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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