of the orthodontic community
towards evidence-based practice. This study will also
identify barriers and potential solutions to practicing
evidence-based orthodontics. It is hoped that this study
will provide insight and provoke further interest and
development of evidence-based orthodontics in the United
States.
55
References
1. Sackett D, Rosenberg W, Gray J, Haynes R, Richardson W.
Evidence based medicine: what it is and what it isn't. Brit
Med J 1996;312:71-72.
2. Rinchuse D, Kandasamy S, Ackerman M. Deconstructing
evidence in orthodontics: making sense of systematic
reviews, randomized clinical trials, and meta-analyses.
World J Orthod 2008;9:167-176.
3. Institute of Medicine. Crossing the quality chasm: A new
health system for the 21st century. Washington: National
Academy Press 2001.
4. White B. Making evidence-based medicine doable in
everyday practice. Fam Pract Manag 2004;11:51-58.
5. Agency of Healthcare Research. Evidence-based practice
centers. Available at http://www.ahrq.gov/clinic/epc
[Accessed October 30, 2009].
6. ADA. Systematic Reviews and Summaries. Center for
Evidence-Based Dentistry. Available at: http://ebd.ada.org
[Accessed September 30, 2009].
7. Rabb-Waytowich D. Evidence-based dentistry: Part 1. An
overview. J Can Dent Assoc 2009;75:27-28.
8. Coleman P, Nicholl J. Influence of evidence-based
guidance on health policy and clinical practice in England.
Brit Med J 2001;10:229-237.
9. McColl A, Smith H, White P, Field J. General
practitioners' perceptions of the route to evidence based
medicine: a questionnaire survey. Brit Med J 1998;316:361365.
10. O'Donnell C, PhD M. Attitudes and knowledge of primary
care professionals towards evidence-based practice: a
postal survey. J Eval Clin Prac 2004;10:197-205.
11. De Smedt A, Buyl R, Nyssen M. Evidence-based practice
in primary health care. Stud Health Tech Informat
2006;124:651-656.
56
12. Yusof Z, Han L, San P, Ramli A. Evidence-Based Practice
Among a Group of Malaysian Dental Practitioners. J Dent
Educ 2008;72:1333-1342.
13. Rabe P, Holmén A, Sjögren P. Attitudes, awareness and
perceptions on evidence based dentistry and scientific
publications among dental professionals in the county of
Halland, Sweden: a questionnaire survey. Swed Dent J
2007;31:113-120.
14. Allison P, Bedos C. Canadian dentists' view of the
utility and accessibility of dental research. J Dent Educ
2003;67:533-541.
15. Bader J. Stumbling into the Age of Evidence. Dent Clin
North Am 2009;53:15-22.
16. Turpin D. Consensus builds for evidence-based methods.
Am J Orthod Dentofacial Orthop 2004;125:1-2.
17. Department of Clinical Epidemiology and Biostatistics
MU. How to read clinical journals, I: why to read them and
how to start reading them critically. Can Med Assoc J
1981;124:555-558.
18. Niederman R, Badovinac R. Tradition-based dental care
and evidence-based dental care. J Dent Res 1999;78:12881291.
19. Evidence-based medicine working group. Evidence-based
medicine. A new approach to teaching the practice of
medicine. J Am Med Assoc 1992;268:2420-2425.
20. ADA. Evidence-based dentistry: glossary of terms.
Center for Evidence-Based Dentistry. Available at:
http://ebd.ada.org [Accessed September 30, 2009].
21. Dodson T. Evidence-based medicine Its role in the
modern practice and teaching of dentistry. Oral Surg Oral
Med O 1997;83:192-197.
22. Iqbal A, Glenny A. General dental practitioners'
knowledge of and attitudes towards evidence based practice.
Brit Dent J 2002;193:587-591.
57
23. Mertz-Fairhurst E, Curtis Jr J, Ergle J, Rueggeberg F,
Adair S. Ultraconservative and cariostatic sealed
restorations: results at year 10. J Am Dent Assoc
1998;129:55-66.
24. Bader J, Ismail A, Clarkson J. Evidence-based dentistry
and the dental research community. J Dent Res 1999;78:14801483.
25. Song F, Landes D, Glenny A, Sheldon T. Prophylactic
removal of impacted third molars: an assessment of
published reviews. Brit Dent J 1997;182:339-346.
26. Bader J. A review of evaluations of effectiveness in
continuing dental education. Cont Educ Health Sciences
1987;7:38-48.
27. Davis D, Thomson M, Oxman A, Haynes R. Changing
physician performance. A systematic review of the effect of
continuing medical education strategies. J Am Med Assoc
1995;274:700-705.
28. Bero L, Grilli R, Grimshaw J, Harvey E, Oxman A,
Thomson M. Closing the gap between research and practice:
an overview of systematic reviews of interventions to
promote the implementation of research findings: Brit Med
J; 1998: p. 465-468.
29. Choudhry N, Fletcher R, Soumerai S. Systematic review:
the relationship between clinical experience and quality of
health care. Am Coll Physicians 2005;142:260-273.
30. Wennberg J, Gittelsohn A. Small area variations in
health care delivery: a population-based health information
system can guide planning and regulatory decision-making.
Science 1973;182:1102.
31. Weinfeld A, Hollier L, Spira M, Stal S. International
trends in the treatment of cleft lip and palate. Clin Plast
Surg 2005;32:19-23.
32. Bader J, Shugars D. Variation, treatment outcomes, and
practice guidelines in dental practice. J Dent Educ
1995;59:61-95.
33. Ecenbarger W. How honest are dentists? Reader's Digest
1997;Feb:50-56.
58
34. MacPherson D. Evidence-based medicine. J Can Med Assoc
1995;152:201-204.
35. Sackett D. Rules of evidence and clinical
recommendations for the management of patients. Can J
Cardiol;9:487.
36. Coronary Drug Project Research Group. Influence of
adherence to treatment and response of cholesterol on
mortality in the coronary drug project. New Engl J Med
1980;303:1038-1041.
37. Sackett D, Haynes R, Guyatt G, Tugwell P. Clinical
epidemiology: a basic science for clinical epidemiology.
Boston: Little, Brown and Company; 1991.
38. Rosenberg W, Donald A. Evidence based medicine: an
approach to clinical problem-solving. Brit Med J
1995;310:1122-1126.
39. Phillips B, Ball C, Sackett D, Badenoch D, Straus S,
Haynes B et al. Oxford Centre for evidence-based medicine
levels of evidence Oxford Center for Evidence-based
Medicine; 2001.
40. Bigby M. Evidence-Based Medicine in a Nutshell A Guide
to Finding and Using the Best Evidence in Caring for
Patients. Arch Dermatol 1998;134:1609-1618.
41. Sackett D. Rules of evidence and clinical
recommendations for the management of patients. The
Canadian journal of cardiology;9:487.
42. Mulrow C. Systematic reviews: rationale for systematic
reviews. Brit Med J 1994;309:597-599.
43. Richards D, Lawrence A. Evidence based dentistry. Brit
Dent J 1995;179:270-273.
44. Ramsey P, Carline J, Inui T, Larson E, LoGerfo J,
Norcini J et al. Changes over time in the knowledge base of
practicing internists. J Am Med Assoc 1991;266:1103-1107.
45. Shin J, Haynes R, Johnston M. Effect of problem-based,
self-directed undergraduate education on life-long
learning. Can Med Assoc J 1993;148:969-976.
59
46. Halm E, Tuhrim S, Wang J, Rojas M, Hannan E, Chassin M.
Has evidence changed practice?: appropriateness of carotid
endarterectomy after the clinical trials. Neurology
2007;68:187-194.
47. Ballini A, Capodiferro S, Toia M, Cantore S, Favia G,
De Frenza G et al. Evidence-Based Dentistry: What's New?
Int J Med Sci 2007;4:174-178.
48. Cannavina C, Cannavina G, Walsh T. Law & ethicsEffects
of evidence-based treatment and consent on professional
autonomy. Brit Dent J 2000;188:302-306.
49. Dickersin K, Straus S, Bero L. Evidence based medicine:
increasing, not dictating, choice. Brit Med J 2007;334:s10.
50. Kitchens J, Pfeifer M. Teaching residents to read the
medical literature. J Gen Intern Med 1989;4:384-387.
51. Bennett K, Sackett D, Haynes R, Neufeld V, Tugwell P,
Roberts R. A controlled trial of teaching critical
appraisal of the clinical literature to medical students. J
Am Med Assoc 1987;257:2451-2454.
52. Shin J, Haynes R. Does a problem-based, self-directed
undergraduate medical curriculum promote continuing medical
competence. Clin Res 1991;39:143-147.
53. Weatherall D. The inhumanity of medicine. Brit Med J
1994;309:1671-1672.
54. McKenna H, Ashton S, Keeney S. Barriers to evidencebased practice in primary care. J Adv Nurs 2004;45:178-189.
55. Sutherland S. The building blocks of evidence-based
dentistry. J Can Dent Assoc 2000;66:241-245.
56. Scarbecz M. Evidence-Based Dentistry Resources for
Dental Practitioners. J Tenn Dent Assoc 2008;88:9-13.
57. Chiappelli F, Prolo P, Newman M, Cruz M, Sunga E,
Concepcion E et al. Evidence-based practice in dentistry:
benefit or hindrance. J Dent Res 2003;82:6-7.
58. Richards D. Is it worth reading this paper? Evid Based
Dent 2000;2:50-52.
60
59. McGivney G. Evidence-based dentistry article series. J
Prosthet Dent 2000;83:11-12.
60. Bader J, Ismail A. Survey of systematic reviews in
dentistry. J Am Dent Assoc 2004;135:464-473.
61. Christophe Bedos D. Do Canadian dentists find dental
research useful? J Can Dent Assoc 2002;68:540-542.
62. Ajayi E. Evidence-based Paradigm In Orthodontics. Nig Q
J Hosp Med 2007;17:79-81.
63. Harrison J. Evidence-based orthodontics: where do I
find the evidence? J Orthod 2000;27:71-78.
64. Ackerman J, Kean M, Ackerman M. Evidence-bolstered
orthodontics. World J Orthod 2006;7:413-414.
65. Rinchuse D, Sweitzer E, Rinchuse D. Understanding
science and evidence-based decision making in orthodontics.
Am J Orthod Dentofacial Orthop 2005;127:618-624.
66. Harradine N, Pearson M, Toth B. The effect of
extraction of third molars on late lower incisor crowding:
a randomized controlled trial. J Orthod 1998;25:117-122.
67. Southard T. Third molars and incisor crowding: when
removal is unwarranted. J Am Dent Assoc 1992;123:75-79.
68. Tulloch J, Phillips C, Koch G, Proffit W. The effect of
early intervention on skeletal pattern in Class II
malocclusion: a randomized clinical trial. Am J Orthod
Dentofacial Orthop 1997;111:391-400.
69. Tulloch J, Proffit W, Phillips C. Outcomes in a 2-phase
randomized clinical trial of early Class II treatment. Am J
Orthod Dentofacial Orthop 2004;125:657-667.
70. Bollen A, Cunha-Cruz J, Bakko D, Huang G, Hujoel P. The
Effects of Orthodontic Therapy on Periodontal Health: A
Systematic Review of Controlled Evidence. J Am Dent Assoc
2008;139:413-422.
71. Antosz M. The evidence against evidence-based
dentistry. Am J Orthod Dentofacial Orthop 2007;131:573-574.
61
72. Amat P. What would you choose: Evidence-based treatment
or an exciting, risky alternative? Am J Orthod Dentofacial
Orthop 2007;132:724-725.
62
CHAPTER 3: SURVEY 1 JOURNAL ARTICLE
Abstract
Introduction:
The purpose of this study was to evaluate
the attitudes, awareness and barriers of using scientific
literature.
Methods: A survey consisting of 35 questions,
pertaining to the use of scientific-evidence in
orthodontics, was sent to 4,771 AAO members in the United
States. The respondent’s age, attainment of a Master’s
Degree and whether or not they were currently involved with
teaching, were also ascertained. Results: A total of 1517
surveys were received (response rate 32%). The majority of
respondents had positive attitudes towards, but a poor
understanding of, evidence-based practice. The major
barrier identified was ambiguous and conflicting research.
Younger orthodontists were more aware, had a greater
understanding, and perceived more barriers than older
orthodontists. Orthodontists involved in teaching were more
aware, had a greater understanding, and reported fewer
barriers than those not involved with teaching. Those with
Master’s Degrees had a greater understanding of evidencebased practice than those without degrees. Conclusion:
Educational initiatives are needed to increase the
understanding and use of evidence-based practice in
orthodontics.
63
Introduction
Evidence-based practice is an approach that emphasizes
finding and using the best, current research evidence to
help make health-care decisions.1 The goal of evidence-based
practice is to provide patients with up-to-date treatment
that research has shown to be safe, effective and
efficient. Ultimately, the goal of evidence-based practice
is to continuously improve patient care based on new
research developments.2
Evidence-based practice is well established in
medicine. The Institute of Medicine has designated
evidence-based practice as a key feature of high-quality
medicine.3 There is a wealth of information regarding
evidence-based medicine, including evidence-based medical
journals, evidence-based summaries and evidence-based
practice guidelines.4 The Agency for Healthcare Research has
12 Evidence-based Practice Centers located in universities
in the United States and Canada that conduct evidence-based
medical research.5 In dentistry, evidence-based practice is
less developed, but is quickly gaining momentum. The
American Dental Association has made a concerted effort to
incorporate evidence-based practice into the dental field
in the United States; its website has an entire section
devoted to Evidence-Based Dentistry.6 The website is an
64
important resource which contains a comprehensive
collection of systematic reviews for all areas in
dentistry. Dental schools are introducing evidence-based
courses into their curriculums, there are journals focused
on evidence-based dentistry, two centers for evidence-based
dentistry have been established, and the Cochrane
Collaboration has included an Oral Health database.7 In
orthodontics, evidence-based practice is still in its
infancy stages.
