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Research methodology in Dentistry: Part I – The essentials and relevance of


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Article  in  Journal of Conservative Dentistry · March 2012


DOI: 10.4103/0972-0707.92598 · Source: PubMed

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Invited Review

Research methodology in Dentistry: Part I – The


essentials and relevance of research
Jogikalmat Krithikadatta
Department of Conservative Dentistry and Endodontics, Mennakshi Ammal Dental College and Hospitals, Maduravoyal, Chennai –
600095, India

Abstract
The need for scientific evidence should be the basis of clinical practice. The field of restorative dentistry and endodontics is
evolving at a rapid pace, with the introduction of several materials, instruments, and equipments. However, there is minimal
information of their relevance in clinical practice. On the one hand, material and laboratory research is critical, however; its
translation into clinical practice is not being substantiated enough with clinical research. This four part review series focuses on
methods to improve evidence-based practice, by improving methods to integrate laboratory and clinical research.
Keywords: Clinical research; evidence-based dentistry; measurement iterative loop; Patient/Population/Problem, intervention,
comparison, and outcome format; research methodology

INTRODUCTION The purpose of this review series is to help the reader to


organize the thought process when considering research
The field of dental research in India has witnessed needs and methods. It also aims to sensitize the mind to
exponential growth in the last five years.[1]However, research avenues that would be beneficial to material and
scientific publications in international peer-reviewed clinical research in particular and improving the quality
journals have been few.[2] The lacuna of Indian contribution of clinical care in general. This four-part review series
to international scientific literature is probably a skewed encompasses topics on essentials of research, fundamentals
understanding of research and its contribution in in biostatistics, observational studies, and experimental
effecting improved patient care. The primary purpose of studies in each part.
research is to produce new knowledge or find new ways
of making the existing knowledge available to those Conduct of research:The head start
who need it. Research is not a separate speciality which Every action is first conceived in the mind and later executed.
is practiced by a few but it is a systematic approach of Planning a good research project forms the primary basis
reasoning, documenting, analysing and reporting unusual of meaningful publication. Certain fundamental requisites
clinical observations that we come across in everyday are listed in Table 1. Focus in a particular area of interest is
clinical practice. Whether one is a “doer” or a “user” of essential to build up a strong forte in academic excellence.
research, a thorough understanding of the methodology Random choice of research projects dilutes the resource
is essential. In addition to individual practitioners, the contribution in random directions and results in lack of
“users” of research includes 1) professional organizations identity of the person or faculty. Generating research
that set “practice guidelines”;2) policy makers (sometimes hypothesis must aim at answering clinically relevant
called as “decision makers”) and 3) program managers questions. The rationale for the choice of a particular
(for example, state or national government managers stream could also result in a new concept of thinking or
of dental health programs). While the academicians and change the methods of treatment protocols.
research scholars (teaching institutions) have a unique
position to be “Doers” of research. The value for research It is prudent to decide apriori as to whom the results of a
for its own sake is limited, and therefore understanding particular research question would be useful and will the
the essential concepts in Research Methodology is vital in results be applicable to patients in dental practices in the
producing dependable knowledge. real world. Conventionally, in-vitro or laboratory research

Address for correspondence: Access this article online


Dr. Jogikalmat Krithikadatta, Department of Conservative Quick Response Code:
Dentistry and Endodontics, Mennakshi Ammal Dental College Website:
www.jcd.org.in
and Hospitals, Maduravoyal, Chennai – 600095, India. E-mail:
drkrithikadatta@hotmail.com
Date of submission: 07.01.2012 DOI:
Review completed: 09.01.2012 10.4103/0972-0707.92598
Date of acceptance: 21.01.2012

