As a dental hygiene graduate student in the late 1970s, I spent many hours in the University of Michigan Dental School Library looking up journal articles for my Master's thesis in the large, red Index Medicus at the reference desk. The Index was published annually with quarterly supplements that indexed the most recent journal articles. After jotting down the citations on index cards, I was off to the stacks to search for the journals. It was slow work, limited by the delay in getting the latest research printed and indexed. A few years later, I was a new mother living in Munich, Germany, and my firstborn son was diagnosed with serious congenital urinary tract defects. Fortunately, I had brought my old anatomy textbook from my dental hygiene student days and was able to refer to it as my husband and I worked to translate the German medical terminology and better understand the treatment recommendations. As we weighed the various surgical options, our pediatrician could only offer reprints of German medical journal articles to assist us.

Fast forward to 2006: As I sit in front of the computer in my dental hygiene treatment room, I can access more than 16 million MEDLINE citations through the free PubMed service of the US National Library of Medicine to provide my patients with the most up-to-date treatment and health information. As a health care consumer, I also can get information for my family and myself from the consumer health library located in our local hospital or from the health information databases on the Internet. With the availability of full-text electronic journals, comprehensive literature reviews can be completed without ever stepping inside a library, from any place in the world with Internet access. Free Internet access to MEDLINE and PubMed is a gift to the world from the United States.¹

As much as the electronic age and the Internet have revolutionized access to information, they also have created challenges for health care providers and for the general public. From the health care practitioner's standpoint, it has become impossible to keep up with the information and research generated from thousands of publications written for various clinical disciplines, published in print as well as electronic formats. The volume of medical papers published is estimated to double every 10 to 15 years. The number of dental hygiene publications has grown from 3 core journals in 1996 to at least 10 monthly publications.² Add more than 400 dental journals into the mix, and the task of keeping up with the most current research in dentistry alone becomes even more daunting.

From the consumer's standpoint, patients can become overwhelmed with information as they attempt to differentiate between credible sources of health information and unsafe or unproven treatments.

A recent Internet search showed that there are currently more than 300,000 health-related Web sites. In 2005, more than 1 billion individuals used the Internet from all over the world. It is estimated that more than 1 million Americans go to the Internet for health diagnoses, support, news, and information every month.³

The consumer does not even have to go to the computer to be exposed to health information. Pharmaceutical advertising in the print media as well as on radio and television has educated the public about health conditions and terminology previously limited to health professionals. The public also can seek out information in the growing number of consumer health libraries located both within hospitals and as separate facilities across the country, as well as in a virtual format on the Internet. Educated consumers have become active participants in their own health care, empowered to make more knowledgeable choices for their self-care and to better discuss their own health conditions and treatments with their care providers.

Dental hygienists need to develop information management skills to keep current with the growing body of knowledge in both dentistry and general medicine.^4,5 Studies have shown that although dental hygienists feel that it is important to keep current with dental hygiene information, the majority of the respondents were still using what are considered traditional sources (dental hygiene journals, continuing education courses, and dental hygiene colleagues) to answer practice-related questions.^4,5 Many of the hygienists surveyed, however, stated that they used computers regularly at home for e-mail and personal use. Clearly, dental hygienists are ready to grow beyond traditional information sources and use the Internet to update their learning.

Evidence-based Medicine and Practice

The concept of evidence-based medicine (EBM) appeared in the mid-1990s along with the process called evidence-based decision making. EBM is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. To practice EBM, the clinician must combine individual clinical expertise with the best available clinical research.⁶

Over the past 10 years, use of the term EBM has increased dramatically as more practitioners have come to recognize the importance of evidence in making all types of health care decisions. EBM principles are cited in professional journals around the world and in disciplines ranging from psychiatry to veterinary medicine. Lay people are learning these principles as they become active partners in their health care, their knowledge enhanced by increased access to the latest research and health information.⁷ The EBM concept has evolved into evidence-based practice (EBP), uniting numerous practitioners committed to the principles of "best practice" and operating on the premise that health care providers must work as a team and use current best evidence to direct health care decisions.⁸

Clinical Applications

As a clinician you may be wondering how all of this theory applies to your daily practice. By applying the practice concepts of EBP (Table 1), the clinician is able to close the gap between research and practice.

Dental hygienists often are questioned about consumer products and their efficacy. To understand the principles of EBP, let's start with a question about temperature-sensitive teeth. Suppose your 35-year-old, female patient would like to know if a sensitivity formula toothpaste will help alleviate the pain that she has when she drinks or eats cold foods and beverages. The first step would be to convert the broad question regarding temperature-sensitive teeth into one that can be answered with relevant information. The well-constructed question, referred to as PICO, has the following components⁹:

P—Patient problem or population

The chief complaint as applied to the individual patient or a population as a whole. The patient's age, sex, and any predisposing factors would be included in this category.

I—Intervention

What is the intervention being considered?

C—Comparison

What is the treatment or therapy being compared with? This could be comparing different treatment modalities or a treatment with a placebo.

O—Outcome

What are the anticipated results?

Utilizing the PICO format, we could phrase the question for our patient with the temperature-sensitive teeth as: "For a 35-year-old patient with temperature-sensitive teeth, is using a potassium nitrate toothpaste an effective treatment for reducing sensitivity?"

Looking for the Evidence

Now that the question has been formed, the clinician can begin the search for the evidence. When using an EBP approach, the clinician will want to rely on scientific research relevant to the question rather than opinion or personal preference. Fortunately, a number of credible electronic databases and evidence-based dental journals exist offering reliable answers (Table 2). For this question, let's begin with a search within the PubMed database (Figure 1).