Studies on evidence-based practice in medicine have
found that most doctors welcome evidence-based practice and
feel that it improves patient care.8-11 Barriers to evidencebased practice include the lack of time, an overwhelming
amount of literature, and difficulties incorporating
evidence into practice. Physicians felt that the best way
to increase evidence-based practice was by using evidencebased guidelines developed by colleagues. Dentists have
also expressed positive attitudes and awareness of
evidence-based practice.12,13 However, their understanding of
evidence-based concepts was poor. The major barriers
dentists reported were lack of time, lack of knowledge
about evidence-based practice and financial constraints.12,13
Dentists felt that the development of practical guidelines,
journal clubs and peer review sessions would help increase
65
evidence-based practice in dentistry.12-14 There is currently
no information about the attitudes and awareness,
perceptions and barriers to evidence-based practice in
orthodontics.
The purpose of this study was to determine the
attitudes and awareness of the use of scientific literature
among orthodontists in the United States. In order to
determine the initiatives that might be needed, barriers to
using scientific evidence were also examined. It was hoped
that this study would identify obstacles and solutions to
incorporating scientific literature into orthodontic
practice.
Methods and Materials
Survey Design
A survey was designed to examine the perception of
orthodontists towards the use of scientific literature in
orthodontics. Each participant was asked to respond to a
set of demographic questions, followed by a set of
questions pertaining to the use of scientific literature in
clinical orthodontics. Most of the survey questions were
derived from similar studies conducted in the medical
field.8-10,13,15,16 The questions were divided into five
66
categories: attitudes, awareness and current practices,
barriers, understanding of terms, and statements to
evaluate the participants’ awareness of literature
regarding major orthodontic controversies, and sources for
guiding clinical practice. IRB approval was granted prior
to starting the research project.
Demographic Variables of Interest
The respondent sample was grouped according to age,
whether they were currently involved in teaching at a
university, and whether they had attained a Master’s
Degree. The age grouping included those 40 years of age or
younger, those between 41 and 60 years of age, and those 61
years of age and older.
Survey Validity
A pilot survey consisting of 45 questions was
administered to seven faculty orthodontists at the Saint
Louis University Center for Advanced Dental Education. The
survey was discussed with each orthodontist to ensure that
the questions were unambiguous and valid. The survey
questions were modified and improved based on feedback from
the orthodontists.
67
Survey Reliability
Reliability was assessed by administering the survey
to 20 orthodontic residents on two separate occasions, two
weeks apart. The reliability analysis was used to identify
and eliminate problematic questions (see Appendix A for the
finalized version of the survey). The final survey
consisted of 35 questions, including six pertaining to
attitudes, awareness and current practices, 10 pertaining
to barriers, 10 pertaining to the understanding of terms,
seven statements on orthodontic issues, and two questions
on solving clinical problems (Table 4).
Survey Distribution
The final version of the survey was submitted to and
approved by the Board of Directors of the American
Association of Orthodontists (AAO). The Board agreed to
send the survey to all orthodontists and residents in the
U.S. with valid email addresses. To maintain the anonymity
and privacy of the respondents, the AAO forwarded the link
by email. A reminder email was sent one week later. Results
of the survey were recorded and maintained anonymously on
the Survey Monkey server (Surveymonkey.com, Portland, OR).
68
Data collection and analysis
The survey data were analyzed using SPSS 14.0 (SPSS
Inc., Chicago, IL). Non-parametric statistics were used to
evaluate group differences because the response variables
were ordinal. The Mann-Whitney U test was used to test for
differences between the dichotomous groupings and the
Kruskal-Wallis H test was used to compare the three age
groups. The sources for guiding clinical practice were
nominal and evaluated with chi-square tests. A p-value of
<0.05 was considered significant.
Results
The survey was sent to 8,455 individuals, it was
opened by 4,771 individuals, and 1,517 individuals
participated in the study. The response rate was 32%. The
modal age group of the sample was 41-60 years, there were
79% males and 21% females, and the modal number of years in
practice group was 16-20 years (Table 5).17 Twenty-eight
percent of the respondents were involved in teaching.
Fifty-nine percent of the respondents had Master’s Degrees.
Frequency tables for each question in the survey can be
found in Appendix B.
69
Attitudes, awareness and current practices:
Orthodontists were generally positive towards the
incorporation of scientific-evidence into their practices
(Table 6). The majority of individuals agreed that
evidence-based practice influenced their daily work (80%)
and that peer-reviewed journals are the best source of
evidence (82%). The majority also indicated that they read
scientific journals at least monthly (91%), and most
expressed interest in more clinical guidelines (75%). The
majority of respondents were completely unaware of the
Cochrane database (55%) and only a slight majority of
respondents had used PubMed in the past year (52%).
Those 40 years of age or younger were significantly
more likely to be interested in guidelines, were more aware
of Cochrane, and had used PubMed in the past year to a
greater extent than those over 40 years of age (Table 7).
Those 61 years of age and older were significantly more
likely to report reading journals than their younger
colleagues. Orthodontists involved in teaching were
significantly (p<0.05) more likely than their non-teaching
colleagues to display positive attitudes, awareness and
current practice towards the use of scientific literature
in clinical practice. Orthodontists with Master’s Degrees
70
reported that research influenced their daily work
significantly more frequently than those without Master’s
Degrees.
Barriers:
A large proportion, though not a majority of
respondents, felt that the practical demands of work (46%)
and insufficient clinical guidelines (44%) were barriers to
using evidence in clinical practice (Table 8). The barrier
identified by a majority of respondents was that the
literature is ambiguous and conflicting (59%).
Those who were less than 40 years of age cited
practical demands of work, insufficient clinical
guidelines, and ambiguous literature as barriers more often
than their older colleagues (Table 9). Those between 41-60
years of age were significantly (p<0.05) more likely to
cite the practical demands of work as a barrier than those
61 years of age and older. Conversely, those 40 years of
age or less were significantly more likely than their older
colleagues, to feel comfortable with their skills to
perform a literature review and were more likely to have
access to research papers (Table 9). Those orthodontists
involved in teaching felt more comfortable with their
skills to perform a literature review than those not
71
involved in teaching. They were also more likely to have
access to research papers and cited that the research is
ambiguous and conflicting more often than those not
involved in teaching. Orthodontists with a Master’s Degree
were more likely to be satisfied with their current
knowledge than those without degrees (p<0.05).
Understanding of terms:
The majority of respondents (>50%) reported at least
some understanding of all of the terms except “PICO”(Table
10). However, less than a third of the orthodontists
understood or could explain the meaning of meta-analysis,
odds ratio, sample power, confidence interval, and
specificity. Only 6% of the respondents understood and
could explain the meaning of the term PICO. However, the
vast majority (87%) of respondents had some understanding
and wanted to learn more about these terms.
Practitioners aged 40 years or less were significantly
(p<0.05) more likely than their older colleagues to
understand all of the evidence-based terms (Table 11).
Those between 41-60 years of age were significantly
(p<0.05) more likely to understand the terms blinding and
confidence interval than those 61 years of age and older.
Orthodontists currently involved in teaching were
72
significantly more likely than those not involved in
teaching to understand all of the terms. Those with a
Master’s Degree were significantly more likely to
understand all of the terms than those without a Master’s
Degree.
Statements regarding orthodontic issues:
The
majority
of
individuals
(>75%)
were
consistent
with the best, current evidence regarding statements about
orthodontic issues (Table 12).
Those less than 61 years of age were significantly
(p<0.05) more likely than their older counterparts to adopt
a stance in agreement with the current best evidence with
regards to the statement “Two-phase treatment of Class II
Division 1 malocclusion is more efficient than one-phase
treatment in the permanent dentition” (Table 13). Those
less than 40 years of age were significantly (p<0.05) more
likely than their older colleagues to agree with the
current, best evidence with respect to the statement “third
molars cause incisor crowding”. Those currently involved in
teaching were significantly (p<0.05) more likely to agree
with the current, best evidence on four of the seven
statements than those not involved in teaching. Those with
a Master’s Degree were significantly (p<0.05) more likely
73
to agree with the current, best evidence on the appropriate
timing of a frenectomy than those without degrees.
Primary reason for changing practice philosophy:
Regardless of their involvement with teaching, number
or years in practice, or whether they had a Master’s
Degree, orthodontists were most likely to change their
practice philosophy based on “expert advice” (Table 14).
Expert advice was followed most closely by clinical
journals.
Those over 40 years of age were more likely to choose
“clinical journals” and less likely to choose “colleague
advice” than those 40 years of age or younger (Table 14).
Orthodontists involved in teaching were more likely to
select “literature reviews” and less likely to select
“colleague advice” than those not involved in teaching.
Those without a Master’s Degree were much more likely to
select “colleague advice” than those with a Master’s
Degree.
Dealing with clinical uncertainties:
When faced with clinical uncertainties, orthodontists
most often consulted colleagues and least often referred
the patient to another orthodontist (Table 15).
74
Orthodontists aged 40 years or younger, as well as those
individuals involved with teaching, were more likely to
consult colleagues and least likely to proceed using their
best judgment. Having a Master’s degree had no effect on
the approach used to manage clinical uncertainties.
Discussion
The response rate in this study was 32%, which is
considerably lower than evidence-based surveys conducted in
the other fields.9,10,15,16,18 The studies in medicine
attributed their high response rate to short, concise
surveys, anonymity, support of professional leaders and
professional membership.9,15,18 Because this was the first
survey of its kind in orthodontics, it was designed to be
comprehensive and was therefore longer. Most importantly,
this study involved a much larger overall number of
respondents (n=1517) than other studies; anonymity and AAO
support were utilized to maximize the response rate. The
response rate in this survey fell within 10-58% range
reported for other surveys conducted in orthodontics.19-21 It
has also been suggested that the response rate among health
care professionals is decreasing.22 Importantly, the present
sample surveyed was comparable in terms of gender, age and
years in practice to the 2008 orthodontic sample survey
75
conducted by Keim et al. (Table 5).17 This suggests that the
present sample was representative of the orthodontic
population as a whole.
Most respondents displayed positive attitudes towards
scientific evidence in clinical practice and reported
current practices that were very encouraging. However, the
majority of respondents’ lack of awareness of Cochrane
highlights an important resource that needs more exposure
among orthodontists. This was in accordance with studies in
general dentistry, which also found that a majority of
respondents were unaware of Cochrane.13,16 Cochrane provides
systematic reviews pertaining to all parts of healthcare
and is therefore an important source of the best, current
literature.13,16
Moreover, most respondents reported only partial or no
understanding of 6 of the 10 terms used in evidence-based
literature. A survey conducted in 1998 also showed that
most physicians reported only some or no understanding of
evidence-based terms.9 Failure to understand such terms
could hinder interpretation of evidence; a vital aspect the
evidence-based approach.9 Without a clear understanding of
the basic terminology, it is unlikely that evidence-based
concepts can be accurately incorporated into clinical
76
practice. For example, the term PICO was only well
understood by 6% of respondents, even though it represents
a major underpinning of evidence-based research. PICO is an
acronym that stands for the process of specifying a
scientific question based on the problem, intervention,
comparison, and outcome. It forms the basis of the
evidence-based protocol. Nonetheless, it was encouraging
that the majority of individuals reported either some
understanding or expressed a desire to learn about these
terms. This suggests that evidence-based learning
initiatives would be useful and welcome.
The responses to statements on orthodontic issues were
encouraging because they were in accordance with the
current, best evidence. The majority of orthodontists
agreed with the evidence-based stance on the issues
examined. This suggests that a majority of orthodontists
have some understanding of the current, best evidence on
major topics of interest in orthodontics. It is important
to note that most of the issues examined are topics that
are commonly discussed at major conferences such as the
American Association of Orthodontists (AAO), annual
conference, and other orthodontic society meetings. This
might help explain why most respondents were aware of the
77
best, current evidence even though they are not necessarily
practicing with an evidence-based approach. Furthermore,
since most of these topics have been issues that have been
around for many years, it is not surprising that
respondents could have had exposure to these topics without
making a concerted effort to self-research the literature.