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Krithikadatta: Research methodology for dentist: The essentials

studies have good internal validity but poor external Table 1: Requisites of good research
validity which means that the results obtained are only Focus Area of interest/expertise
applicable to similar samples of the study. In other words, Meaningful progress
the results may not transfer to the clinical behaviour Rationale Clinically relevant
of the material. On the other hand, clinical studies have Proof of concept
Challenge /change current treatment methods
good external validity because they are tested on samples/
Validity Will the results be useful and to whom?
subjects that are closely related to the clinical condition
In-vitro studies – Good Internal Validity
and most often representative of all individuals with the Clinical studies – Moderate to good External Validity
condition; however they are more complex since so many Feasibility Time
other factors may influence the outcome of interest. Study population/ Samples
Infra-structure
Skill/aptitude
To understand validity, let us consider the research question
Ethics Do unto other what you would do unto you.
on dentin bonding agents (DBA). In-vitro assessment of
Budget Materials
dentin bonding agents is usually measured in terms of bond Manpower
strength and microleakage. In this scenario, all the samples Equipment
and procedures are standardized to a specific methodology,
that is, dentin cylinders 5 mm in height, with 4 mm of
composite material, x N force at 0.5 cross-head speed, dissociated from dental clinical research and is regarded to
and so on. The bond strength values obtained can be best be a practice under community dentistry. Hence research
extrapolated to a similar set of conditions in the laboratory methods described under epidemiology have also not
and may not deliver the same performance clinically to been used in answering many of our clinical research
patients. On the contrary, if we conduct a clinical study to questions. David Sackett, in 1969, coined the term clinical
evaluate the performance of dentin bonding agents, the epidemiology, which is the, “application, by a physician
methodology would include a randomized controlled trial who provides direct patient care, of epidemiological
involving the restoration of non-carious cervical lesions and biometric methods, to the study of diagnostic and
((NCCL), considered the ideal for bonding agent testing), therapeutic processes, in order to effect an improvement
the clinical evaluation criteria recommended by the United in health.”[5]This concept identifies the clinician as the
States Public Health System (USPHS), and followed over a epidemiologist, which chiefly includes practitioners
period of time. The results of the study can be extrapolated (general/specialist), students, and academicians, who are
to all similar patients requiring restoration of NCCLs. Hence, constantly involved in patient care. Almost four decades
the valid method of testing the ultimate performance of since this concept was introduced, our fraternity is waking
DBA is by a clinical trial and not just bond strength testing. up to this approach. It is important to note that knowledge
However, in-vitro studies provide an insight into which DBA of the disease process and treatment protocols constitute
is the best among the available, to be tested clinically. In- clinical knowledge. This forms only one essential part
vitro studies provide internal validity, that is, they tell us if of clinical epidemiology. In order to understand the
a particular drug or procedure works, but external validity involvement of clinicians in clinical research, we need to be
questions if it is of use to the patient population at large, aware of certain disease manifestations in the community,
which can only be determined by clinical trials on patients. with regard to the magnitude of the problem and measures
to deliver dental care.
Feasibility in terms of time, cost, samples, and infrastructure
are vital to set a logistic time frame for the functioning and Consider this question being asked by the Head of
completion of the study. Finally, a study that does not adhere Department of an institution, “What is the best endodontic
to ethical principles both for in-vitro and clinical designs, regime for patients being treated in my department?”
fails to answer clinically relevant questions. The principles Traditionally, this question would be answered by schools of
of ethics are not restricted only to the handling of human thought, textbook evidence, and findings reported in peer-
participants, but also encompass the ethics followed in the reviewed literature. In reality, this simple question has the
methodology and reporting of results. The Indian Council ability to raise meaningful research questions if we could
of Medical Research (ICMR) has comprehensive guidelines apply this to the measurement iterative loop proposed by
for conducting experimental studies in India.[3] Tugwell et al.[6] [Figure1]. The measurement iterative loop
breaks up the disease cycle into distinct component steps.
Clinical epidemiology It is iterative because, each step logically leads to the next,
The term Epidemiology refers to the study of the and thus comes back to the first step thus ‘closing’ the
distribution and determinants of health-related states or loop. Each step in the loop has the capacity to generate
events (including disease), and the application of these several research questions.
methods to the control of diseases and other health
problems.[4]Erroneously in India, this science is often In this loop, the first step is to ascertain the burden of illness.

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Krithikadatta: Research methodology for dentist: The essentials

study if interventions against them will work. After


identifying interventions, in vitro studies are carried out
when necessary, and then the successful interventions are
tried on humans. The initial trials should be to determine
Efficacy. This means that it should be determined whether
the intervention works if given in the right dose using the
right methods, for the right duration, that is, Can it work in
ideal circumstances?

