Prac%ced based research networks and evidenced based den%stry : A bridge to help close the research to prac%ce gap. Southwest Region Annual Mee8ng

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gap. Southwest Region Annual Mee8ng Miami, Fl.

1 Prac%ced based research networks and evidenced based den%stry : A bridge to help close the research to prac%ce gap. Southwest Region Annual Mee8ng Miami, Fl. Febuary 21, 2014 Paul Benjamin DMD, MAGD, FACD Private Prac8ce Miami, Florida 1

Rochester South Atlan8c Region University of Florida Southwest Region University of Texas

2 The Na8onal Dental PBRN Regions Western Region Kaiser Permanente Center for Health Research Midwest Region HealthPartners Research Founda8on Northeast Region University of Rochester South Atlan8c Region University of Florida Southwest Region University of Texas Health Science Center at San Antonio South Central Region University of Alabama at Birmingham 2

3 The Na8onal Dental PBRN Regions Western Region Kaiser Permanente Center for Health Research Midwest Region HealthPartners Research Founda8on Northeast Region University of Rochester South Atlan8c Region University of Florida Southwest Region University of Texas Health Science Center at San Antonio South Central Region University of Alabama at Birmingham 2

4 Reprinted with permission

5 What would you do and why? Reprinted with permission

6 What would you do and why? Reprinted with permission

7 What would you do and why? Reprinted with permission

8 Would you treat this tooth? Why? Reader s Digest Reprinted with permission

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10 5

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13 With permission from Espelid et al., 1997

14 When would you treat surgically? With permission from Espelid et al., 1997

15 When would you treat surgically? E-1 With permission from Espelid et al., 1997

16 When would you treat surgically? E-1 With permission from Espelid et al., 1997

17 When would you treat surgically? E-1 E-2 With permission from Espelid et al., 1997

18 When would you treat surgically? E-1 E-2 With permission from Espelid et al., 1997

19 When would you treat surgically? E-1 E-2 D-1 With permission from Espelid et al., 1997

20 When would you treat surgically? E-1 E-2 D-1 With permission from Espelid et al., 1997

21 When would you treat surgically? E-1 E-2 D-1 D-2 With permission from Espelid et al., 1997

22 When would you treat surgically? E-1 E-2 D-1 D-2 With permission from Espelid et al., 1997

23 When would you treat surgically? E-1 E-2 D-1 D-2 D-3 With permission from Espelid et al., 1997

24 When would you treat surgically? E-1 E-2 D-1 D-2 D-3 With permission from Espelid et al., 1997

25 When would you treat surgically? Caries depth Risk Assessment E-1 E-2 D-1 D-2 D-3 With permission from Espelid et al., 1997

26 New Products you must have?

27 Courses you should atend?

28 Evidenced Based Den8stry For Everyday Prac8ce A f!ndation to build on

29 What is EVIDENCE- BASED DENTISTRY? According to the ADA Evidence- based den8stry (EBD) is an approach to oral health care that requires the judicious integra%on of systema%c assessments of clinically relevant scien%fic evidence, rela8ng to the pa8ent s oral and medical condi8on and history, with the den8st s clinical exper%se and the pa%ent s treatment needs and preferences.

30 11

31 best relevant scien8fic evidence 11

32 best relevant scien8fic evidence den8st clinical exper8se 11

33 best relevant scien8fic evidence den8st clinical exper8se pa8ent s treatment values and preferences 11

34 best relevant scien8fic evidence den8st clinical exper8se pa8ent s treatment values and preferences to help deliver dental care 11

35 best relevant scien8fic evidence den8st clinical exper8se pa8ent s treatment values and preferences to help deliver dental care Researched evidence should help guide, rather than dictate clinical decision making. 11

37 Why prac8ce EBD?

38 Why prac8ce EBD? Improved pa8ent outcomes Pa8ents and den8sts save time and money by u8lizing protocols that work Improved pa8ent, den8st and staff sa8sfac8on Pa8ents, staff and den8sts have pride in high quality care EBD makes you look hip and smart