Identifying the barriers is an important step toward
increasing evidence-based practice in orthodontics. For
orthodontists, barriers include the ambiguous and
conflicting nature of the literature, demands of work, and
insufficient clinical guidelines. General dental
practitioners, as well as nurses and physicians, also have
reported uncertainty created by conflicting research
results as the most frequently reported barrier.8,15
Literature that is ambiguous or conflicting makes it
difficult for practitioners to identify the most accurate
answer to a clinical question. This may be the impetus for
desiring more clinical guidelines. Systematic reviews have
the potential to clarify uncertainty pertaining to
conflicting results and are an important tool in the
evidence-based approach.13,15 Systematic reviews follow
explicit, documented protocols to reduce bias and aim to
78
provide an objective and thorough review of the
literature.13,23
Due to the demands of clinical practice, orthodontists
reported being too overburdened to sort through conflicting
literature. Studies in medicine and dentistry have
previously shown that clinicians do not have the time or
inclination to appraise the research evidence
themselves.9,10,13,16 This suggests that research evidence
needs to be presented in formats that are easier for
orthodontists to appraise and understand.13
The
introduction of guidelines and protocols developed by peers
skilled in the evidence-based process may help overcome
many of the barriers cited.9,15
Younger orthodontists were more interested and aware
of evidence in practice and understood the terms examined
better than their older colleagues. However, those aged 40
years or less also reported more barriers than their older
colleagues, suggesting that they more fully understood the
requirements of this approach. Those aged 40 years or less
were more likely to agree with the evidence-based stance on
the orthodontic issues examined than their older
colleagues. The recent introduction of evidence-based
courses to the curriculum and the shorter time span since
79
finishing formal education might explain why the younger
respondents are more in touch with the evidence than their
older colleagues.
Orthodontists currently involved in teaching had more
positive attitudes towards evidence in practice, greater
awareness of evidence in practice, and reported current
practices that were more consistent with the evidence.
Those involved in teaching also perceived fewer barriers
and were less likely to report the demands of work as a
barrier, perhaps because research is often emphasized in
teaching institutions. Teachers also reported greater
understanding of the terms examined and were more likely to
adopt an evidence-based stance on the orthodontic issues
examined. Furthermore, their increased access to papers and
increased skills of assessing research perhaps led them to
be more skeptical of the current literature. As expected,
it appears that those involved with a teaching institution
are more likely to be in touch with the current, best
evidence.
Overall, there were few significant differences
between those with and those without a Master’s Degree.
However, those with Master’s Degree were more likely to
report that research had a greater influence on their
80
practice and had a greater understanding of the terms
examined. Considering that a Master’s Degree requires a
hands-on approach to research, it might be expected that
those with a Master’s Degree have a solid understanding of
the scientific method involved in conducting research.
The most frequently selected reason for changing a
practice philosophy was expert advice, which is
inconsistent with evidence-based practice. While experts
generally possess much experience, they may be biased.
Without considering other sources of less biased
information as well, a practitioner risks changing their
practice philosophy on erroneous and unsubstantiated
information.24 This may lead to less efficient treatment,
increased cost of treatment, or inconvenience to the
patient that is unnecessary.
The majority of individuals responded that they would
consult colleagues when faced with clinical uncertainties.
This is consistent with general dental practitioners, who
tend to select friends and colleagues as the primary source
of advice when facing clinical uncertainties.13,16 While
colleagues represent a quick, inexpensive, convenient
source of advice, they may be subject to biases and
conflicts of interest.16,24 Furthermore, colleagues’ advice
81
may represent experience within their practices but may not
reflect best practices.13 Ideally, clinicians should be
consulting electronic databases, such as PubMed and
Cochrane, and seek evidence from systematic reviews or
meta-analysis of randomized control trials where possible,
to identify the best current evidence which can help guide
decision-making.13 However, these sources are not always as
accessible as colleagues and may not cover the relevant
topic of interest.16 Hopefully, with time and increased
attention to these resources, more areas of clinical
uncertainty will be addressed. In cases where systematic
reviews are not available, the hierarchy of evidence will
help identify the best level of appropriate evidence that
should be considered.
This study was not without its limitations. Conducting
a survey that requires self-completion of a questionnaire
is not the most accurate method of gathering the
perceptions of health care professionals on a complex
subject.10,25 Furthermore, it has been shown that
respondents’ verbal explanation of terms can differ from
written responses. However, it would have been very
difficult to gather information from such a large number of
individuals with another method other than a survey.
82
It was also possible that there may be inconsistencies
between the respondents’ true versus reported attitudes,
awareness, current practices and understanding of terms.
Another problem was that respondents may have tried to make
a good impression rather than declare their true views on
the subject, even though the surveys were anonymous.
While every attempt was made to obtain a large and
representative sample of the orthodontic population, it is
possible that the sample was not representative of the
orthodontic population as a whole. Individuals who were not
in support of using evidence in clinical practice may have
chosen not to partake in the survey. If this were the case,
the results may have been skewed towards a more positive
outlook on the use of evidence in clinical practice than
was actually the case. Lastly, due to the immense breadth
of evidence-based practice in orthodontics, it was not
possible to explore all areas of this very comprehensive
subject. Further exploration is warranted especially to
identify solutions to increase the use of literature in
scientific practice.
83
Conclusions and Recommendations
Orthodontists expressed awareness and positive
attitudes towards evidence-based practice. However,
awareness of the Cochrane database was low and
understanding of evidence-based practice terminology was
poor. Most respondents currently seek advice from
colleagues when faced with clinical uncertainty, and expert
advice was the most frequently selected reason for changing
a practice philosophy. Conflicting and ambiguous
literature, lack of clinical guidelines, and practical
demands of work were the major barriers identified in this
study.
Due to the interest orthodontists have expressed in
evidence-based practice, it appears to be an optimal time
to
initiate
educational
programs
that
will
enhance
the
knowledge, understanding and use of evidence-based practice
in orthodontics.
84
References
1. Sackett D, Rosenberg W, Gray J, Haynes R, Richardson W.
Evidence based medicine: what it is and what it isn't. Brit
Med J 1996;312:71-72.
2. Rinchuse D, Kandasamy S, Ackerman M. Deconstructing
evidence in orthodontics: making sense of systematic
reviews, randomized clinical trials, and meta-analyses.
World J Orthod 2008;9:167-176.
3. Medicine Io. Crossing the quality chasm: A new health
system for the 21st century. Washington: National Academy
Press 2001.
4. White B. Making evidence-based medicine doable in
everyday practice. Fam Pract Manag 2004;11:51-58.
5. Research AoHa. Evidence-based practice centers; 2009.
6. ADA. Systematic Reviews and Summaries. Center for
Evidence-Based Dentistry 2009.
7. Rabb-Waytowich D. Evidence-based dentistry: Part 1. An
overview. J Can Dent Assoc 2009;75:27-28.
8. De Smedt A, Buyl R, Nyssen M. Evidence-based practice in
primary health care. Stud Health Tech Informat
2006;124:651-656.
9. McColl A, Smith H, White P, Field J. General
practitioners' perceptions of the route to evidence based
medicine: a questionnaire survey. Brit Med J 1998;316:361365.
10. O'Donnell C, PhD M. Attitudes and knowledge of primary
care professionals towards evidence-based practice: a
postal survey. J Eval Clin Prac 2004;10:197-205.
11. Coleman P, Nicholl J. Influence of evidence-based
guidance on health policy and clinical practice in England.
Brit Med J 2001;10:229-237.
85
12. Rabe P, Holmén A, Sjögren P. Attitudes, awareness and
perceptions on evidence based dentistry and scientific
publications among dental professionals in the county of
Halland, Sweden: a questionnaire survey. Swed Dent J
2007;31:113-120.
13. Yusof Z, Han L, San P, Ramli A. Evidence-Based Practice
Among a Group of Malaysian Dental Practitioners. J Dent
Educ 2008;72:1333-1342.
14. Allison P, Bedos C. Canadian dentists' view of the
utility and accessibility of dental research. J Dent Educ
2003;67:533-541.
15. McKenna H, Ashton S, Keeney S. Barriers to evidencebased practice in primary care. J Adv Nurs 2004;45:178-189.
16. Iqbal A, Glenny A. General dental practitioners'
knowledge of and attitudes towards evidence based practice.
Brit Dent J 2002;193:587-591.
17. Keim R, Gottlieb E, Nelson A, Vogels 3rd D. 2008 JCO
study of orthodontic diagnosis and treatment procedures,
Part 1: Results and trends. J Clin Orthod 2008;42:625-640.
18. Heywood A, Mudge P, Ring I, Sanson-Fisher R. Reducing
systematic bias in studies of general practitioners: the
use of a medical peer in the recruitment of general
practitioners in research. Fam Prac 1995;12:227-231.
19. Gentry S. Extraction decision-making in Class I
malocclusions: a survey identifying values for definite
extraction and non-extraction therapy. Master's Thesis
2009.
20. O'Connor B. Contemporary trends in orthodontic
practice: A national survey. American Journal of
Orthodontics and Dentofacial Orthopedics 1993;103:163-170.
21. Yang E, Kiyak H. Orthodontic treatment timing: a survey
of orthodontists. American Journal of Orthodontics and
Dentofacial Orthopedics 1998;113:96-103.
22. McAvoy B, Kaner E. General practice postal surveys: a
questionnaire too far? Brit Med J 1996;313:732-734.
86
23. Mulrow C. Systematic reviews: rationale for systematic
reviews. Brit Med J 1994;309:597-599.
24. Slawson D, Shaughnessy A. Obtaining useful information
from expert based sources. Brit Med J 1997;314:947-949.
25. Young J, Ward J. Evidence-based medicine in general
practice: beliefs and barriers among Australian GPs. J Eval
Clin Prac 2001;7:201-210.
87
Table 4. Survey 1 questions, abbreviated questions and answer choices with assigned
numerical values used for data analysis.
Answer choices (assigned numerical value in
Question
parentheses)
Abbreviation
Research
Research influences my daily
strongly
strongly
disagree
(0)
(-1)
agree (1)
influences daily
work
neutral
agree (2)
disagree
work
(-2)
Peer-reviewed journals
Journals are the
strongly
strongly
provide the best current
disagree
(0)
(-1)
agree (1)
best source of
agree (2)
evidence for me to
neutral
disagree
evidence
(-2)
incorporate into my practice.
I would be interested in more
strongly
clinical practice guidelines
Interested in
strongly
that help guide treatment
more guidelines
agree (2)
neutral
disagree
(0)
(-1)
agree (1)
disagree
(-2)
decision making.
I read Scientific Peer-
Frequency of
daily (4)
reviewed Journals
reading journals
Please evaluate your
monthly
rarely
not at
(2)
(1)
all (0)
weekly (3)
aware of
Awareness of
fully
awareness of the Cochrane
not aware
only by
Cochrane
aware (2)
Collaboration
(-1)
name (1)
88
Table 4 Continued. Survey 1 questions, abbreviated questions and answer choices with
assigned numerical values used for data analysis.
Question
Abbreviation
Answer choices (assigned numerical value in parentheses)
I have used PubMed/Medline in
Used Pub/Med in
uncertain
yes (1)
the past year to answer a
no (-1)
past year
(0)
clinical question.
The practical demands of work
make it difficult for me to
Practical demands
strongly
agree
neutral
disagree
strongly
of work
agree (2)
(1)
(0)
(-1)
disagree (-2)
strongly
agree
neutral
disagree
strongly
agree (2)
(1)
(0)
(-1)
disagree (-2)
strongly
agree
neutral
disagree
strongly
agree (2)
(1)
(0)
(-1)
disagree (-2)
strongly
agree
neutral
disagree
strongly
agree (2)
(1)
(0)
(-1)
disagree (-2)
keep up-to-date with current
best evidence relating to
practice.
There are not enough clinical
Insufficient
practice guidelines in the
clinical
literature.
guidelines
Literature is
The literature is often
ambiguous/
conflicting and ambiguous.
conflicting
I am satisfied with my current
Satisfied with
knowledge and practice and feel
current knowledge
it is sufficient.
89
Table 4 Continued. Survey 1 questions, abbreviated questions and answer choices with
assigned numerical values used for data analysis.
Answer choices (assigned numerical value
Question
Abbreviation
I have the skills to undertake a
Skills to undertake a
comprehensive literature review
literature review
I feel comfortable performing a
Comfortable performing a
comprehensive literature review
literature review
in parentheses)
yes (1)
no (-1)
uncertain (0)
yes (1)
no (-1)
uncertain (0)
yes (1)
no (-1)
uncertain (0)
yes (1)
no (0)
yes (1)
no (0)
yes (1)
no (0)
I can obtain copies of published
I have access to published
research papers relating to my
research papers
clinical practice
I have no access to the Internet
No access to the internet
I have access to the Internet at
Access to the internet at
home
home
I have access to the Internet at
Access to the internet at
work
work
90
Table 4 Continued. Survey 1 questions, abbreviated questions and answer choices with
assigned numerical values used for data analysis.
Question
Blinding
Systematic
review
Meta-Analysis
RCT
Abbreviation
Blinding
Answer choices (assigned numerical value in parentheses)
understand and could
some
explain it to others
understanding
(2)
(1)
understand and could
some
explain it to others
understanding
(2)
(1)
Systematic
review
Meta-Analysis
RCT
understand and could
some
explain it to others
understanding
(2)
(1)
understand and could
some
explain it to others
understanding
(2)
(1)
91
don't
don't
understand but
understand and
would like to
don't want to
(-1)
(-2)
don't
don't
understand but
understand and
would like to
don't want to
(-1)
(-2)
don't
don't
understand but
understand and
would like to
don't want to
(-1)
(-2)
don't
don't
understand but
understand and
would like to
don't want to
(-1)
(-2)
Table 4 Continued. Survey 1 questions, abbreviated questions and answer choices with
assigned numerical values used for data analysis.