Once this is achieved, the intervention (preventive and


restorative) methods are applied to the community, that
is, patients seeking treatment for failed endodontic
treatment or among the general population at a risk of
developing failure of primary endodontic treatment. This
Figure 1: The measurement iterative loop step is Community effectiveness, which measures how
well an intervention can work in real life. It assesses the
The burden of illness (e.g., patients requiring root canal benefit/harm ratio of potentially feasible interventions
treatment) could be measured among the patients seeking and estimates the reduction of burden of illness, if
dental care in the hospital or in a defined population. The the program is successful. Community effectiveness is
former will provide an answer to the rate of occurrence of determined by five factors: (a) Efficacy, (b) Screening and
endodontic disease and the latter addresses the prevalence diagnostic accuracy, (c) Evaluation of health care provider
of endodontic disease, both of which would vary with place compliance, (d) Evaluation of patient compliance, and (e)
and time. The burden of illness could be subdivided into: Evaluation of coverage. To understand this better let us
(a) Unavoidable and (b) avoidable. Avoidable burden of consider the question of treating symptomatic irreversible
illness comprises of disability, symptoms, and morbidity, pulpitis with Mineral trioxide aggregate (MTA) pulpotomy
for which efficacious caries preventive and intervention in Department of Endodontics at a dental college and give
methods are present. The unavoidable burden of illness of hypothetical percentages of success for each factor and
disability comprises of symptoms and morbidity for which compute the community effectiveness.
no efficacious prevention or cure exists. Eg if the tooth 1. Efficacy: Will the current treatment do more good
has been lost then root canal treatment is not possible. than harm in treating patients who are diagnosed
The focus on research in this area should be an effort to correctly and fully comply with recommendations for
transfer the burden from unavoidable to avoidable. treatment?(100%)
2. Screening and diagnostic accuracy: Does the department
Second is to identify and assess the possible cause of the have adequate diagnostic methods to identify patients
burden of disease. The etiology and risk-factor assessment with irreversible pulpitis and ensure methods to follow-
of a multifactorial disease like pulpal and periapical up the disease/recovery status? (90%)
pathology in itself generates a lot of research avenues. 3. Evaluation of health provider compliance: Is a
This step also makes use of several traditional study postgraduate student competent enough to perform
designs to derive clinically significant conclusions. This MTA pulpotomy? (80%)
step identifies the factors against which an intervention 4. Evaluation of patient compliance: Will the patient
can reduce the burden of illness, for example, failure of comply with the treatment and follow-up for MTA
primary endodontic treatment. To name a few obvious pulpotomy compared to conventional endodontic
causes, inadequate cleaning and shaping, missed canals, treatment? As there are chances that postoperative pain
and incomplete obturation. The risk factors in association with MTA pulpotomy could be a possibility, the patient
to this failure could be: Vitality status of the pulp during suffering from this complication can resort to another
initial endodontic treatment, amount of remaining tooth dentist for relief. (80%)
structure, and type of tooth. 5. Evaluation of coverage: Is the treatment available
to all potential patients who could benefit from the
Defining factors for causation also requires that there new method? Is there access to a dental college or
should be well-defined, specific, and reproducible knowledge of the treatment? (90%)
definitions for both the disease state and the risk factors.
Developing such criteria for defining disease and causative Now community effectiveness can be computed using
or risk factors contribute to increased diagnostic accuracy. the Multiplicative law of combining probabilities (P),[7]
considering the probability of each of these factors
The third step of the loop is the most significant. Having
identified the ‘intervenable’ factors, it is important to Community Effectiveness = P (Efficacy 100% x diagnostic

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accuracy 90% x health provider compliance 80% x patient the reliability of information or from evidence derived from
compliance 80% x coverage 90%) = 52% a scientific study,.[9]

