Introduction

Oral health is an essential component of comprehensive primary care.

The delivery of preventive oral healthcare is consistent with the principles of whole-

person care and should be standard practice within a patient-centered medical home

(PCMH) or advanced primary care practice. The integration of oral health into

primary care is not intended to displace dental care, but rather to expand the

workforce addressing preventive oral health and improve patient health outcomes.1-3

Organized, evidence-based care (OEBC) is care that is based on

scientific evidence and planned and delivered so that the team optimizes the health

of their entire panel of patients.OEBC in a PCMH consists of designing each visit to

meet a patient’s preventive and chronic illness needs, using+ planned interactions,

and ensuring appropriate follow-up care. Evidence-based guidelines are embedded

into daily clinical practice as well as shared with patients and their family/caregiver.

High-risk patients are identified to ensure they are receiving appropriate care

management services.4-6

Scientific evidence is a crucial underpinning of clinical practice.

Nevertheless, the first series of articles aimed at providing clinicians with guidelines

for critically appraising the evidence that informs clinical practices did not appear

until 1981. Ten years later, the term “evidence-based medicine” first appeared in the

medical literature. Subsequently, between 1993 and 2000, a group of evidence-based

medicine enthusiasts published a series of 25 articles that aimed at assisting

clinicians in understanding and applying the medical literature to their clinical

decision making in a clinical setting.7-10

 Introduction

The concept of evidence-based medicine soon expanded to other clinical

areas. The first article to use the term “evidence-based dentistry” (EBD) was

published in 1995 by Richards and Lawrence, and since then other articles have been

published on the topic. However, it should be acknowledged that improvements in

Dental education and practice have taken place over the last 100 years. The

American Dental Association defines EBD as “an approach to oral healthcare 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.”7,8,11,12

There is, however, still no guide easily accessible for practicing dentists

in the United States that addresses the critical appraisal and use of evidence

specifically aimed at clinicians in oral health care fields. A series of articles (Box)

were published in The Journal of the American Dental Association, aimed at

providing an overview of the basic concepts of EBD to assist oral health care

professionals in making use of evidence to inform their clinical decisions.13-16

Evidence-based medicine has existed as a concept for many years,

gaining recognition and respect especially in the past few decades. From its first

appearance in the literature, the term “evidence-based medicine” quickly gained

prominence,2 inspiring reviews and Clinical Practice Guidelines focused on using

available, carefully gathered proof to define recommendations.17,18

These works have defined recommendations for and against medications,

surgical interventions, management practices, and diagnostic testing modalities, and

they have equally focused scientific awareness on areas in which convincing

 Introduction

evidence does not yet exist. Of course, evidence-based medicine is fraught with

challenges, including the burden of proof required to formulate Clinical Practice

Guidelines, the necessarily narrow definitions of success and end points, and the

inability for such combined statements to appropriately reflect individual patient

presentations or outcomes.19-21

Evidence-based guidelines, the studies that support them, and reviews of

these studies are formulated by a variety of stakeholders, including patients,

practicing clinicians, researchers, policy makers, and health care administrators. One

major source of this knowledge, and of support for the synthesis of available data, is

the Cochrane Collaboration. The Cochrane Collaboration employs dedicated staff to

support subject-specific systematic reviews and meta-analyses, and distributes

standards to guide the completion of such studies. Their efforts have helped to spread

evidence based medicine and highlighted its importance for all health care

practitioners. In dental medicine, the importance of evidence-based medicine has

experienced a parallel evolution.22-25

Soon after evidence-based medicine became a recognized term, the

concept of “evidence-based dentistry” likewise started to appear in literature. In the

past 15 years, this term has also become widely used to refer to dental practice

informed by scientific evidence. As they evolve, evidence-based dentistry

recommendations have recently become increasingly specialty-specific and

procedure-specific. As in medicine, evidence must be synthesized and disseminated

in dental medicine to inform a Clinical Practice Guideline. The increase in available

evidence based guidelines has and will continue to refine and improve the worldwide

practice of dentistry.26-28
 Introduction

Oral medicine is “the discipline of dentistry concerned with the oral

health care of medically complex patients, including the diagnosis and primarily

nonsurgical treatment and/or management of medically related conditions affecting

the oral and maxillofacial region.” In each of these areas, evidence-based medicine

has shaped theoretic understanding and clinical practice. The available evidence

allows for improved patient management.29-31

Oral medicine is a subset of dental medicine that has been defined by

various sources. These include the American Academy of Oral Medicine, European

Association of Oral Medicine, and multiple groups of practicing oral medicine

physicians. In the United States, the definition of oral medicine has been proposed as

“the discipline of dentistry concerned with the oral health care of medically complex

patients, including the diagnosis and primarily nonsurgical treatment and/or

management of medically related conditions affecting the oral and maxillofacial

region.” The worldwide training of practitioners in this emerging field also has been

recently defined, suggesting that residency programs focus on competency in the

following:32-34

 Diagnosis and primarily nonsurgical management of oral mucosal and

salivary gland disorders

 Diagnosis and primarily nonsurgical management of temporomandibular,

orofacial pain, and neurosensory disorders

 Management of the medically complex patient.