Question
Abbreviation
Answer choices (assigned numerical value in parentheses)
don't
some
understand and
Strength of
Strength of
evidence
evidence
don't understand
understand
could explain it to
understanding
and don't want to
but would
others (2)
(1)
(-2)
like to (-1)
don't
some
understand and
don't understand
understand
Odds Ratio
Odds Ratio
could explain it to
understanding
and don't want to
but would
others (2)
(1)
(-2)
like to (-1)
don't
some
understand and
don't understand
understand
Sample Power
Sample Power
could explain it to
understanding
and don't want to
but would
others (2)
(1)
(-2)
like to (-1)
don't
some
understand and
Confidence
Confidence
Interval
Interval
don't understand
understand
could explain it to
understanding
and don't want to
but would
others (2)
(1)
(-2)
like to (-1)
92
Table 4 Continued. Survey 1 questions, abbreviated questions and answer choices with
assigned numerical values used for data analysis.
Question
Abbreviation
Answer choices (assigned numerical value in parentheses)
don't
don't
understa
understa
nd but
nd and
would
don't
like to
want to
(-1)
(-2)
don't
don't
understa
understa
nd but
nd and
would
don't
like to
want to
(-1)
(-2)
neutral
disagree
strongly
(0)
(-1)
disagree (-2)
understand
Specificity
Specificity
and could
some
explain it
understanding
to others
(1)
(2)
understand
PICO questions
PICO questions
and could
some
explain it
understanding
to others
(1)
(2)
Two-phase treatment of
Class II Division 1
2-phase tx more
strongly
malocclusion is more
agree (1)
efficient than 1agree (2)
efficient than onephase tx
phase treatment in the
permanent dentition.
93
Table 4 Continued. Survey 1 questions, abbreviated questions and answer choices with
assigned numerical values used for data analysis.
Question
Abbreviation
Answer choices (assigned numerical value in parentheses)
Occlusion is a
strongly
Occlusion causes
strongly
TMD
agree (2)
neutral
disagree
(0)
(-1)
agree (1)
primary etiologic
disagree
factor in TMD
(-2)
Third molar eruption
strongly
Third molars cause
strongly
incisor crowding
agree (2)
neutral
disagree
(0)
(-1)
agree (1)
causes lower incisor
disagree
crowding.
(-2)
A frenectomy should
Frenectomy
be performed before
strongly
strongly
disagree
(0)
(-1)
agree (1)
performed before
agree (2)
orthodontic
neutral
tx starts
disagree
(-2)
treatment commences.
94
Table 4 Continued. Survey 1 questions, abbreviated questions and answer choices with
assigned numerical values used for data analysis.
Question
Abbreviation
Answer choices (assigned numerical value in parentheses)
Premolar extraction
smiles are rated as
Premolar ext.
strongly
strongly
significantly less
disagree
(0)
(-1)
agree (1)
smiles are less
agree (2)
esthetic than non-
neutral
disagree
esthetic
(-2)
extraction smiles.
strongly
Extraction treatment
Extraction tx
strongly
causes TMD.
causes TMD
agree (2)
neutral
disagree
(0)
(-1)
agree (1)
disagree
(-2)
All casts should be
Casts should be
mounted to improve
strongly
strongly
disagree
(0)
(-1)
agree (1)
mounted for
agree (2)
diagnosis and
neutral
diagnosis
disagree
(-2)
treatment.
95
Table 4 Continued. Survey 1 questions, abbreviated questions and answer choices with
assigned numerical values used for data analysis.
Question
Abbreviation
Answer choices (assigned numerical value in parentheses)
I change my
reading
I change my practice
expert
practice
colleague
philosophy based
clinical
literature
journals
review (4)
other (5)
advice
philosophy based
advice (1)
primarily on:
(2)
primarily on
(3)
When faced with
consult
proceed
When faced with
consult with
clinical uncertainties
the
colleagues
best
textbooks
uncertainties I
I usually :
with my
consult
clinical
literature
(1)
usually
(2)
judgment
(3)
(4)
96
refer (5)
Table 5. Comparison of the sample in Survey 1 with the sample in Keim et al.’s 2008
survey of orthodontists in the United States.17
Sample in orthodontic survey by
Survey 1 sample
Keim et al.
17
Age
41-50 years (modal value)
52 years (median value)
Male
79%
85%
Female
21%
15%
Years in practice
16-20 years (modal value)
21 years (median value)
97
Table 6. Percentage of respondents who selected each answer choice for Survey 1 questions
pertaining to attitudes, awareness and current practices.
Strongly
Disagree
Disagree
Neutral
Agree
Strongly Agree
1
4
15
52
28
1
2
15
50
32
1
5
19
48
27
Daily
Weekly
Monthly
Rarely
Not At All
5
33
53
9
0
Unaware
Some Awareness
Fully Aware
55
20
25
No
Yes
Uncertain
Research influences
daily work
Journals are the best
source of evidence
Interested in more
guidelines
Frequency of reading
journals
Awareness of Cochrane
52
Used Pub/Med in past
year
47
1
98
Table 7. Survey 1 trends regarding attitudes, awareness and current practices among the
three demographic variables: age (group 1=<40 years, group 2= 41-60 years, groups 3= 61
years +), involved in teaching (yes or no), and Master’s Degree (yes or no)
Age
Involved in teaching
Master's Degree
Research influences
N.S.
(p=0.130)
yes>no
(p<0.001)
yes>no
(p=0.013)
N.S.
(p=0.496)
yes>no
(p<0.001)
N.S.
(p=0.099)
guidelines
1>2=3
(p<0.001)
N.S.
(p=0.110)
N.S.
(p=0.385)
Awareness of Cochrane
1>2=3
(p<0.001)
yes>no
(p<0.001)
N.S.
(p=0.095)
1>2=3
(p<0.001)
yes>no
(p<0.001)
N.S.
(p=0.552)
3>1=2
(p=0.022)
yes>no
(p<0.001)
N.S.
(p=0.960)
daily work
Journals are the best
source of evidence
Interested in more
Used Pub/Med in past
year
Frequency of reading
journals
N.S.: not significant,
>: more likely to agree with the statement in the question
99
Table 8. Percentage of respondents who selected each answer choice for Survey 1 questions
on barriers.
strongly
strongly
disagree
disagree
neutral
agree
agree
Practical demands of work
4
31
20
40
6
Insufficient clinical guidelines
3
18
35
37
7
Literature is ambiguous/conflicting
1
14
26
48
11
Satisfied with current knowledge
6
39
25
26
4
no
yes
uncertain
Skills to undertake a literature review
6
79
15
Comfortable performing a literature review
16
67
17
I have access to published research papers
5
85
10
no
yes
No access to the internet
87
13
Access to the internet at home
9
91
Access to the internet at work
3
97
100
Table 9. Survey 1 trends regarding barriers among the three demographic variables: age
(group 1=<40 years, group 2= 41-60 years, groups 3= 61 years +), involved in teaching
(yes or no), and Master’s Degree (yes or no)
Involved in
Age
teaching
Master's Degree
Practical demands of work
1>2>3
(p<0.001)
no>yes
(p<0.001)
N.S.
(p=0.228)
Insufficient clinical guidelines
1>2=3
(p<0.001)
N.S.
(p=0.436)
N.S.
(p=0.419)
Literature is ambiguous/conflicting
1>2=3
(p<0.001)
yes>no
(p=0.019)
N.S.
(p=0.105)
Satisfied with current knowledge
N.S.
(p<0.300)
no>yes
(p<0.006)
yes>no
(p=0.009)
Skills to undertake a literature review
1>2=3
(p<0.001)
yes>no
(p<0.001)
N.S.
(p=0.194)
1>2=3
(p<0.001)
yes>no
(p<0.001)
N.S.
(p=0.160)
1>2=3
(p=0.016)
yes>no
(p<0.001)
N.S.
(p=0.719)
Access to the internet at home
N.S.
(p=1.000)
N.S.
(p=1.000)
N.S.
(p=1.000)
Access to the internet at work
N.S.
(p=0.922)
N.S.
(p=0.139)
N.S.
(p=0.670)
No access to the internet
N.S.
(p=0.317)
N.S.
(p=0.924)
N.S.
(p=0.742)
Comfortable performing a literature
review
I have access to published research
papers
N.S.: not significant, >: more likely to agree with the statement in the question
101
Table 10. Percentage of respondents
questions on understanding of terms.
who
selected
each
answer
choice
for
Survey
1
Understand and could
Some
Don’t understand
Don’t understand and
explain it to others
understanding
but would like to
don't want to
Blinding
52
28
16
4
Systematic review
50
43
5
2
Meta-Analysis
32
36
24
8
RCT
75
23
1
1
Strength of evidence
49
43
7
1
Odds Ratio
21
40
32
7
Sample Power
31
40
24
6
Confidence Interval
31
39
24
6
Specificity
30
44
21
5
PICO questions
6
15
66
13
102
Table 11. Survey 1 trends regarding understanding of terms among the three demographic
variables: age (group 1=<40 years, group 2= 41-60 years, groups 3= 61 years +), involved
in teaching (yes or no), and Master’s Degree (yes or no)
Age
Involved in teaching
Master's Degree
Blinding
1>2>3
(p<0.001)
yes>no
(p<0.001)
yes>no
(p=0.037)
Systematic review
1>2=3
(p<0.001)
yes>no
(p<0.001)
yes>no
(p<0.001)
Meta-Analysis
1>2=3
(p<0.001)
yes>no
(p<0.001)
yes>no
(p=0.018)
RCT
1>2=3
(p<0.001)
yes>no
(p<0.001)
yes>no
(p<0.001)
1>2=3
(p<0.001)
yes>no
(p<0.001)
yes>no
(p<0.001)
Odds Ratio
1>2=3
(p<0.001)
yes>no
(p<0.001)
yes>no
(p<0.001)
Sample Power
1>2=3
(p<0.001)
yes>no
(p<0.001)
yes>no
(p<0.001)
1>2>3
(p<0.001)
yes>no
(p<0.001)
yes>no
(p<0.001)
Specificity
1>2=3
(p<0.001)
yes>no
(p<0.001)
yes>no
(p<0.001)
PICO questions
1>2=3
(p=0.022)
yes>no
(p<0.001)
yes>no
(p=0.036)
Strength of
evidence
Confidence
Interval
N.S.:not significant; >: more likely to agree with the statement in the question
103
Table 12. Percentage of respondents who selected
statements regarding major orthodontic controversies.
each
answer
choice
for
Survey
strongly
strongly agree
agree
neutral
disagree
disagree
2-phase tx more efficient than
4
8
11
46
31
2
8
8
41
41
1
3
10
42
44
1
2
5
43
48
1
8
10
43
38
Extraction tx causes TMD
<1
<1
2
29
68
Casts should be mounted for
2
5
10
45
38
1-phase tx
Occlusion causes TMD
Third molars cause incisor
crowding
Frenectomy performed before tx
starts
Premolar ext. smiles are less
esthetic
diagnosis
104
1
Table 13. Survey 1 trends regarding statements on major orthodontic controversies among
three demographic variables: age (group 1=<40 years, group 2= 41-60 years, groups 3= 61
years +), involved in teaching (yes or no), and Master’s Degree (yes or no).
Age
Involved in teaching
Master's Degree
2-phase tx more efficient than 1-phase
tx
Occlusion causes TMD
Third molars cause incisor crowding
3>2=1
(p=0.027)
N.S.
(p=0.206)
N.S.
(p=0.314)
N.S.
(p=0.117)
no>yes
(p=0.001)
N.S.
(p=0.336)
3=2>1
(p<0.001)
N.S.
(p=0.243)
N.S.
(p=0.051)
Frenectomy performed before tx starts
N.S.
(p=0.088)
N.S.
(p=0.208)
no>yes
(p=0.30)
Premolar ext. smiles are less esthetic
N.S.
(p=0.219)
no>yes
(p=0.001)
N.S.
(p=0.645)
Extraction tx causes TMD
N.S.
(p=0.273)
no>yes
(p=0.022)
N.S.
(p=0.483)
Casts should be mounted for diagnosis
N.S.
(p=0.201)
no>yes
(p=0.013)
N.S.
(p=0.482)
N.S.:not significant
> : more likely to agree with the statement in the question
105
Table 14. Percentage of respondents who selected each answer choice for the Survey 1
statement “I change my practice philosophy primarily based on”.
Involved in teaching*
Age* (p<0.001)
(p<0.001)
Master's Degree* (p=0.033)
<40 yrs
41-60 yrs
61 yrs+
No
Yes
No
Yes
Colleague advice
24
12
9
17
10
18
14
Expert advice
32
35
36
36
29
36
33
Clinical journals
15
26
29
22
25
21
23
Literature reviews
18
13
11
12
22
14
15
Other
11
14
15
13
14
11
15
Total
100
100
100
100
100
100
100
106
Table 15. Percentage of respondents who selected each answer choice for the Survey 1
statement “When faced with clinical uncertainties I usually”.
Involved in teaching*
Master's Degree
(p=0.015)
(p=0.275)
Age* (p<0.001)
<40 yrs
41-60 yrs
61 yrs+
No
Yes
No
Yes
Consult colleagues
63
41
47
49
52
52
49
Consult textbooks
5
2
2
4
3
4
3
21
28
26
23
29
23
26
best judgment
11
29
25
24
16
21
22
Refer
0
<1
<1
<1
0
<1
0
Total
100
100
100
100
100
100
100
Consult the
literature
Proceed using my
107
CHAPTER 4: SURVEY 2 JOURNAL ARTICLE
Abstract
Introduction:
This study evaluated the attitudes,
awareness and barriers of evidence-based practice among
orthodontists in the United States.