After determining an effective treatment plan for the There are five levels, and each level has sub-ranks as shown
community/patients, the efficiency of the same needs to be in Figure 2.[7]
evaluated. This step determines the relationships between
costs and effects of options within and across the program. Level I
Cost could be a major deterrent in MTA pulpotomy. This a. Meta-Analysis
could propel ingenious preparations to match commercially b. Systematic review (SR) of Randomized Controlled Trials
available MTA, or allocate funds to deliver this treatment (RCT)
to indicated patients. This is followed by the synthesis c. Randomized Controlled Trials
and implementation of MTA pulpotomy as a standard of
care for indicated patients with irreversible pulpitis. This Level II
is done after integration of the feasibility of community a. Systematic review of Cohort Studies
effectiveness and efficiency. Any program implemented b. Cohort Studies/Poor quality RCT
needs to be followed up with systematic documentation
and monitoring. It should include markers for success and Level III
failure on the basis short-term, intermediate, and long- a. Systematic review of Case-Control Studies
term treatment outcomes. b. Case-Control Studies
c. In-vitro Studies
With success data in hand, the burden of illness should
again be re-assessed, to ascertain any modifications Level IV
required within the existing program. Case Series/Cross-sectional studies/Poor quality case
control studies
Era of evidence-based dentistry
Evidence-based practice is defined as, “the conscientious, Level V
explicit, and judicious use of current best evidence in Case Reports/Expert opinion/Literature review.
making decisions about the care of individual patients. The
practice of evidence-based medicine means integrating It must be noted, with caution, that the level of evidence
individual clinical expertise with the best available external is only a stratification based on the information that is
clinical evidence from systematic research.”[8] Individual obtained from each method, with minimal bias, and these
clinical expertise is the proficiency and clinical judgment levels in no way rank the study design. It is logical to
that is often a summation of clinical experience and perceive that study designs are chosen based on research
clinical practice. This systematic clinical research in our questions. For example, even though Randomized Clinical
field includes both in-vitro and clinical research, with equal Trials provide the best evidence, this study design is not
importance. The sensible transition to clinical research meant to identify risk factors for occurrence of disease
by making use of the conclusions of in-vitro research will (determined by case-control study) or disease occurrence/
contribute evidence to various steps of the measurement prognosis (determined by Cohort study). Hence, levels of
iterative loop. It is often observed that the thrust for evidence are a logical ranking for evidence rather than a
clinical research is feeble and as a result there is insufficient ranking for study designs.
evidence from laboratory research translating to clinical
practice. The ideal place to enable contribution to the best
clinical evidence would undoubtedly be the institutional
organization, which has the balance between clinical
expertise from the teachers end and the requirement for
research projects from the students’ end. The only missing
link is a properly planned research, which can be fullfilled by
employing the measurement iterative loop.

The awareness of evidence-based dentistry is growing


not only on the research/clinical front, but also from
patients seeking quality dental care. Hence, the possibility
of a research study being acknowledged in scientific
literature is often driven by the relevance of evidence that
a particular research study can deliver. There is a certain
hierarchy termed as ‘Levels of Evidence,’ purely based on Figure 2: Levels of evidence

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What is your research question? Intervention [or ‘exposure’-making it PECO for causation
With the understanding of the measurement iterative loop questions]— It is important to identify what has been planned
and the significance to generate relevant evidence for clinical for the patient or the problem. Depending on the problem, this
practice, the research question should aim at focusing on may include the use of a specific diagnostic test, treatment,
one primary issue at a time. The method to identify and medication or the recommendation to the patient, to
prioritize research questions is given in Figure 3. use a product or procedure. If the problem measures the
causation of a particular disease, then the etiological agent
is assumed as the intervention.
A well-built research question should include four parts,
referred to as the PICO format, which includes Patient/
Comparison — It is an alternative to the intervention under
Population/Problem, Intervention, Comparison, and
study.
Outcome (PICO).[10]
Outcome(s) — This pertains to the result of the study
Patient/population/problem — Defines the condition of preferably outcomes that can be measured accurately that
interest. This is usually derived from the patients’ chief are important to the patient.
complaint in a clinical situation (in particular or on a larger
population) or is derived from the problem faced in a The PICO format can be used to generate a research question
particular material research. for determining the causation of disease, diagnosis of a