39 Why prac8ce EBD? Improved pa8ent outcomes Pa8ents and den8sts save time and money by u8lizing protocols that work Improved pa8ent, den8st and staff sa8sfac8on Pa8ents, staff and den8sts have pride in high quality care EBD makes you look hip and smart Maybe you won t have to make up stories

40 Used by permission of the ADA. December, 2008

41 Three Components of EBD Used by permission of the ADA. December, 2008

42 Three Components of EBD Evidence Clinical exper8se Pa8ent preferences & needs Used by permission of the ADA. December, 2008

43 Three Components of EBD Evidence Clinical exper8se EBD Pa8ent preferences & needs Used by permission of the ADA. December, 2008

44 Three Components of EBD Is an approach to oral health care Is a method to acquire, understand and apply the most current science to pa8ent care Evidence EBD Pa8ent preferences & needs Clinical exper8se Used by permission of the ADA. December, 2008

45 Three Components of EBD Is an approach to oral health care Is a method to acquire, understand and apply the most current science to pa8ent care Evidence EBD Pa8ent preferences & needs Clinical exper8se Used by permission of the ADA. December, 2008

46 What is the best evidence?

47 What are the RELATIVE levels of evidence? Systema8c Reviews Strong RCT s Cohort study Case control study Case series Case report Expert opinion Animal research Bench- top research Weak 15 Used by permission of the ADA. December, 2008

48 Pyramid of Quality of Evidence From Niederman et al JADA

50 Show me the evidence!

51 Show me the evidence! It is es8mated that as litle as 8% of clinical prac8ce is based on peer- reviewed and cri8cally appraised evidence.

52 Show me the evidence! It is es8mated that as litle as 8% of clinical prac8ce is based on peer- reviewed and cri8cally appraised evidence. It can be proven that most claimed research findings are false.

53 Show me the evidence! It is es8mated that as litle as 8% of clinical prac8ce is based on peer- reviewed and cri8cally appraised evidence. It can be proven that most claimed research findings are false. Ioannidis 2005, Antczak-Bouckoms 1995, Kugel 1998

54 18

55 We need more PRACTICE based evidence 18

56 An Introduc%on to the Na%onal Dental PBRN

57 Are PBRN s New? mainly a development in the past decades as a network of health care providers whose purpose is to evaluate the health care that occurs in real world prac8ces at least 40 PBRNs in the U.S., some in Europe a broad range of prac88oner types: family medicine internal medicine gastroenterology pediatrics nurse prac88oners ophthamology obstetrics and gynecology emergency medicine

58 PBRN are new in dentistry NIDCR (Na8onal Ins8tute of Dental Cranial Research) funded the Dental PBRN for a 7- year period beginning April groups selected UAB/UF DPBRN, NYU(PEARL) and Univ. of Washington (PRECEDENT) Total of $75 million

60 In 2005, many skep8cs asked...

61 In 2005, many skep8cs asked... Would we be able to recruit a large number of prac88oners? Would busy clinicians be effec8ve in doing studies in their prac8ces? Would we be able to establish the necessary regulatory and contractual rela8onships? Would prac88oner- inves8gators contribute ideas for research projects? Would they par8cipate at every step of the research process including peered reviewed publica8ons?

62 In 2005, many skep8cs asked... Would we be able to recruit a large number of prac88oners? Would busy clinicians be effec8ve in doing studies in their prac8ces? Would we be able to establish the necessary regulatory and contractual rela8onships? Would prac88oner- inves8gators contribute ideas for research projects? Would they par8cipate at every step of the research process including peered reviewed publica8ons? Did the experiment work??