Methods: A survey
consisting of 20 questions was sent to 3,456 AAO members in
the United States. The respondent’s age, attainment of a
Master’s Degree and whether or not they were currently
involved with teaching, were also ascertained. Results: The
response rate was 30%. A majority of respondents were aware
of and had positive attitudes towards evidence-based
practice. Understanding of evidence-based practice was poor
and no major barriers were identified. Most respondents
felt that the development of evidence-based summaries and
guidelines was the best method to increase evidence-based
practice in orthodontics. Younger orthodontists, as well as
those involved with teaching, were more positive, reported
fewer barriers and displayed better understanding of
evidence-based practice than older orthodontists and those
not involved with teaching, respectively. Those without
Master’s Degrees reported more barriers than those with
degrees. Conclusion: The development of evidence-based
summaries and guidelines will help promote evidence-based
practice in orthodontics.
108
Introduction
Evidence-based practice is an approach that emphasizes
finding and using the best, current research evidence to
help make health-care decisions.1 The goal of evidence-based
practice is to provide patients with up-to-date treatment
that research has shown to be safe, effective and
efficient. Ultimately, the goal of evidence-based practice
is to continuously improve patient care based on new
research developments.2
The concept of evidence-based practice is well
established in medicine. The Institute of Medicine has
designated evidence-based medicine as a key feature of
high-quality health care.3 There is a wealth of information
regarding evidence-based medicine, including evidence-based
medical journals, evidence-based summaries and evidencebased practice guidelines.4 The Agency for Healthcare
Research has 12 Evidence-based Practice Centers located in
universities in the United States and Canada that conduct
evidence-based medical research.5 In dentistry, evidencebased practice is less developed, but is quickly gaining
momentum. The American Dental Association has made a
concerted effort to incorporate evidence-based practice
into the dental field in the United States; its website has
an entire section devoted to Evidence-Based Dentistry.
109
6
Dental schools are introducing evidence-based courses into
their curriculums, there are journals focusing on evidencebased dentistry, two centers for evidence-based dentistry
have been established, and the Cochrane Collaboration has
included an Oral Health database.7 In orthodontics,
evidence-based practice is still in its infancy stages.
Studies on evidence-based practice in medicine found
that most physicians welcome evidence-based practice and
feel that it improves patient care.8-11 Barriers to
evidence-based practice include the lack of time, an
overwhelming amount of literature, and difficulties
incorporating evidence into practice. Physicians felt that
the best way to increase evidence-based practice was by
using evidence-based guidelines developed by colleagues.
Dentists have also expressed positive attitudes and
awareness of evidence-based practice.12,13 However, their
understanding of evidence-based concepts were poor. The
major barriers dentists reported were lack of time, lack of
knowledge about evidence-based practice and financial
constraints.12,13 Dentists felt that the development of
practical guidelines, journal clubs and peer review
sessions would help increase evidence-based practice in
dentistry.14 There is currently no information about the
110
attitudes and awareness, perceptions and barriers to
evidence-based practice in orthodontics.
The purpose of this study was to determine the
attitudes and awareness of evidence-based practice among
orthodontists in the United States. In order to determine
the initiatives that might be needed, barriers to evidencebased practice were also examined. It was hoped that this
study would identify obstacles and solutions to
incorporating an evidence-based approach in orthodontics.
Methods and Materials
Survey Design
A survey was designed to examine the perception of
orthodontists towards evidence-based practice. Each
participant was asked to respond to a set of demographic
questions, followed by a set of questions pertaining to the
evidence-based practice in orthodontics. Most of the survey
questions were derived from similar studies conducted in
the medical field.9-12,15,16 The questions were divided into
four categories: attitudes and awareness, barriers,
understanding, and the best method to increase evidencebased practice in orthodontics. IRB approval was granted
prior to starting the research project.
111
Demographic Variables of Interest
The respondent sample was grouped according to age,
whether they were currently involved in teaching at a
university, and whether they had attained a Master’s
Degree. The age grouping included those 40 years of age or
younger, those between 41 and 60 years of age, and those 61
years of age and older.
Survey Validity
A pilot survey consisting of 22 questions was
administered to seven faculty orthodontists at Saint Louis
University Center for Advanced Dental Education. The survey
was discussed with each orthodontist to ensure that each
question was clear, unambiguous and valid. The survey
questions were modified and improved based on feedback from
the orthodontists.
Survey Reliability
Reliability was assessed by administering the survey
to 20 orthodontic residents on two separate occasions, two
weeks apart. The reliability analysis was used to identify
and eliminate problematic questions (see Appendix C for the
finalized version of the survey). The final survey
consisted of 20 questions, including six pertaining to
112
attitudes, awareness and current practices, eight questions
pertaining to barriers, five questions pertaining to
understanding of evidence-based practice, and one question
on the best method to increase evidence-based practice
(Table 16).
Survey Distribution
The final version of the survey was submitted to and
approved by the Board of Directors of the American
Association of Orthodontists (AAO). The Board agreed to
send the survey to the all orthodontists and residents in
the U.S. with valid email addresses. To maintain the
anonymity and privacy of the respondents, the AAO forwarded
the link by email. A reminder email was sent one week
later. Results of the survey were recorded and maintained
anonymously on the Survey Monkey server (Surveymonkey.com,
Portland, OR).
Data Collection and Analysis
The survey data were analyzed using SPSS 14.0 (SPSS
Inc., Chicago, IL). Non-parametric statistics were used to
evaluate group differences because the response variables
were ordinal. The Mann-Whitney U test was used to test for
differences between the dichotomous groupings and the
113
Kruskal-Wallis H test was used to compare the three age
groups. The methods to increase evidence based practice in
orthodontics were nominal and evaluated with chi-square
tests. A p-value of <0.05 was considered significant.
Results
The survey was sent to 8,455 individuals, it was
opened by 3,456 individuals, and 1,047 individuals
participated in the study. The response rate was 30%. The
modal age of the sample was 41-60 years, there were 82%
males and 18% females, and the median years in practice
were 16-20 years (Table 17).17 25% of the respondents were
involved in teaching. 61% of the respondents had Master’s
Degrees. Frequency tables for each question in the survey
can be found in Appendix D.
Attitudes, awareness and current practices:
A majority of the respondents were aware of evidencebased practice in orthodontics (94%) and had previously
participated in an evidence-based course (63%) (Table 18).
The attitudes towards evidence-based practice among
respondents were positive. Most respondents also felt that
their colleagues’ attitudes were welcoming (50%), that
114
evidence-based practice was useful (80%), and that it
improved patient care (77%).
Those 40 years of age or younger were significantly
more likely to feel that their colleagues’ attitudes
towards evidence-based practice were welcoming than those
over 40 years of age (p<0.05) (Table 19). Those involved
with teaching were significantly more aware and reported
more positive attitudes towards evidence-based practice
than those not involved in teaching (p<0.05). There were no
significant differences in terms of attitudes and awareness
for those with and without Master’s Degrees (p>0.05).
Barriers:
Most respondents were either neutral or felt that the
barriers evaluated in this study, including evidence-based
practice is more appropriate for research settings than
clinical practice, evidence-based practice is not
practical, evidence-based practice is best for the next
younger generation of orthodontists, evidence-based
practice has questionable benefit to patient care, and
there is no financial gain to evidence-based practice, were
not obstacles to evidence-based practice (Table 20).
115
Those 61 years of age and older were significantly
more likely to report that evidence-based practice was more
appropriate for research settings than those 40 years of
age or younger (p<0.05)(Table 21). Orthodontists between 41
and 60 years of age were significantly less likely to
report that evidence-based orthodontics was best suited for
the next, younger, generation of orthodontists than other
age groups (p<0.05). Those not currently involved in
teaching were significantly more likely to report that
evidence-based practice was not practically useful, that it
posed a threat to clinician’s autonomy and experience, to
express a lack of interest in evidence-based practice, and
to lack knowledge about evidence-based practice (p<0.05).
Those without Master’s Degrees were significantly (p<0.05)
more likely than those with degrees to state that lack of
knowledge of evidence-based practice was a barrier.
Understanding of evidence-based practice:
The majority (57%) of respondents did not believe that
randomized-control trials were the only good source of
evidence. Only a minority of respondents correctly
identified the level of evidence of case-control (33%),
case series (40%), and cohort (39%) study designs. A
majority of respondents correctly identified the relative
116
level of evidence of the randomized-control trial study
(81%)(Table 20).
Those 40 years of age or younger were significantly
(p<0.05) more likely to report the correct level of
evidence of the “case series” study design than their older
colleagues (Table 21). Those between 41-60 years of age
were significantly (p<0.05) more likely to report the
correct level of evidence of the “case series” study design
than those 61 years of age and older.
For 3 of the 4 study
types, those involved with teaching were significantly more
likely to identify the correct level of evidence than those
not involved with teaching (p<0.05). There were no
significant differences in terms of understanding of
evidence-based concepts among the groups with and without
Master’s Degrees (p>0.05).
Best method to increased evidence-based practice:
Most orthodontists indicated that the best method of
increasing evidence-based practice was to provide evidencebased summaries, followed by evidence-based guidelines
(Table 22). There were no significant differences between
any of the groups as to the best method to increase
evidence-based practice (p>0.05).
117
Discussion
The response rate in this study was 30% which was
considerably lower than evidence-based surveys conducted in
the other fields.9,10,15,16,18 The studies in medicine
attributed their high response rate to the following
factors: short, concise surveys, anonymity, support of
professional leaders and professional membership.9,15,18 Since
this was a follow-up to the first survey, it was expected
that fewer individuals would be interested in participating
in another survey again within a short time span. Anonymity
and AAO support were utilized to maximize the response
rate. The response rate in this survey fell within 10-58%
range reported for other surveys conducted in
orthodontics.19-21 It has also been suggested that the
response rate among health care professionals is
decreasing.22 Importantly, the composition of the present
sample was comparable in terms of gender, age and years in
practice to the 2008 orthodontic sample survey conducted by
Keim et al. (Table 17).17 This suggests that the present
sample was representative of the orthodontic population as
a whole.
A majority of respondents reported awareness and
positive attitudes towards evidenced-based practice and
118
felt that evidence-based practice improved patient care.
This was in accordance with the results of studies done in
medicine and dentistry.11,12 Most general dentists were aware
of (70%) and felt that evidence-based practice was
important (87%).12 Most of physicians (78%) surveyed agreed
that evidence-based practice improved patient care.11 The
positive attitudes and awareness reported by orthodontists
suggests that the climate and timing is favorable for
increasing evidence-based practice in orthodontics.
Introduction of evidence-based practice into the
orthodontic curriculum as well as a component of continuing
education has been suggested as ways to stimulate such
practices in orthodontics.12 Knowledgeable consumers with
high demands could be a precipitating factor for an
increased awareness and role of evidence-based practice in
orthodontics in the future.12
The majority of respondents did not find the barriers
examined in this study to be important factors inhibiting
evidence-based practice in orthodontics. It may be that
practitioners recognize the value of the evidence-based
approach and therefore did not view the barriers evaluated
in this study to be significant. Alternatively, it could be
that the actual barriers were not identified by this study,
119
or respondents were not willing to report barriers, or
there were not many perceived barriers to evidence-based
practice among orthodontists. However, the previous survey
in this study identified conflicting and ambiguous
literature, the practical demands of work and insufficient
clinical guidelines as major barriers. This is consistent
with studies conducted in medicine and dentistry which also
found these, as well as time and financial constraints, to
be barriers.9,10,12 The introduction of evidence-based
guidelines and summaries may help overcome some of these
barriers to evidence-based practice.
Only a minority of respondents properly identified the
hierarchy of evidence suggesting a lack of fundamental
knowledge about evidence-based practice. This coincides
with the results of the first part of this study which also
found that respondents lacked knowledge about the evidencebased resources and evidence-based terminology. This is
also in agreement with a study conducted in dentistry which
found that even though most respondents were aware of
evidence-based practice, more than 43% of respondents were
unaware of the hierarchy of evidence and thought that all
evidence from scientific journals was acceptable for
evidence-based practice.12 The hierarchy of levels of
120
evidence is a major underpinning of evidence-based
practice. It forms the basis of critical appraisal and is
therefore, imperative for evidence-based practice.
Evidence-based summaries were most commonly identified
as the method to increase utilization of evidence-based
practice. This suggests that most orthodontists would
prefer not to read and critically appraise primary research
and are more interested in secondary evidence. Most
physicians also preferred evidence-based guidelines to
appraising primary research individually.9 Preference for
guidelines may stem from a lack of time for appraising
primary research, feeling overburdened by the clinical
demands of work and difficulty interpreting primary
research. This is an important finding because it suggests
that the introduction of more evidence-based summaries and
guidelines would be helpful to promote evidence-based
practice in orthodontics.
Younger orthodontists were more likely to perceive
their colleagues as welcoming towards evidence-based
practice than older orthodontists. This may be due to the
fact that younger orthodontists discuss evidence-based
practice more frequently with their colleagues than would
older orthodontists. The results of the first survey in
121
this study also found that younger orthodontists were more
interested and aware of evidence-based orthodontics and had
a better understanding of evidence-based terminology than
older orthodontists.
Those less than 40 years of age may
have more knowledge and awareness of evidence-based
practice because they may have had more exposure to courses
in evidence-based practice than their older colleagues.
Exposure might also explain why those 40 years of age or
younger were more positive towards evidence-based practice.
