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An Evidence-Based Journal Club for Dental Residents in a GPR Program

Key words: evidence-based dentistry, journal club, dental residency

Submitted for publication 12/28/04; accepted 03/30/05

	Abstract

Top Abstract First meeting: understanding the... First assignment: converting... Second and Subsequent sessions:... Appraising the evidence and... Discussion References

 
The journal club offers a significant opportunity to serve as both an educational experience but also as a real-world example of the application of the principles and practices of evidence-based dentistry (EBD). Designed around the American Dental Association’s recommended four steps in the implementation of the EBD process, the journal clubs are held once per month for GPR residents. The structured process allows residents to formulate answerable clinical questions, track down with maximum efficiency the best evidence with which to answer the questions, critically appraise the evidence for its validity and usefulness, and apply the results of this appraisal in clinical practice as appropriate.

The American Dental Association (ADA) defines evidence-based dentistry as "an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidences, 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."¹

The ADA identifies four steps in the implementation of the EBD process: 1) define a clinically relevant focused question for which one seeks the best evidence; 2) systematically search for studies and other information that will help address the clinical question; 3) translate the findings into practical use; and 4) assess health care outcomes.

Similarly, Hassig² has identified specific steps needed to effectively implement evidence-based approaches into practice: 1) convert your information needs into answerable questions; 2) identify with maximum efficiency the best evidence with which to answer the questions; 3) critically appraise the evidence for its validity and usefulness; and 4) apply the results of this appraisal in clinical practice.

The importance of EBD to the future of dentistry cannot be underestimated. As with medicine, dental practitioners are faced with increasing demands to demonstrate that selection of treatment options is based on research that supports the effectiveness of therapeutic approaches. The need for students and residents to understand the process of evidence-guided patient care and to be able to employ its techniques has major implications for educational programs.

Journal clubs for residents offer a learning environment that can serve as an educational experience and a real-world example of the application of EBD. Historically, the structure of journal clubs has varied widely. Some are based on articles that an attending or faculty member or resident has recently read and identified as interesting. Some are based on a given issue of a relevant journal. Other journal clubs may be more highly structured. We have chosen to structure our residency journal club around the ADA EBD implementation process. The EBD sessions are held once per month for one hour each.

	First Meeting: Understanding the Language

Top Abstract First meeting: understanding the... First assignment: converting... Second and Subsequent sessions:... Appraising the evidence and... Discussion References

 
Facility within any new field requires that one understand the shorthand language that is used. Common terminology allows for efficient communication as well as a standard for the expression of content. Thus, the first journal club session is devoted to an introduction to new terminology. This includes discussion of randomized control trials (RCT), systematic reviews (SR), well-formulated clinical questions, levels of evidence (as outlined at Oxford’s evidence-based medicine website at www.cebm.net/levels_of_evidence.asp) as related to the validity of the evidence, and recommendations for grading the evidence based on Cook et al. as modified by Harbour and Miller.^3,4

Levels of Evidence.
"Levels of evidence" are used to rank the validity of evidence. First developed in 1979, the level description continued to evolve to its current format of five major levels.⁵ These range from Level 1 that includes systematic reviews and randomized controlled trials with narrow confidence intervals, down to Level 5 that includes expert opinion without explicit critical appraisal. A complete evidence level table with full descriptions of the major and sublevels may be found at the Oxford website.

Grades of Recommendations.
In Grade A (the top level), the evidence pertaining to a particular research question contains at least one meta-analysis, systematic review, or RCT rated as Level 1 and is directly applicable to the target population or a systematic review of RCTs or a body of evidence consisting principally of studies rated as Level 1 directly applicable to the target population and demonstrating overall consistency of results. Grade B is used for a body of evidence including studies rated as Level 2 (cohort studies or outcomes research studies) directly applicable to the target population and demonstrating overall consistency of results or extrapolated evidence from studies rated as Level 1. Grade C is used for a body of evidence including studies rated as Level 2 directly applicable to the target population and demonstrating overall consistency of results or extrapolated evidence from studies rated as Level 2. Grade D refers to Level 3 or 4 (case-control or case-series studies) evidence or extrapolated evidence from studies rated as lower Level 2.

Trials Scoring System.
Clinical trials are assessed for their strength in supporting the evidence. This is done using the methodology as proposed by Jadad et al.⁶ The scoring system is easy to use and provides a summary score ranging from 0 to 5. (See Table 1.)

	First Assignment: Converting Information into a Clinical Question

Top Abstract First meeting: understanding the... First assignment: converting... Second and Subsequent sessions:... Appraising the evidence and... Discussion References

Patient population—group of interest

Intervention—what effect do you wish to study?

Comparison—what is the comparison intervention (or no intervention)?

Outcomes—what is the effect of the intervention?

Thus a possible question might be the following: P—in patients requiring crowns, I—is a single etch preparation, C—compared to multi-step system, O—more effective in reducing subsequent decay? The PICO format not only helps to clarify the question to be addressed but also helps the residents limit the articles that they must evaluate by providing parameters around the search.