63 In 2005, many skep8cs asked... Would we be able to recruit a large number of prac88oners? Would busy clinicians be effec8ve in doing studies in their prac8ces? Would we be able to establish the necessary regulatory and contractual rela8onships? Would prac88oner- inves8gators contribute ideas for research projects? Would they par8cipate at every step of the research process including peered reviewed publica8ons? Did the experiment work??

64 YES New 7 year grant of 67 million

65 The Na8onal Dental PBRN Regions Western Region Kaiser Permanente Center for Health Research Midwest Region HealthPartners Research Founda8on Northeast Region University of Rochester South Atlan8c Region University of Florida Southwest Region University of Texas Health Science Center at San Antonio South Central Region University of Alabama at Birmingham 24

66 25

67 Pick your level of involvement Informa(onal* newsle&ers(( ( ((((and( ((((((((((correspondence((((((((((* * * ( Prac(cing* *&** Non7prac(cing* invited*to*join!** Limited* surveys( ((((((((((((((and(( (((((ques2onnaires* Full in4office( (((((research* 15

69 Studies that have been done within the PBRN :

70 Studies that have been done within the PBRN :

71 Studies that have been done within the PBRN : Dental tobacco control randomized clinical trial Prac8ce- based root canal treatment effec8veness Assessment of caries diagnosis and caries treatment Reasons for placing the 1 st restora8on on permanent tooth surfaces Reasons for replacement or repair of dental restora8ons Case- control study of osteonecrosis of the jaws Retrospec8ve cohort study of osteonecrosis of the jaws Pa8ent sa8sfac8on with dental restora8ons Impact of par8cipa8on in prac8ce- based research on clinical prac8ce and pa8ent care Prevalence of ques8onable occlusal carieslesions Blood glucose tes8ng in dental prac8ce CONDOR TMJD study Development of a pa8ent- based provider interven8on for early caries management Peri- opera8ve pain and root canal therapy

72 How do you train to do a study?

73 What was it like to do a study in my prac8ce

74 What was it like to do a study in my prac8ce Aper a short learning curve the study was easy

75 What was it like to do a study in my prac8ce Aper a short learning curve the study was easy Made me think about refining various clinical prac8ces because of what I learned

76 What was it like to do a study in my prac8ce Aper a short learning curve the study was easy Made me think about refining various clinical prac8ces because of what I learned Improved my organiza8on skills

77 What was it like to do a study in my prac8ce Aper a short learning curve the study was easy Made me think about refining various clinical prac8ces because of what I learned Improved my organiza8on skills

78 Conduc8ng a study in my office

80 Lunch and Learn Session

81 Lunch and Learn Session Helps de- bug and customize the process to our prac8ce thanks to the regional coordinator The whole team sees the importance of this study to our office

82 Lunch and Learn Session Helps de- bug and customize the process to our prac8ce thanks to the regional coordinator The whole team sees the importance of this study to our office

83 Lunch and Learn Session Helps de- bug and customize the process to our prac8ce thanks to the regional coordinator The whole team sees the importance of this study to our office

84 Lunch and Learn Session Helps de- bug and customize the process to our prac8ce thanks to the regional coordinator The whole team sees the importance of this study to our office Need to explain properly what to do!

85 KISS- Keep it simple stupid!

86 Informed consent harder to simplify!

Quick Links Plans for a Cracked Tooth Registry Studyinterested?

Cracked Tooth Registry study in the coming months. The overall goal is to identify factors that predict adverse outcomes in cracked teeth.

Overall study design: This will be a four-year observational study of 3,000 cracked teeth nationally.