 Introduction

Oral medicine competency in the United States is in line with the

training of oral medicine practitioners worldwide, although some variation exists

between countries in scope of practice.

Clinical care in oral medicine is available across the United States in

many practice settings, including hospitals, medical/dental schools, and private

practice clinics. As defined by a recent study, patients are referred for oral medicine

evaluation by a wide variety of practitioners, most commonly general dentists.

Referrals also come from specialty physicians, including otorhinolaryngologists,

hematologists, oncologists, radiation oncologists, rheumatologists, and

dermatologists. As a dedicated link between dental and medical care, oral medicine

physicians provide thorough medical and dental evaluations to reach an accurate

diagnosis and recommend appropriate treatment. Broadly speaking, oral medicine

providers are frequently consulted for evaluation, diagnosis, and treatment of oral

lesions, salivary gland diseases, facial pain conditions, and care of medically

complex patients.35,36 

A treatment recommendation in oral medicine depends on the individual

patient presentation, but in many cases consists of medications, behavioural

modifications, and/or oral appliance fabrication. Patients may also be referred for

medical evaluation when an oral cavity finding suggests a systemic disease. For

patients with significant medical comorbidities, the role of the oral medicine

practitioner also includes consulting with other members of the health care team and

advising on the appropriate modifications to dental treatment or timing of

treatment.37,38
 Introduction

The importance of evidence-based practice in oral medicine stems

directly from the theoretic and practical complexity of the field. The wide variety of

conditions encountered in an oral medicine practice, as well as variations in the

individual patient presentation and response to treatment, defines the need for careful

evaluation and synthesis of practice recommendations to provide appropriate and

effective treatment.39,40

The goal of evidence-based dentistry is to assess which is the best

available care for the patient, by taking into account all available high-quality

evidence. A resulting achievement is that both health care practitioner and patient are

reassured that treatment options have been tested in a scientific way, so that they can

more easily trust that specific cure. The more we will move toward broad-based use

of evidence-based dentistry in clinical practice, the more physicians will benefit

through better and standardized clinical guidelines that will help in decision-making

and improve the quality of clinical results.41-43

One of the most important issues in deciding what kind of therapy is

more indicated is to consider the balance between the potential risks and benefits of a

treatment. A framework for evidence-based decision-making includes formulating

the clinical question, retrieving and appraising available evidence, and then

considering whether the evidence can be applied to that single case. It is mandatory

for all health care providers to reduce treatment burden perceived by patients, by

selecting appropriate therapies and explaining possible unavoidable risks.44,45

“What are we to do when the irresistible force of the need to offer

clinical advice meets with the immovable object of flawed evidence? All we can do
 Introduction

is our best: give the advice, but alert the advisees to the flaws in the evidence on

which it is based”.

The ancestor of this set of pages was created by Dave Sackett and

colleagues who generated "levels of evidence" for ranking the validity of evidence

about the value of preventive manoeuvres, and then tied them as "grades of

recommendations".46,47

Evidence-based practice has been defined as the practice of dentistry that

integrates the best available evidences with clinical experience and what a patient

prefer in making clinical decisions. To do it successfully, certain skills need to be

obliviously acquired, being the intention of evidence-based dentistry the providing

better information for the clinician, improved treatment for the patient, and

consequently an increased standing of the profession.46,48

The use of evidence-based oral medicine may help in the reducing the

variations of patient care and outcomes that appears to be associated with four

factors: 1. the quality of science underlying clinical care, 2. the quality in making

clinical decisions, 3. The variations of the level of clinical skill, 4. the large and

increasing volume of literature.

Evidence-based practice (EBP) is said to be the current best approach to

provide interventions that are scientific, safe, efficient and cost effective. The

reasons for this are assumed to be through improvements in physicians’ and dentists’

skills and knowledge, as well as in the communication between patients and their

physicians about the rationale behind clinical recommendations made. While studies

have attempted to assess the levels of awareness and implementation of EBOM

 Introduction

amongst various groups of clinicians in different settings, it is not possible to

generalize the results to all clinicians.27,49

Evidence is based on the existence of at least one well-conducted

randomized control trial (RCT). When asked about evidence-based practice, general

dentists have a problem with the words themselves. The word “base” conjures an

image of fundamental change. It implies a change in an essential entity, a foundation,

something the practitioner cannot do without. The word “evidence” also causes a

problem, because it has not been part of the vocabulary of clinical practice. It may

conjure fear, because it relates to legal and regulatory matters. Evidence is what

lawyers bring before a judge and jury in the pursuit of truth and justice.50

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