At the end of the first session, the group determines a PICO question to investigate. They are then provided only minimal instruction regarding information sources to examine and web resources to utilize. This is intentional because part of the second session is devoted to understanding and evaluating various information sources. Residents are asked to work on their own to identify at least one high-quality relevant article that can be used to help answer the PICO question. Once they have identified an article, they are requested to bring extra copies to the Journal Club to facilitate for the discussion. The attending dentist and faculty who will lead the second Journal Club also search for and identify appropriate articles.

	Second and Subsequent Sessions: Tracking Down the Evidence

Top Abstract First meeting: understanding the... First assignment: converting... Second and Subsequent sessions:... Appraising the evidence and... Discussion References

 
The second session begins with a discussion of the difficulties residents encountered in identifying relevant articles. It is interesting that, in the beginning, residents turn to their stack of handy journals or resort to a generalized Google^TM or Yahoo^TM search of the Internet. Few think to ask the question "Is there an evidence-based dentistry site on the Internet?" In fact, there is one at Oxford’s Centre for Evidence-Based Dentistry (www.cebd.org).

At this point, the group discusses a variety of useful sites for evidence-based information. Although most are heavily devoted to medicine, a significant number cross-index dental articles. We have found the following sites to be particularly useful.

PubMed.
PubMed (www.ncbi.nlm.nih.gov/entrez/query.fcgi), a service of the National Library of Medicine, includes over 15 million citations for biomedical articles back to the 1950s. These citations are from MEDLINE and additional life science journals. PubMed includes links to many sites providing full text articles and other related resources. The website includes extensive help files and a complete self-instructional tutorial.

Centre for Evidence-Based Dentistry.
The Centre for Evidence-Based Dentistry (www.cebd.org) is an independent body whose aim is to promote evidence-based dentistry worldwide. The center is linked to the Institute of Health Sciences in Oxford that has a website with additional links to many other initiatives designed to promote evidence-based clinical practice. The main objective of the center is to promote the teaching, learning, practice, and evaluation of evidence-based dentistry.

SUMsearch.
Maintained at the University of Texas Health Science Center at San Antonio, SUMSearch (sumsearch.uthscsa.edu/) combines meta-searching and contingency searching. Meta-searching means simultaneously searching multiple Internet sites and collating the results into one page. In addition, SUMSearch adds the idea of contingency searching. If SUMSearch finds too many hits from an Internet site, SUMSearch will execute more restrictive, contingency searches. On the other hand, if SUMSearch finds few hits from an Internet site, it may add a search of another site. SUMSearch allows the clinician to enter a query one time and then will select the best Internet sites to search, format the query for each site, execute contingency searches, and then return a single document to the clinician. After searching, SUMSearch organizes the list of links by breadth of discussion. The majority of the links provided by SUMSearch come from three Internet sites: the National Library of Medicine (NLM), DARE, and the National Guideline Clearinghouse (NGC). SUMSearch uses validated search filters as much as possible. These filters have been developed by various researchers to optimally search for certain types of articles. For example, when the clinician clicks the "treatment" focus, SUMSearch includes a search of MEDLINE using a filter validated to find randomized controlled clinical trials.

Bandolier.
The impetus behind Bandolier (www.jr2.ox.ac.uk/bandolier/) was to find information about evidence of effectiveness of treatment strategies for various health care problems (or lack of it) and put the results forward as simple bullet points of those things that worked and those that did not: a bandolier with bullets. Information comes from systematic reviews, meta-analyses, randomized trials, and high-quality observational studies. Each month Bandolier searches PubMed and the Cochrane Library for systematic reviews and meta-analyses published in the recent past. For other web content (such as the specialist resource areas), residents and faculty search over all times and, where necessary, do their own systematic reviews. Other types of information, like large epidemiological studies, may be included if they shed important light on a topic.

It should be noted that the generalized searches using Google^TM or Yahoo^TM may provide useful guidance in the identification of candidate articles. However, those articles appearing in the more formalized databases are more likely to derive from peer-reviewed sources. We recommend to residents that they search a variety of sites to be certain of full coverage of the topic.

Early in the process, residents sometimes complain that all they can access are abstracts of the articles. This may be especially true for residents in community programs without ready access to university libraries. First, we instruct the residents to go to the home page of the journal in which the article appeared. An increasing number of journals are making archival copies of articles available on the Internet. Some journals simultaneously publish both print and Internet copies of articles. Given that the journal club meets once per month, it also allows time for the residents to contact the senior authors (either by phone or email) to ask for reprint copies. We have been very pleased with the positive and supportive response that residents have received when they have asked for access to the articles. The personal contact has an added side effect in that the resident has the opportunity to discuss with the author the details of the study.

	Appraising the Evidence and Applying the Results

Top Abstract First meeting: understanding the... First assignment: converting... Second and Subsequent sessions:... Appraising the evidence and... Discussion References

 
We begin our discussion of the articles that have been identified by asking each resident to report on the search strategies that were employed including the terms used and the databases searched. We then classify each article based upon the level of evidence presented and its Jadad score. We begin with the article with the highest evidence level and highest Jadad score and then, as time permits, work our way through the lower level articles. At times there are no Level 1 articles that have been found to answer the clinical question. This is actually a good teaching point in that it reminds residents that there is not always an evidence-based answer to a clinical question. Therefore, the question may be worthy of further study.