Using the key terms "dentin hypersensitivity AND potassium nitrate toothpaste" with limits set to include only articles written in English with abstracts and/or full text that are either meta-analyses; randomized, controlled trials; or reviews in adult populations aged 19 to 44 years, our search yielded 9 studies and 1 review article (Figure 2). Table 3 explains the basic research terminology.

Figure 1—PubMed home page (www.pubmed.gov). Links to online tutorials, help, and FAQs are available from the left-hand sidebar. Searches can be started with topics, specific authors or journals, or article title. Use the "Limits" tab to narrow the search. The search can be limited to only include specific types of studies (randomized, control trial, meta-analysis, practice guideline, or review article) as well as other categories.

Figure 2—Display page for the search results from entering the key terms, "dentin hypersensitivity AND potassium nitrate toothpaste." All articles displayed have abstracts, which are available for viewing online.

Figure 3—Display of the abstract from the systematic review on potassium nitrate toothpaste and dentin hypersensitivity.

Evaluate the Evidence

The clinician can then evaluate the various articles for their relevance to the particular question being addressed. Initially this may seem overwhelming within the parameters of daily practice, but with the help of the abstract and the description of the study methodology, the clinician can form an opinion on the validity of the results rather quickly. In the case of our hypersensitivity question, the review article found in our original search comes from the Cochrane Database of Systematic Reviews (Figure 3). The review summarized 8 different studies relating to the effectiveness of toothpastes containing potassium nitrate and potassium nitrate's effect on dentin hypersensitivity. Based on the reviewers' analysis of the data from the randomized, clinical trials, the reviewers concluded that there does not appear to be any strong evidence supporting the efficacy of potassium nitrate toothpaste for dentin hypersensitivity and that further studies are necessary to support the hypothesis. In this particular case, the conclusion of the reviewers may come as a surprise to clinicians because of their clinical experiences with patients using potassium nitrate products for dentin hypersensitivity. Where does this dilemma leave us in terms of advising our patient?

Application of the Evidence to Clinical Practice

Based on the review of the randomized, controlled trials studying the efficacy of potassium nitrate containing dentifrices, it remains questionable as to whether or not this is an effective treatment for hypersensitivity. However, when combining clinical experience with the evaluation process, the recommendation may change to endorsing or trying the therapy as the first line of treatment for the problem. Clinical experience and patient needs are not to be discounted in the EBP process. The important point to remember is that treatment recommendations are made using the latest research combined with clinical experience and the needs of the patient.

Evaluate the Results

Evaluation is the final step in the EBP approach. Did the treatment recommendation actually help the patient? Was the patient able to implement the recommended therapy? How can our performance be improved for better patient care? In the case of the hypersensitive patient, if the potassium nitrate dentifrice does not help resolve the pain, what other treatment options are available for this condition? New products are being developed on a regular basis. As dental health professionals, we have the responsibility to keep abreast of the many changes taking place in dentistry and in general health care, and to apply the information in daily practice based on the best evidence.

Accessing Electronic Consumer Health Information and Patient Education Materials

One of our most important roles as dental hygienists is as health educators for patients. Quality health information has been demonstrated to be a key component in facilitating evidence-based, informed patient choice.¹² While the Internet has opened information access to the public, the lay person faces the challenge of discriminating between valid information and hearsay. As health care providers, dental hygienists can play a key role in providing patients with credible health information as well as helping them evaluate the information they find on the Internet.

Evaluation Criteria for Internet Information

The same basic criteria for evaluating printed material apply to information found on the Internet.¹³ The quality of the source and of the information should be based on established guidelines for comprehensive assessment rather than any single criterion (Table 4).¹³

With all of the resources available on the Internet, the clinician can be as overwhelmed as the patient in determining where to begin the search. Credible online health information resources exist, and library sites are often the best places to begin (Table 5). A library Web site offers many of the resources found in the actual library. Reference librarians are often a forgotten resource as one begins to search the virtual reality library. Medical librarians, specializing in the health sciences, are available to assist the professional and the layperson with researching credible health information. Some library sites have an e-mail feature for online research assistance (Figure 4).

Putting the Resources into Practice

After clinicians become familiar with the wealth of information available online, it is time to put all of the components into practice. The best way to get started is to sit down at your computer and practice accessing the many databases and Web sites that are at your fingertips.

• Construct a clinical practice question using the PICO format and review the research that pertains to your question.
• Visit the resources listed in this article.
• Explore the National Library of Medicine pages.
• Check out the patient education brochures and fact sheets that are available on MedlinePlus (Figure 5).
• Print out materials that you would like to give to your patients.

Be prepared to give your patients the resources they need to make educated decisions about their health care. The information management skills you develop are essential tools for your own best practice.

Catherine Draper, RDH, MS

Cathy has been a dental hygienist for more than 30 years. She has a Master's Degree in Dental Hygiene from the University of Michigan and has practiced clinically in Germany and California. She is past president of the California Dental Hygienists' Association and was the 2001 leader of the People to People Delegation of Dental Hygienists to China. Cathy is a 2005 recipient of the Sunstar/Butler RDH Award of Distinction. She currently works in a general, cosmetic, and implant dental practice in Mountain View, California, and is a member of the adjunct faculty at Foothill College in Los Altos Hills. Cathy has been a library reference associate, assisting patients and their families access health information, at the Stanford Health Library for over 10 years. Cathy may be contacted at .

References

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