87 Quick Links Plans for a Cracked Tooth Registry Studyinterested? National Dental PBRN News National Dental PBRN Web Site Because cracked teeth represent such a frequent concern to most dentists we anticipate launching a Cracked Tooth Registry study in the coming months. The overall goal is to identify factors that predict adverse outcomes in cracked teeth. The final protocol has not been approved yet; preliminary information is below. Overall study design: This will be a four-year observational study of 3,000 cracked teeth nationally. Patients must be at least 19 years old and have a posterior permanent natural tooth with a crack. You will record an assessment of the patient, tooth, and crack(s) at baseline, and then once each year for four years. If you do any treatment on that tooth, you will also record that information. We anticipate that both practitioners and patients will receive some compensation for the time spent doing the study. 34

88 PBRN Web Site Na8onaldentalPBRN.org 35

89 Research to prac8ce gap Knowledge gap Knowing gap Knowing to doing gap

90 Transfer of Research into Dental Prac%ce Original Research Total Submission Elapsed Acceptance Time Publication Bibliographic Databases Review, Paper, Textbook Implementation 17+ years Contopoulos-Ioannidis et al., 2008

Transla8on of informa8on Between 1500-1800 2 million sailors died from scurvy 1593 Admiral

conclusively citrus preven8on 1795 Bri8sh Navy made lemon juice mandatory- but rum to

91 Transla8on of informa8on Between million sailors died from scurvy 1593 Admiral Hawkins advocated orange/lemon for preven8on 1747 James Lind clinical trials showed conclusively citrus preven8on 1795 Bri8sh Navy made lemon juice mandatory- but rum to preserve 1867 Lauchlin Rose (patented a Rose s lime juice) 1867 Royal Navy requires daily lime ra8on (hence: limey)

92 Have we improved over James Lind? How about sealant usage among den8st? First introduced in 70 s Reams of informa8on showing that they work to prevent dental decay. Do den8st rou8nely place sealants? Ahovuo-Saloranta A, Hiiri A, Nordblad A, Worthington H, Mäkelä M. Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents. Cochrane Database Syst Rev 2004(3):CD

93 No- den8st s8ll are not placing sealants In rou8ne prac8ce less than 40 percent of den8sts use sealants Personal correspondence with Dr. Robert Weyant

94 PBRN s can help close the research to clinical prac8ce gap! Informa(onal* newsle&ers(( ( ((((and( ((((((((((correspondence((((((((((* * * ( Prac(cing* *&** Non7prac(cing* invited*to*join!** Limited* surveys( ((((((((((((((and(( (((((ques2onnaires* Full in4office( (((((research* 15

95 Listening to us the Clinical Dentist Has anyone asked us real world clinical den8st what answers we need in our prac8ces?

96 Listening to us the Clinical Dentist Has anyone asked us real world clinical den8st what answers we need in our prac8ces? Allowing wet gloved den8st to decide on research projects that they consider valuable.

97 Listening to us the Clinical Dentist Has anyone asked us real world clinical den8st what answers we need in our prac8ces? Allowing wet gloved den8st to decide on research projects that they consider valuable. Improving the collabora8on between researchers and practicing den8st.

98 Repair or Replacement of Defec8ve Restora8ons U.S. National Institutes of Health grants DE-16746, DE and DE

99 Background 50% of all restora8ons placed in general dental prac8ce are replacement of restora8ons. The removal of the exis8ng restora8on will significantly remove sound tooth structure resul8ng in subsequently larger dental restora8ons. Repair provides the opportunity for minimally invasive treatment. 44

100 Background 50% of all restora8ons placed in general dental prac8ce are replacement of restora8ons. The removal of the exis8ng restora8on will significantly remove sound tooth structure resul8ng in subsequently larger dental restora8ons. Repair provides the opportunity for minimally invasive treatment. 44

101 Study Procedures and Methods This cross-sectional study used a consecutive patient/restoration recruitment design. A total of 197 network dentists/practices were enrolled in this study Total of 5,452 patients and 9,484 restorations DPBRN Project Regional Center staff met with each dentist and their staff for training of the protocol for this study. The mean number of patients recruited per practice was 28. Patients often had multiple defective restorations with the median number of restorations per practice at 50.