Those involved with teaching were more frequently
aware of and had more positive towards evidence-based
practice than those not involved with teaching. The first
survey in this study also found that those involved with
teaching had a better understanding of evidence-based
practice and terminology, perceived fewer barriers to
evidence-based practice, were more likely to adopt an
evidence-based stance on the orthodontic issues examined
and reported current practices that were more consistent
with the evidence. Considering that research and evidence
are important aspects of teaching and teaching
institutions, it was not surprising that those involved
with teaching placed greater emphasis on evidence-based
practice. Those not involved with teaching reported more
122
barriers and less understanding of the levels of evidence
than those involved with teaching. This might be expected
considering that those not involved with teaching might not
place the same importance on research and evidence as they
may on clinical experience.
There were few differences found in either of the two
surveys of this study between those with and without
Master’s Degrees. This suggests that both groups possessed
a similar potential to practice evidence-based
orthodontics. Due to the relatively recent development of
the approach, individuals with Master’s Degrees were not
necessarily more likely to have had formal training in the
process of critical appraisal or evidence-based practice
than those without such degrees. It may be the case that
orthodontic programs in the United States are similar in
terms of provision of courses in evidence-based practice
and research appraisal.
This study was not without its limitations. Conducting
a survey that requires self-completion of a questionnaire
is not the most accurate method of gathering the
perceptions of health care professionals on a complex
subject.10,23 Furthermore, one study found that respondents’
verbal explanation of terms can differ from written
123
responses.10,23 However, it would have been very difficult to
gather information from such a large number of individuals
with any method other than a survey.
It was also possible that there may be inconsistencies
between the respondents’ actual versus reported attitudes,
awareness, current practices and understanding of evidencebased practice. Another problem was that respondents may
have tried to make a good impression rather than declare
their true views on the subject, even though the surveys
were anonymous.
While every attempt was made to obtain a large and
representative sample of the orthodontic population, it is
possible that the sample was not representative of the
orthodontic population as a whole. Individuals who were not
in support of using evidence in clinical practice may have
chosen not to partake in the survey. If this were the case,
the results may have been skewed towards a more positive
outlook on the use of evidence in clinical practice than
was actually the case.
Lastly, due to the immense breadth of evidence-based
practice in orthodontics, it was not possible to explore
all areas of this very comprehensive subject. Further
124
exploration is warranted especially in identifying and
addressing resistance to evidence-based practice.
Conclusions and Recommendations
The general attitudes and awareness towards evidencebased practice were positive. The major barriers that have
been identified are the conflicting and ambiguous research,
the demands of work and insufficient guidelines. Poor
understanding of the hierarchy of evidence suggests that
educational initiatives are required. The solutions to
increase evidence-based practice favored by respondents
were introduction of evidence-based summaries and
guidelines. It is recommended that an evidence-based
educational task force be set-up to implement courses and
guide the development of evidence-based summaries and
guidelines.
125
References
1. Sackett D, Rosenberg W, Gray J, Haynes R, Richardson W.
Evidence based medicine: what it is and what it isn't. Brit
Med J 1996;312:71-72.
2. Rinchuse D, Kandasamy S, Ackerman M. Deconstructing
evidence in orthodontics: making sense of systematic
reviews, randomized clinical trials, and meta-analyses.
World J Orthod 2008;9:167-176.
3. Medicine Io. Crossing the quality chasm: A new health
system for the 21st century. Washington: National Academy
Press 2001.
4. White B. Making evidence-based medicine doable in
everyday practice. Fam Pract Manag 2004;11:51-58.
5. Research AoHa. Evidence-based practice centers; 2009.
6. ADA. Systematic Reviews and Summaries. Center for
Evidence-Based Dentistry 2009.
7. Rabb-Waytowich D. Evidence-based dentistry: Part 1. An
overview. J Can Dent Assoc 2009;75:27-28.
8. Coleman P, Nicholl J. Influence of evidence-based
guidance on health policy and clinical practice in England.
Brit Med J 2001;10:229-237.
9. McColl A, Smith H, White P, Field J. General
practitioners' perceptions of the route to evidence based
medicine: a questionnaire survey. Brit Med J 1998;316:361365.
10. O'Donnell C, PhD M. Attitudes and knowledge of primary
care professionals towards evidence-based practice: a
postal survey. J Eval Clin Prac 2004;10:197-205.
11. De Smedt A, Buyl R, Nyssen M. Evidence-based practice
in primary health care. Stud Health Tech Informat
2006;124:651-656.
12. Yusof Z, Han L, San P, Ramli A. Evidence-Based Practice
Among a Group of Malaysian Dental Practitioners. J Dent
Educ 2008;72:1333-1342.
126
13. Rabe P, Holmén A, Sjögren P. Attitudes, awareness and
perceptions on evidence based dentistry and scientific
publications among dental professionals in the county of
Halland, Sweden: a questionnaire survey. Swed Dent J
2007;31:113-120.
14. Allison P, Bedos C. Canadian dentists' view of the
utility and accessibility of dental research. J Dent Educ
2003;67:533-541.
15. McKenna H, Ashton S, Keeney S. Barriers to evidencebased practice in primary care. J Adv Nurs 2004;45:178-189.
16. Iqbal A, Glenny A. General dental practitioners'
knowledge of and attitudes towards evidence based practice.
Brit Dent J 2002;193:587-591.
17. Keim R, Gottlieb E, Nelson A, Vogels 3rd D. 2008 JCO
study of orthodontic diagnosis and treatment procedures,
Part 1: Results and trends. J Clin Orthod 2008;42:625-640.
18. Heywood A, Mudge P, Ring I, Sanson-Fisher R. Reducing
systematic bias in studies of general practitioners: the
use of a medical peer in the recruitment of general
practitioners in research. Fam Prac 1995;12:227-231.
19. Gentry S. Extraction decision-making in Class I
malocclusions: a survey identifying values for definite
extraction and non-extraction therapy. Master's Thesis
2009.
20. O'Connor B. Contemporary trends in orthodontic
practice: A national survey*. American Journal of
Orthodontics and Dentofacial Orthopedics 1993;103:163-170.
21. Yang E, Kiyak H. Orthodontic treatment timing: a survey
of orthodontists. American Journal of Orthodontics and
Dentofacial Orthopedics 1998;113:96-103.
22. McAvoy B, Kaner E. General practice postal surveys: a
questionnaire too far? Brit Med J 1996;313:732-734.
23. Young J, Ward J. Evidence-based medicine in general
practice: beliefs and barriers among Australian GPs. J Eval
Clin Prac 2001;7:201-210.
127
Table 16. Survey 2 questions, abbreviated questions and answer choices with assigned
numerical values used for data analysis.
Question
Abbreviation
Answer choices (assigned numerical value in parentheses)
I have previously
heard or read about
strongly
evidence based
Previously heard
strongly
orthodontics.
about EBP
agree (2)
agree (1)
yes (1)
no (-1)
neutral
disagree
disagree
(0)
(-1)
(-2)
I have participated in
a course about
Participated in
evidence based
a course about
.
EBP
orthodontics
Colleagues
The attitudes of my
attitudes
very
colleagues to evidence
towards EBP is
welcoming
welcoming
I don’t
unwelcoming
unwelcoming
based orthodontics:
welcoming
(2)
(1)
know (0)
(-1)
(-2)
very
neutral/
128
Table 16 Continued. Survey 2 questions, abbreviated questions and answer choices with
assigned numerical values used for data analysis.
Question
Abbreviation
Answer choices (assigned numerical value in parentheses)
Evidenced based
EBO in day-to-
orthodontics in day-
day practice is
very useful
useful
neutral
not useful
useless
to-day practice is:
useful
(2)
(1)
(0)
(-1)
(-2)
An evidence based
approach to practice
strongly
improves patient
Improves patient
strongly
agree
neutral
disagree
disagree
care.
care
agree (2)
(1)
(0)
(-1)
(-2)
Evidence based
orthodontics is more
appropriate for
research settings not
strongly
the clinical practice
More appropriate
strongly
agree
neutral
Disagree
disagree
of orthodontics
for research
agree (2)
(1)
(0)
(-1)
(-2)
129
Table 16 Continued. Survey 2 questions, abbreviated questions and answer choices with
assigned numerical values used for data analysis.
Question
Abbreviation
Answer choices (assigned numerical value in parentheses)
Evidence based
orthodontics sounds good
strongly
in theory but is not
Theoretical not
strongly
agree
neutral
disagree
disagree
practically useful.
practical
agree (2)
(1)
(0)
(-1)
(-2)
Evidence based
orthodontics is best
suited for the next,
Best for
younger, generation of
younger
strongly
agree
neutral
disagree
disagree
orthodontists.
generation
agree (2)
(1)
(0)
(-1)
(-2)
strongly
I can practice evidence
based orthodontics
through careful
observation of what does
Careful
and does not work in my
observation of
strongly
agree
neutral
Disagree
disagree
practice.
my practice
agree (2)
(1)
(0)
(-1)
(-2)
strongly
130
Table 16 Continued. Survey 2 questions, abbreviated questions and answer choices with
assigned numerical values used for data analysis.
Question
Abbreviation
Answer choices (assigned numerical value in parentheses)
The benefit of evidencebased orthodontics to
strongly
patient treatment is
Questionable
strongly
agree
neutral
disagree
disagree
questionable.
benefit
agree (2)
(1)
(0)
(-1)
(-2)
There is no financial
gain to practicing
strongly
evidenced based
No financial
strongly
agree
neutral
disagree
disagree
orthodontics.
gain
agree (2)
(1)
(0)
(-1)
(-2)
Evidence based
orthodontics is a threat
strongly
to clinician’s autonomy
Threat to
strongly
agree
neutral
disagree
disagree
and experience.
autonomy
agree (2)
(1)
(0)
(-1)
(-2)
I am not interested in
strongly
evidence based
orthodontics.
Not interested
I have very little
strongly
agree
neutral
disagree
disagree
agree (2)
(1)
(0)
(-1)
(-2)
strongly
knowledge of evidence
Very little
based orthodontics.
knowledge
agree (2)
131
strongly
agree
neutral
Disagree
disagree
(1)
(0)
(-1)
(-2)
Table 16 Continued. Survey 2 questions, abbreviated questions and answer choices with
assigned numerical values used for data analysis.
Question
Abbreviation
Answer choices (assigned numerical value in parentheses)
Randomized clinical trials
RCTs only
are the only good sources
good
strongly agree
of evidence in literature.
evidence
(2)
agree (1)
neutral (0)
Highest level
Second highest
Second lowest
Lowest level
(0)
level (0)
level (1)
(0)
Highest level
Second highest
Second lowest
Lowest level
(0)
level (0)
level (0)
(1)
Highest level
Second highest
Second lowest
Lowest level
(0)
level (1)
level (0)
(0)
Please place the following
study design in order
according to the hierarchy
of evidence: Case control
Case Control
Please place the following
study designs in order
according to the hierarchy
of evidence: Case Series
Case Series
Please place the following
study designs in order
according to the hierarchy
of evidence: Cohort
Cohort
132
Table 16 continued. Survey 2 questions, abbreviated questions and answer choices with
assigned numerical values used for data analysis.
Question
Abbreviation
Answer choices (assigned numerical value in parentheses)
Please place the following
study designs in order
according to the hierarchy
of evidence: RCT
Highest level
Second highest
Second lowest
Lowest level
(1)
level (0)
level (0)
(0)
provide
evidence
RCT
teach
provide
evidence based
based
orthodontists
evidence based
practice
practice
I feel the best method to
Best method
the skills of
summaries for
guidelines for
should not
increase evidence based
to increase
evidence based
orthodontists
orthodontists
be promoted
practice in orthodontics:
EBP
practice (1)
to use (2)
to use (3)
(-1)
133
Table 17. Comparison of the sample in Survey 2 with the sample in Keim et al.’s 2008
survey of orthodontists in the United States.17
Sample from the orthodontic survey
Survey 2 sample
by Keim et al.17
Age
41-50 years (modal value)
52 years (median)
Male
82%
85%
Female
18%
15%
Years in practice
16-20 years (modal value)
21 years (median)
134
Table 18. Percentage of respondents who selected each answer for Survey 2 questions on
attitudes and awareness of evidence-based practice.
strongly
Statement
strongly agree
agree
neutral
disagree
disagree
Previously heard
71
23
yes
no
63
37
5
1
1
about EBP
Participated in a
course about EBP
neutral/
very welcoming
welcoming
very
unwelcoming
unwelcoming
I don’t know
Colleagues
attitudes toward
8
42
42
EBP
135
6
2
Table 18 Continued. Percentage of respondents who selected each answer for Survey 2
questions on attitudes and awareness of evidence-based practice.
very useful
useful
neutral
not useful
totally useless
30
50
16
4
0
strongly agree
agree
neutral
disagree
EBO in day-to-day
practice
strongly
disagree
Improves patient
32
45
18
care
136
3
2
Table 19. Survey 2 trends regarding attitudes, awareness and current practices among the
three demographic variables: age (group 1=<40 years, group 2= 41-60 years, groups 3= 61
years +) involved in teaching (yes or no), and Master’s Degree (yes or no).
Age
Involved in teaching
Master's Degree
Previously heard
about EBP
N.S.
(p=0.619)
yes>no
(p=0.012)
N.S.
(p=0.488)
N.S.
(p=0.084)
yes>no
(p<0.001)
N.S.
(p=0.096)
1>2=3
(p<0.001)
N.S.
(p=0.119)
N.S.
(p=0.998)
N.S.