Figure 3: Method used to identify and prioritize research questions

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Krithikadatta: Research methodology for dentist: The essentials

disease or therapy and prognosis of particular condition/ Role of biostatistics


disease. Examples for each are given in Table 2. The Role of Biostatistics is often overlooked and ignored in
the current research work in our speciality. Biological systems
Although the PICO format is best applied to intervention form a dynamic continuum and variation between the units
studies and experimental designs, research questions for forming the biological systems (people, teeth, bacteria, etc.)
all other study designs can also be formulated using this is the norm. On account of this variability within the systems,
approach. it is often difficult to differentiate between groups within
the system. The science of biostatistics helps us to quantify
Role of study designs and evaluate its variability within and between groups that
Both in-vitro and clinical study designs for various make up the biological systems. Statistics is not absolute; it
questions arising from clinical practice or knowledge can is a measure of the probabilities of occurrence of an event.
be determined by applying various sections of the iterative
loop. Depending on the research question, the structure of Biostatistics is less mathematics and more a method of
each study design facilitates the derivation of appropriate determining the relevance of the research findings by
answers. Prior to choosing the study design, there has to application of statistical methods. This retains equal
be a valid research question. The genesis of a research importance in both in-vitro as well as clinical research,
question should primarily focus on answering several because this statistical inference lays a foundation for the
aspects of a broader research interest. For example, if the evidence deduced from any study. Hence the role of the
research interest lies in stem cell research, then the best statistician and the clinical researcher are equivalent in
source of stem cells, ideal growth environment for stem finding answers to any research question. The next part on
cells, potential differentiation of stem cells into tissues, research methodology focuses on understanding biostatics
confluence of growth obtained by different processing for dental research.
methods, clinical application of laboratory-derived
stem cells, storage of stem cells, potential for malignant The research processes both in-vitro and clinical studies can
transformation of stem cells, and so on, form the several be best summarized by the flow chart in Figure 4.
aspects or avenues to generate research questions. The
primary effort in research is not to focus on the research question, CONCLUSION
but to focus on your research interest. on study designs and its
relevance in answering specific research question will be The need for good research is to find the best evidence
dealt with in detail in the subsequent articles of this review for clinical practice, for specific problems, and to address
series on research methodology. methods in reducing the burden of illness on a larger scale.

Table 2: Use of PICO format to generate research questions


Scenario Research idea PICO Research question
Problem Intervention Comparison Outcome
Causation Enterococcus Endodontic failure Enterococcus Fusobacteriumnucleatum Periapical Is Enterococcus fecalis
fecalis in causing fecalis lesion responsible in causing
endodontic failure. periapical lesion in root canal
treated teeth as compared to
Fusobacterium nucleatum?
Diagnositic Estimation of pulp Estimation of Pulse Thermal testing Provide Does pulse oximetry provide
vitality in replanted pulp vitality in oximetry accurate and accurate and reliable
tooth with immature replanted tooth with reliable results results on pulp vitality when
apex. immature apex. on pulp vitality compared to thermal testing
in replanted tooth with
immature apex?
Therapy Reduction of white School children CPP-ACP 2% Sodium Fluoride Reduction in Is CPP-ACP effective in
spot lesions (WSL) suffering from WSL WSL reducing WSL in School
using Casein children suffering from WSL
phosphopeptide- as compared to 2% Sodium
Amorphous Calcium Fluoride?
Phosphate (CPP-
ACP)
Prognosis Single visit Single visit Teeth with Teeth without periapical Successful Is prognosis of endodontic
endodontics endodontics in teeth periapical lesion treatment treatment performed in single
in teeth with with periapical lesion outcome visit affected by the presence
periapical lesion lesion of periapical lesion?
and endodontic
treatment outcome.

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Krithikadatta: Research methodology for dentist: The essentials

of Medicine University of Ottawa, Canada, Prof. Emeritus. Vic


Neufeld, Faculty of Health Sciences, McMaster University, Canada
and Prof. Manjula Datta, Retd Prof & Head of Epidemiology, The
Tamilnadu MGR Medical university for having accepted to review
the manuscript and for their valuable inputs in the preparation of
the same and Chennai Dental Research Foundation, Chennai for
their support.

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ACKNOWLEDGMENT Conserv Dent 2012;15:5-11.

The author would like to thank Prof. Peter Tugwell, Professor Source of Support: Nil, Conflict of Interest: None declared.

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