Sutherland⁷ wrote a series of articles on assessing evidence-based dentistry that included a useful overview of the types of research designs often used in dental studies along with advantages and limitations of each. Accordingly, residents use an appropriate worksheet from the AMA Manual for Evidence-Based Clinical Practice to assess the research design and relevance of each study that we review in the journal club.⁸ These worksheets provide a rapid means of evaluating the relevance of the article to the clinical question as well as providing implications for clinical practice.

At the end of the session, we always conclude with the same question: "Based on the evidence presented here, would you consider changing your clinical practice?" This leads to a discussion of whether one should change practice on the basis of a single report and/or what would constitute a threshold of evidence that would be required for one to consider a change in practice related to the topic at hand.

At times, the discussion has led to other information-gathering activities. For example, a local practitioner who is a D.M.D./J.D. has participated in the journal club to address the legal implications of treatment alternatives when the evidence is unclear such as the use of prophylactic antibiotics prior to dental procedures in patients with endocarditis.

In all discussions regarding treatment, we stress to residents that it is important to remember that the patient’s own preferences and understanding must be taken into account. The availability of well-documented evidence helps the resident present the alternatives to the patient in a balanced manner as might be the case in explaining the selection among different dental implants.¹⁰

	Discussion

Top Abstract First meeting: understanding the... First assignment: converting... Second and Subsequent sessions:... Appraising the evidence and... Discussion References

 
The implementation of an evidence-based journal club has provided a specific structure for investigating clinical questions. The process helps residents understand and effectively apply the "Usefulness Equation" when addressing clinical questions.⁹ To be useful, information should be relevant to everyday practice, correct (valid), and easy to obtain. The relation of these factors can be expressed as:

In the equation, "validity" refers to evaluating the soundness of the articles under consideration. Relevance is based on the frequency that dentists are exposed to the clinical question in practice and the type of evidence presented. In other words, does the research focus on common problems? It is important to balance the relevance and validity with the work needed to obtain the information. The most useful information is therefore relevant to our practice, has high validity, and doesn’t take much work to access.⁹

Table 2 illustrates how this developed for one journal club. The question raised by the residents was whether caries in children could be prevented through the use of sealants. A PICO question was developed, search terms identified, and Level 1 evidence sought. The conclusion from this study was that while sealing with resin-based sealants is a recommended procedure to prevent caries, caries prevalence levels of both the individual and the local population should be considered. Further, "the benefit of sealing should be considered locally and specified guidelines for clinicians should be used."¹¹ This session pointed out the need to balance evidence, local conditions, dental decision making, and patient-based information in the development of treatment plans for patients.

	Footnotes

 
Dr. Grant is Research Professor, Family Medicine, State University of New York, Upstate Medical University, and Member, Dental Attending Staff, General Practice Residency Program, St. Joseph’s Hospital Health Center, Syracuse, New York. Direct correspondence and requests for reprints to him at 475 Irving Avenue #200, Syracuse, NY 13210; 315-464-6997 phone; 315-464-6982 fax; GrantW{at}upstate.edu.

	REFERENCES

Top Abstract First meeting: understanding the... First assignment: converting... Second and Subsequent sessions:... Appraising the evidence and... Discussion References

 

1. A complete statement of the ADA definitions and process. At: www.ada.org/prof/resources/positions/statements/evidencebased.asp. Accessed: December 2004.
2. Hassig RA. Evidence based medicine. Upstate Univ Connecticut Health Center 1999;13(3/4):1–2.
3. Cook DJ, Sackett DL, Spitzer WO. Methodologic guidelines for systematic reviews of randomized controlled trials in health care from the Potsdam Consultation on Meta-Analysis. J Clin Epidemiol 1995;48(1):167–72.[Medline]
4. Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ 2001;323:334–6.[Free Full Text]
5. Canadian Task Force on the Periodic Health Examination. The periodic health examination. CMAJ 1979; 121:1193–254.[Medline]
6. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, McQuay HJ. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996;17(1):1–12.[Medline]
7. Sutherland SE. Evidence-based dentistry: Part IV: Research design and levels of evidence. J Can Dent Assoc 2001;67:375–8.
8. Guyatte G, Rennie D. User’s guides to the medical literature: a manual for evidence-based clinical practice. Chicago: American Medical Association, 2001.
9. Rosser W, Slawson D, Shaughnessy A. Information mastery. 2^nd ed. New York: BC Decker, 2004.
10. Esposito M, Coulthard P, Thomsen P, Worthington HV. Interventions for replacing missing teeth: different types of dental implants. The Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD003815. DOI: 10.1002/14651858.CD003815.pub2.
11. Ahovuo-Saloranta A, Hiiri A, Nordblad A, Worthington H, Makela M. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database of Systematic Reviews (3):CD001830, 2004.

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