Methods Data collec8on form asked about pa8ent demographics and clinical details of the restora8on replacement including about original and new

102 Methods Data collec8on form asked about pa8ent demographics and clinical details of the restora8on replacement including about original and new materials, tooth number, and the surfaces involved main reason for the visit. It was completed during the treatment visit. Reprinted with permission

103 Results 9,484 Restorations REPAIRED (n=2411) 25% REPLACED (n=7073) 75% 47

104 n=5,110! n=3,342! n=620! n=211! 481"

105 49

Dentists' and Practices' characteristics (n=197) Time spend non-implant restorative (20) Revenue from dental insurance (32) 56% 58% Public Health (n=11) 6% Large Group (n=72) 37% Solo /

106 Dentists' and Practices' characteristics (n=197) Time spend non-implant restorative (20) Revenue from dental insurance (32) 56% 58% Public Health (n=11) 6% Large Group (n=72) 37% Solo / Small Group (n=114) 58% Dental Chairs per office (2.3) 4% Full-time (n=162) 86% Yrs since dental school graduation (10.5) 22% Gender (male) (n=138) 70% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 50

107 Den8sts characteris8cs associated with the decision to repair: 51

108 Pa8ents Characteris8cs Patients AGE influenced the decision to repair The older the patient, the higher the chance of the restoration being repaired. Other patients characteristics such as patients race, gender, and having private dental insurance were NOT associated with a likelihood of repair. 52

109 Restora8on characteris8cs associated with repair: A restoration in a MOLAR was more likely to be repaired than in a premolar or an anterior tooth Teeth with a SINGLE restored surface than teeth with multiple restored surfaces Restorations that had received a pre-diagnosis of SECONDARY CARIES than those with any other pre diagnosis DIRECT TOOTH COLORED MATERIAL was twice as likely to be repaired than amalgam 53

110 Conclusions Secondary caries was the most common reason for the repair or replacement of an exis8ng restora8on. Den8sts who did not place the original restora8on were more likely to replace it than den8sts who did (p<.001). Molar teeth were most affected compared to premolar and anterior teeth. Repair seem to be significantly associated with certain den8sts and prac8ces characteris8cs. 54

111 In summary Evidence- based den%stry is an approach to improving pa8ent care through decision making Incorporates research evidence, along with clinical exper8se and pa8ent preferences. Research evidence should help guide, rather than dictate, clinical decisions. Prac%ce Based Research Networks can gather real world evidence by conduc8ng research directly in prac8ce where the majority of the popula8on receives its dental care and can help to close the research to prac8ce gap. 55

112 56

113 56

114 Take home message: 56

115 Take home message: 1-Thanks for being part of the Practiced Based Research Networks 56

116 Take home message: 1-Thanks for being part of the Practiced Based Research Networks 2- Practice with an evidenced based mind 56

117 Take home message: 1-Thanks for being part of the Practiced Based Research Networks 2- Practice with an evidenced based mind 3- Learn to critical appraise what you read 56

Take home message: 1-Thanks for being part of the Practiced Based Research Networks 2- Practice with an evidenced based mind 3- Learn to critical appraise what you read 4-21

118 Take home message: 1-Thanks for being part of the Practiced Based Research Networks 2- Practice with an evidenced based mind 3- Learn to critical appraise what you read 4-21 st century clinician who cannot critically read a study is as unprepared as one who cannot take a blood pressure or examine the cardiovascular system BMJ 2008;337:

119 Science is what we do to keep from lying (telling stories)to ourselves. Richard Feynman 57

120

Welcome! Pragmatic Clinical Studies. David Hickam, MD, MPH Program Director Clinical Effectiveness Research. David Hickam, MD, MPH

Welcome! Pragmatic Clinical Studies. David Hickam, MD, MPH Program Director Clinical Effectiveness Research. David Hickam, MD, MPH Pragmatic Clinical Studies David Hickam, MD, MPH Program Director Clinical Effec2veness Research June 23, 2015 Welcome! David Hickam, MD, MPH Program Director Clinical Effectiveness Research 2 In this