(p=0.157)
yes>no
(p=0.041)
N.S.
(p=0.890)
N.S.
(p=0.710)
yes>no
(p=0.025)
N.S.
(p=0.606)
Participated in a
course about EBP
Colleagues
attitudes towards
EBP is welcoming
EBO in day-to-day
practice is
useful
Improves patient
care
N.S. : not significant
> : significantly (p<0.05) more likely to agree with the statement in the question
137
Table 20. Percentage of respondents who selected each answer for Survey 2 questions
pertaining to barriers and understanding of evidence-based practice.
Statement
strongly agree
agree
neutral
disagree
strongly disagree
4
15
24
43
14
4
11
26
46
13
1
4
18
51
26
my practice
7
33
24
27
9
Questionable benefit
3
10
19
51
16
No financial gain
4
14
43
31
8
More appropriate for
research
Theoretical not
practical
Best for younger
generation
Careful observation of
138
Table 20 Continued. Percentage of respondents who selected each answer for Survey 2
questions pertaining to barriers and understanding of evidence-based practice.
Statement
strongly agree
agree
neutral
disagree
strongly disagree
Threat to autonomy
3
7
21
50
19
Not interested
2
4
14
52
28
Very little knowledge
3
9
19
49
20
RCTs only good evidence
4
16
24
50
7
Correct Level
Incorrect
Case control
33
67
Case series
40
60
Cohort
39
61
RCT
81
19
139
Table 21. Survey 2 trends regarding barriers among the three demographic variables: age
(group 1=<40 years, group 2= 41-60 years, groups 3= 61 years +), involved in teaching
(yes or no), and Master’s Degree (yes or no).
Age
Involved in teaching
Master's Degree
More appropriate for
3>2=1
(p=0.020)
N.S.
(p=0.056)
N.S.
(p=0.359)
Theoretical not practical
N.S.
(p=0.489)
no>yes
(p=0.032)
N.S.
(p=0.642)
Best for younger generation
1=3>2
(p=0.024)
N.S.
(p=0.073)
N.S.
(p=0.188)
Questionable benefit
N.S.
(p=0.283)
N.S.
(p=0.095)
N.S.
(p=0.863)
practice
N.S.
(p=0.881)
N.S.
(p=0.060)
N.S.
(p=0.546)
No financial gain
N.S.
(p=0.405)
N.S.
(p=0.172)
N.S.
(p=0.814)
research
Careful observation of my
N.S. : not significant
> : significantly (p<0.05) more likely to agree with the statement in the question
140
Table
21
Continued.
Survey
2
trends
regarding
barriers
among
the
three
demographic
variables: age (group 1=<40 years, group 2= 41-60 years, groups 3= 61 years +), involved
in teaching (yes or no), and Master’s Degree (yes or no).
Age
Involved in teaching
Master's Degree
Threat to autonomy
N.S.
(p=0.224)
no>yes
(p=0.001)
N.S.
(p=0.111)
Not interested
N.S.
(p=0.943)
no>yes
(p=0.002)
N.S.
(p=0.595)
Very little knowledge
N.S.
(p=0.618)
no>yes
(p<0.001)
no>yes
(p=0.011)
RCTs only good evidence
N.S.
(p=0.915)
no>yes
(p=0.032)
N.S.
(p=0.940)
Case control
N.S.
(p=0.383)
yes>no
(p=0.004)
N.S.
(p=0.812)
Case series
1>2>3
(p=0.004)
yes>no
(p=0.001)
N.S.
(p=0.737)
Cohort
N.S.
(p=0.146)
yes>no
(p<0.001)
N.S.
(p=0.222)
RCT
N.S.
(p=0.601)
N.S.
(p=0.103)
N.S.
(p=0.053)
N.S. : not significant
> : significantly (p<0.05) more likely to agree with the statement in the question
141
Table 22. Percentage of respondents who selected each answer for the Survey 2 statement
“I feel the best method to increase evidence-based practice in orthodontics”.
Involved in teaching
Age (p=0.129)
Teach skills of EBP
(p=0.125)
Master's Degree (p=0.634)
<40 yrs
41-60 yrs
61 yrs+
No
Yes
No
Yes
19
21
29
20
27
23
21
50
50
40
50
43
45
49
28
27
28
27
27
29
27
3
3
3
3
3
3
3
Provide evidencebased summaries
Provide evidencebased
practice
guidelines
EBP should not be
promoted
142
APPENDIX A: SURVEY 1
1. Gender
Male
Female
2. Age
21-30 years
31-40 years
41-50 years 51-60 years
61 years+
3. Do you have a Master’s Degree?
Yes
No
4. Currently involved in research or teaching at a university:
Yes
 No
5. Research influences my daily work.
strongly agree agree
neutral
disagree
strongly disagree
6. Peer-reviewed journals provide the best current evidence for me to incorporate
into my practice.
strongly agree agree
neutral
disagree
strongly disagree
7. I would be interested in more clinical practice guidelines that help guide treatment
decision making.
strongly agree agree
neutral
disagree
strongly disagree
8. I read Scientific Peer-reviewed Journals (please check applicable statements)
daily
weekly
monthly
rarely
not at all
9. Please evaluate your awareness of the Cochrane Collaboration (please check one)
fully aware
aware of only by name
not aware
10. I have used PubMed/Medline in the past year to answer a clinical question.
yes no
uncertain
143
11. The practical demands of work make it difficult for me to keep up-to-date with
current best evidence relating to practice.
strongly agree agree
neutral
disagree
strongly disagree
12. There are not enough clinical practice guidelines in the literature.
strongly agree agree
neutral
disagree
strongly disagree
13. The literature is often conflicting and ambiguous.
strongly agree agree
neutral
disagree
strongly disagree
14. I am satisfied with my current knowledge and practice and feel it is sufficient.
strongly agree agree
neutral
disagree
strongly disagree
15. I have the skills to undertake a comprehensive literature review.
yes no
uncertain
16. I feel comfortable performing a comprehensive literature review.
yes no
uncertain
17. I can obtain copies of published research papers/reports relating to my clinical
practice.
yes no
uncertain
18. I have no access to the Internet:
 yes no
19. I have access to the Internet at home:
 yes no
20. I have access to the Internet at work:
 yes no
144
21. Please indicate your understanding of the term “bliniding”:
understand and could explain it to others
some understanding
don’t understand but would like to
don’t understand and don’t want to
22. Please indicate your understanding of the term “systematic review”:
understand and could explain it to others
some understanding
don’t understand but would like to
don’t understand and don’t want to
23. Please indicate your understanding of the term “Meta-Analysis”:
understand and could explain it to others
some understanding
don’t understand but would like to
don’t understand and don’t want to
24. Please indicate your understanding of the term “Randomized-control trial”:
understand and could explain it to others
some understanding
don’t understand but would like to
don’t understand and don’t want to
25. Please indicate your understanding of the term “Strength of evidence”:
understand and could explain it to others
some understanding
don’t understand but would like to
don’t understand and don’t want to
26. Please indicate your understanding of the term “Odds ratio”:
understand and could explain it to others
some understanding
don’t understand but would like to
don’t understand and don’t want to
145
27. Please indicate your understanding of the term “Sample power”:
understand and could explain it to others
some understanding
don’t understand but would like to
don’t understand and don’t want to
28. Please indicate your understanding of the “Confidence interval”:
understand and could explain it to others
some understanding
don’t understand but would like to
don’t understand and don’t want to
29. Please indicate your understanding of the “Specificity”:
understand and could explain it to others
some understanding
don’t understand but would like to
don’t understand and don’t want to
30. Please indicate your understanding of the “PICO questions”:
understand and could explain it to others
some understanding
don’t understand but would like to
don’t understand and don’t want to
31. Two-phase treatment of Class II Division 1 malocclusion is more efficient than
one-phase treatment in the permanent dentition.
strongly agree agree
undecided
disagree
strongly disagree
32. Occlusion is a primary etiologic factor in TMD.
strongly agree agree
undecided
disagree
strongly disagree
33. Third molar eruption causes lower incisor crowding.
strongly agree agree
undecided
disagree
strongly disagree
34. A frenectomy should be performed before orthodontic treatment commences.
strongly agree agree
undecided
disagree
strongly disagree
146
35. Premolar extraction smiles are rated as significantly less esthetic than nonextraction smiles.
strongly agree agree
undecided
disagree
strongly disagree
36. Extraction treatment causes TMD.
strongly agree agree
undecided
disagree
strongly disagree
37. All casts should be mounted to improve diagnosis and treatment.
strongly agree agree
undecided
disagree
strongly disagree
38. I change my practice philosophy based primarily on: (please select one)
colleague advice
expert advice
reading clinical journals
literature review
other
39. When faced with clinical uncertainties I usually : (please select one)
consult colleagues
consult textbooks
consult the literature
proceed using my best judgment
refer the patient
147
APPENDIX B: FREQUENCY TABLES FOR SURVEY 1 QUESTIONS
Table B.1. Gender distribution of Survey 1 respondents.
Gender
Frequency
Percent
Female
310
21
Male
1187
79
Total
1497
100
Table B.2. Age distribution of Survey 1 respondents.
Age
Frequency
Percent
21-30 years
181
12
31-40 years
368
24
41-50 years
295
19
51-60 years
366
24
61+ years
292
19
Total
1502
100
Table B.3. Distribution of responses to the question: Do
you have a Master's Degree?
Master's Degree
Frequency
Percent
No
609
41
Yes
883
59
Total
1492
100
Table B.4. Distribution of responses to the question: Are
you currently involved in research or teaching at a
university?
University involvement
Frequency
Percent
No
1051
72
Yes
409
28
Total
1460
100
148
Table B.5. Distribution of responses to the statement:
Research influences my daily work.
Frequency
Percent
strongly disagree
17
1
disagree
55
4
neutral
212
15
agree
748
52
strongly agree
394
28
Total
1426
100
Table B.6. Distribution of responses to the statement:
Peer-reviewed journals provide the best current evidence
for me to incorporate into my practice.
Frequency
Percent
strongly disagree
10
1
disagree
31
2
neutral
211
15
agree
718
50
strongly agree
455
32
Total
1425
100
Table B.7. Distribution of responses to the statement: I
would be interested in more clinical practice guidelines
that help guide treatment decision making.
Frequency
Percent
strongly disagree
18
1
disagree
68
5
neutral
269
19
agree
679
48
strongly agree
384
27
Total
1418
100
149
Table B.8. Distribution of responses to the statement: I
read Scientific Peer-reviewed Journals.
Frequency
Percent
daily
64
5
weekly
471
33
monthly
748
53
rarely
132
9
Total
1415
100
Table B.9. Distribution of responses to the statement:
Please evaluate your awareness of the Cochrane
Collaboration.
Frequency
Percent
unaware
773
55
aware of but only by
name
284
20
fully aware
348
25
Total
1405
100
Table B.10. Distribution of responses to the statement: I
have used PubMed/Medline in the past year to answer a
clinical question.
Frequency
Percent
no
659
47
uncertain
14
1
yes
734
52
Total
1407
100
150
Table B.11. Distribution of responses to the statement: The
practical demands of work make it difficult for me to keep
up-to-date with current best evidence relating to practice.
Frequency
Percent
strongly disagree
58
4
disagree
419
31
neutral
267
20
agree
542
40
strongly agree
80
6
Total
1366
100
Table B.12. Distribution of responses to the statement:
There are not enough clinical practice guidelines in the
literature.
Frequency
Percent
strongly disagree
46
3
disagree
245
18
neutral
479
35
agree
500
37
strongly agree
99
7
Total
1369
100
Table B.13. Distribution of responses to the statement: The
literature is often conflicting and ambiguous.
Frequency
Percent
strongly disagree
9
1
disagree
195
14
neutral
360
26
agree
660
48
strongly agree
147
11
Total
1371
100
151
Table B.14. Distribution of responses to the statement: I
am satisfied with my current knowledge and practice and
feel it is sufficient.
Frequency
Percent
strongly disagree
88
6
disagree
530
39
neutral
339
25
agree
357
26
strongly agree
51
4
Total
1365
100
Table B.15. Distribution of responses to the statement: I
have the skills to undertake a comprehensive literature
review.
Frequency
Percent
no
87
6
uncertain
208
15
yes
1103
79
Total
1398
100
Table B.16. Distribution of responses to the statement: I
feel comfortable performing a comprehensive literature
review.
Frequency
Percent
no
228
16
uncertain
241
17
yes
931
67
Total
1400
100
152
Table B.17. Distribution of responses to the statement: I
can obtain copies of published research papers relating to
my clinical practice.
Frequency
Percent
no
66
5
uncertain
149
11
yes
1187
85
Total
1402
100
Table B.18. Distribution of responses to the statement: I
have no access to the internet.
Frequency
Percent
no
1336
87
yes
191
13
Total
1517
100
Table B.19. Distribution of responses to the statement: I
have access to the Internet at home.
Frequency
Percent
yes
1378
91
no
139
9
Total
1517
100
Table B.20. Distribution of responses to the statement: I
have access to the internet at work.
Frequency
Percent
no
44
3
yes
1311
97
Total
1355
100
153
Table B.21. Distribution of responses regarding
comprehension of blinding.
Frequency
Percent
don't understand and
don't want to
62
4
don't understand but
would like to
217
16
some understanding
378
28
understand and could
explain it to others
699
52
Total
1356
100
Table B.22. Distribution of responses regarding
comprehension of systematic review.
Frequency
Percent
don't understand and
don't want to
28
2
don't understand but
would like to
69
5
some understanding
578
43
understand and could
explain it to others
678
50
Total
1353
100
Table B.23. Distribution of responses regarding
comprehension of meta-analysis.
Frequency
Percent
don't understand and
don't want to
112
8
don't understand but
would like to
328
24
some understanding
481
36
understand and could
explain it to others
431
32
Total
1352
100
154
Table B.24. Distribution of responses regarding
comprehension of randomized control trial.
Frequency
Percent
don't understand and
don't want to
16
1
don't understand but
would like to
17
1
some understanding
304
23
understand and could
explain it to others
1024
75
Total
1361
100
Table B.25. Distribution of responses regarding
comprehension of strength of evidence.
Frequency
Percent
don't understand and
don't want to
18
1
don't understand but
would like to
89
7
some understanding
577
43
understand and could
explain it to others
665
49
Total
1349
100
Table B.26. Distribution of responses regarding
comprehension of odds ratio.
Frequency
Percent
don't understand and
don't want to
96
7
don't understand but
would like to
431
32
some understanding
547
40
understand and could
explain it to others
279
21
Total
1353
100
155
Table B.27. Distribution of responses regarding
comprehension of sample power.
Frequency
Percent
don't understand and
don't want to
76
6
don't understand but
would like to
321
24
some understanding
543
40
understand and could
explain it to others
417
31
Total
1357
100
Table B.28. Distribution of responses regarding
comprehension of confidence interval.
Frequency
Percent
don't understand and
don't want to
76
6
don't understand but
would like to
324
24
some understanding
532
39
understand and could
explain it to others
428
31
Total
1360
100
Table B.29. Distribution of responses regarding
comprehension of specificity.
Frequency
Percent
don't understand and
don't want to
71
5
don't understand but
would like to
278
21
some understanding
595
44
understand and could
explain it to others
408
30
Total
1352
100
156
Table B.30. Distribution of responses regarding
comprehension of PICO questions.
Frequency
Percent
don't understand and
don't want to
174
13
don't understand but
would like to
890
66
some understanding
209
15
understand and could
explain it to others
79
6
Total
1352
100
Table B.31. Distribution of responses to the statement: Two
phase treatment of Class II Division 1 malocclusion is more
efficient than one-phase treatment in the permanent
dentition.
Frequency
Percent
strongly disagree
420
31
disagree
620
46
neutral
150
11
agree
114
8
strongly agree
51
4
Total
1355
100
Table B.32. Distribution of responses to the statement:
Occlusion is a primary etiologic factor in TMD.
Frequency
Percent
strongly disagree
555
41
disagree
552
41
neutral
110
8
agree
106
8
strongly agree
29
2
Total
1352
100
157
Table B.33. Distribution of responses to the statement:
Third molars eruption causes lower incisor crowding.
Frequency
Percent
strongly disagree
593
44
disagree
572
42
neutral
137
10
agree
39
3
strongly agree
13
1
Total
1354
100
Table B.34. Distribution of responses to the statement:
Frenectomy should be performed before orthodontic treatment
commences.
Frequency
Percent
strongly disagree
655
48
disagree
588
43
neutral
67
5
agree
31
2
strongly agree
11
1
Total
1352
100
Table B.35. Distribution of responses to the statement:
Premolar extraction smiles are rated as significantly less
esthetic than non-extraction smiles.
Frequency
Percent
strongly disagree
516
38
disagree
587
43
neutral
132
10
agree
103
8
strongly agree
18
1
Total
1356
100
158
Table B.36: Distribution of responses to the statement:
Extraction treatment causes TMD.
Frequency
Percent
strongly disagree
919
68
disagree
395
29
neutral
24
2
agree
7
<1
strongly agree
9
<1
Total
1354
100
Table B.37. Distribution of responses to the statement: All
casts should be mounted to improve diagnosis and treatment.
Frequency
Percent
strongly disagree
509
38
disagree
609
45
neutral
137
10
agree
65
5
strongly agree
33
2
Total
1353
100
Table B.38. Distribution of responses to the statement: I
change my practice philosophy based primarily on.
Frequency
Percent
colleague advice
208
15
expert advice
468
34
clinical journals
308
23
literature review
197
14
other
181
13
Total
1362
100
159
Table B.39: Distribution of responses to the statement:
When faced with clinical uncertainties I usually.
Frequency
Percent
consult colleagues
688
50
consult textbooks
46
3
consult the literature
341
25
proceed using my best
judgment
295
22
refer
2
0
Total
1372
100
160
APPENDIX C: SURVEY 2
1. Gender
Male
Female
1. Age
21-30 years
31-40 years
41-50 years 51-60 years
61 years+
2. Do you have a Master’s Degree?
Yes
No
3. Currently involved in research or teaching at a university:
Yes
 No
4. I have previously heard or read about evidence based orthodontics.
strongly agree agree
neutral
disagree
strongly disagree
5. I have participated in a course about evidence based orthodontics.
yes
no
6. The attitudes of my colleagues to evidence based orthodontics:
very welcoming
welcoming
unwelcoming
7. Evidenced based orthodontics in day-to-day practice is:
very useful useful neutral
not useful totally useless
8. An evidence based approach to practice improves patient care.
strongly agree agree
neutral
disagree
strongly disagree
9. Evidence based orthodontics is more appropriate for research settings not the
clinical practice of orthodontics.
strongly agree agree
neutral
disagree
strongly disagree
10. Evidence based orthodontics sounds good in theory but is not practically useful.
strongly agree agree
neutral
disagree
strongly disagree
161
11. Evidence based orthodontics is best suited for the next, younger, generation of
orthodontists.
strongly agree agree
neutral
disagree
strongly disagree
12. I can practice evidence based orthodontics through careful observation of what
does and does not work in my practice.
strongly agree agree
neutral
disagree
strongly disagree
13. The benefit of evidence-based orthodontics to patient treatment is questionable.
strongly agree agree
neutral
disagree
strongly disagree
14. There is no financial gain to practicing evidenced based orthodontics.
strongly agree agree
neutral
disagree
strongly disagree
15. Evidence based orthodontics is a threat to clinician’s autonomy and experience.
strongly agree agree
neutral
disagree
strongly disagree
16. I am not interested in evidence based orthodontics.
strongly agree agree
neutral
disagree
strongly disagree
17. I have very little knowledge of evidence based orthodontics.
strongly agree agree
neutral
disagree
strongly disagree
18. Randomized clinical trials are the only good sources of evidence in literature.
strongly agree agree
neutral
disagree
strongly disagree
Please indicate the relative level of evidence of the following study design:
Lowest
Highest
2nd highest 2nd lowest
level
level
level
level
19. Case control
20. Case series
21. Cohort
22. Randomized control
trial
162
23. I feel the best method to increase evidence based practice in orthodontics:
teach orthodontists the skills of evidence based practice
provide evidence based summaries for orthodontists to use
provide evidence based practice guidelines for orthodontists to use
evidence based practice should not be promoted
163
APPENDIX D: FREQUENCY TABLES FOR SURVEY 2 QUESTIONS
Table D.1. Gender distribution of Survey 2 respondents.
Frequency
Percent
Female
199
18
Male
924
82
Total
1,123
100
Table D.2. Age distribution of Survey 2 respondents.
Frequency
Percent
21-30 years
64
6
31-40 years
252
22
41-50 years
247
22
51-60 years
329
29
61 years +
234
21
Total
1,126
100
Table D.3. Distribution of responses to the question: Do
you have a Master's Degree?
Frequency
Percent
No
433
39
Yes
691
61
Total
1,124
100
Table D.4. Distribution of responses to the question: Are
you currently involved in research or teaching at a
university?
Frequency
Percent
No
836
75
Yes
280
25
Total
1,116
100
164
Table D.5. Distribution of responses to the statement: I
have previously heard or read about evidence-based
orthodontics.
Frequency
Percent
Strongly disagree
8
1
Disagree
7
1
Neutral
49
5
Agree
245
23
Strongly agree
750
71
Total
1,059
100
Table D.6. Distribution of responses to the statement: I
have participated in a course about evidence-based
orthodontics.
Frequency
Percent
No
394
37
Yes
666
63
Total
1,060
100
Table D.7. Distribution of responses to the statement: The
attitudes of my colleagues to evidence-based orthodontics.
Frequency
Percent
I don't know
145
14
very unwelcoming
18
2
unwelcoming
65
6
neutral
291
28
welcoming
448
42
very welcoming
88
8
Total
1,055
100
165
Table D.8. Distribution of responses to the statement:
Evidenced-based orthodontics in day-to-day practice is.
Totally useless
Not useful
Neutral
Useful
Very useful
Total
Frequency
Percent
2
0
42
4
172
16
527
50
313
30
1,056
100
Table D.9. Distribution of responses to the statement: An
evidence-based approach to practice improves patient care.
Frequency
Percent
strongly disagree
20
2
disagree
31
3
neutral
190
18
agree
474
45
strongly agree
333
32
Total
1,048
100
Table D.10. Distribution of responses to the statement:
Evidence-based orthodontics is more appropriate for
research settings not the clinical practice of
orthodontics.
Frequency
Percent
strongly disagree
146
14
disagree
452
43
neutral
251
24
agree
152
15
strongly agree
46
4
Total
1,047
100
166
Table D.11. Distribution of responses to the statement:
Evidence-based orthodontics sounds good in theory but is
not practically useful.
Frequency
Percent
strongly disagree
132
13
disagree
479
46
neutral
275
26
agree
117
11
strongly agree
43
4
Total
1,046
100
Table D.12. Distribution of responses to the statement:
Evidence-based orthodontics is best suited for the next,
younger, generation of orthodontists.
Frequency
Percent
strongly disagree
271
26
disagree
530
51
neutral
187
18
agree
42
4
strongly agree
15
1
Total
1,045
100
Table D.13. Distribution of responses to the statement: I
can practice evidence-based orthodontics through careful
observation of what does and does not work in my practice.
Frequency
Percent
strongly disagree
94
9
disagree
280
27
neutral
250
24
agree
349
33
strongly agree
76
7
Total
1,049
100
167
Table D.14. Distribution of responses to the statement: The
benefit of evidence-based orthodontics to patient treatment
is questionable.
Frequency
Percent
strongly disagree
169
16
disagree
541
51
neutral
203
19
agree
105
10
strongly agree
33
3
Total
1,051
100
Table D.15. Distribution of responses to the statement:
There is no financial gain to practicing evidenced-based
orthodontics.
Frequency
Percent
strongly disagree
83
8
disagree
326
31
neutral
450
43
agree
152
14
strongly agree
39
4
Total
1,050
100
Table D.16. Distribution of responses to the statement:
Evidence-based orthodontics is a threat to clinician’s
autonomy and experience.
Frequency
Percent
strongly disagree
204
19
disagree
522
50
neutral
224
21
agree
70
7
strongly agree
34
3
Total
1,054
100
168
Table D.17. Distribution of responses to the statement: I
am not interested in evidence-based orthodontics.
Frequency
Percent
strongly disagree
278
28
disagree
517
52
neutral
143
14
agree
39
4
strongly agree
22
2
Total
999
100
Table D.18. Distribution of responses to the statement: I
have very little knowledge of evidence-based orthodontics.
Frequency
Percent
strongly disagree
202
20
disagree
486
49
neutral
188
19
agree
93
9
strongly agree
30
3
Total
999
100
Table D.19. Distribution of responses to the statement:
Please indicate the relative level of evidence of the case
control study design.
Frequency
Percent
Incorrect answer
604
67
Correct answer
296
33
Total
900
100
169
Table D.20. Distribution of responses to the statement:
Please indicate the relative level of evidence of the case
series study design.
Frequency
Percent
Incorrect answer
544
60
Correct answer
364
40
Total
908
100
Table D.21. Distribution of responses to the statement:
Please indicate the relative level of evidence of the case
series study design.
Frequency
Percent
Incorrect answer
549
61
Correct answer
351
39
Total
900
100
Table D.22. Distribution of responses to the statement:
Please indicate the relative level of evidence of the
randomized control trial study design.
Frequency
Percent
Incorrect answer
173
19
Correct answer
761
81
Total
934
100
170
Table D.23. Distribution of responses to the statement:
Randomized clinical trials are the only good sources of
evidence in literature.
Frequency
Percent
strongly disagree
68
7
disagree
492
50
neutral
233
24
agree
153
16
strongly agree
39
4
Total
985
100
Table D.24. Distribution of responses to the statement:
Please identify the best method to increase evidence-based
practice in orthodontics.
Frequency
Percent
Evidence-based
practice should not
be promoted
29
3
Teach orthodontists
the skills of
evidence-based
practice
218
22
Provide evidencebased summaries for
orthodontists to use
469
48
Provide evidencebased practice
guidelines for
orthodontists to use
269
27
Total
985
100
171
VITA AUCTORIS
Asha Madhavji was born on December 2, 1982 in South
Africa and moved to Canada with her family at 11 years of
age. She is the second child of Maya Harilal and Bhupen
Madhavji.
Asha graduated from Winston Churchill High School in
2000. She then attended the University of Lethbridge until
2003 when she was accepted into dental school.
She
received her D.M.D. degree from the University of Manitoba
in 2007 and is planning to receive her Master of Science in
Dentistry from Saint Louis University in January, 2010.
Asha is married to her husband, Neel, and they plan to
live happily ever after.
172