Attitudes, awareness, and barriers toward ... - Semantic Scholar

ORIGINAL ARTICLE

Attitudes, awareness, and barriers toward evidence-based practice in orthodontics Asha Madhavji,a Eustaquio A. Araujo,b Ki Beom Kim,c and Peter H. Buschangd St Louis, Mo, and Dallas, Tex

Introduction: The purpose of this study was to evaluate the attitudes, awareness, and barriers toward evidencebased practice. Methods: A survey consisting of 35 questions pertaining to the use of scientific evidence in orthodontics was sent to 4771 members of the American Association of Orthodontists in the United States. Each respondent’s age, attainment of a master’s degree, and whether he or she was currently involved with teaching were ascertained. To minimize bias, the survey questions were phrased as an examination of the use of scientific literature in orthodontics. Results: A total of 1517 surveys were received (response rate, 32%). Most respondents had positive attitudes toward, but a poor understanding of, evidence-based practice. The major barrier identified was ambiguous and conflicting research. Younger orthodontists were more aware, had a greater understanding, and perceived more barriers than did older orthodontists. Orthodontists involved in teaching were more aware, had a greater understanding, and reported fewer barriers than those not involved with teaching. Those with master’s degrees had a greater understanding of evidence-based practice than those without degrees. Conclusions: Educational initiatives are needed to increase the understanding and use of evidence-based practice in orthodontics. (Am J Orthod Dentofacial Orthop 2011;140:309-16)

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vidence-based practice is an approach that emphasizes finding and using the best current research evidence to help make health-care decisions.1 The goal of evidence-based practice is to give patients up-to-date treatment that research has shown to be safe, effective, and efficient. Ultimately, the goal of evidence-based practice is to continuously improve patient care based on new research developments.2 Evidence-based practice is well established in medicine. The Institute of Medicine has designated evidencebased practice as a key feature of high-quality medicine.3 There is a wealth of information regarding evidence-based medicine, including evidence-based medical journals, evidence-based summaries, and evidence-based practice guidelines.4 The Agency for Healthcare Research has 12 a

Private practice, St Louis, Mo. Professor and assistant program director, Department of Orthodontics, Center for Advanced Dental Education, Saint Louis University, St Louis, Mo. c Assistant professor, Department of Orthodontics, Center for Advanced Dental Education, Saint Louis University, St Louis, Mo. d Professor and director of orthodontic research, Department of Orthodontics, Baylor College of Dentistry, Texas A&M University Health Science Center, Dallas. The authors report no commercial, proprietary, or financial interest in the products or companies described in this article. Reprint requests to: Peter H. Buschang, Department of Orthodontics, Baylor College of Dentistry, Texas A&M University Health Science Center, 3302 Gaston Ave, Dallas, TX 75246; e-mail, [email protected]. Submitted, January 2010; revised and accepted, May 2010. 0889-5406/$36.00 Copyright Ó 2011 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2010.05.023 b

evidence-based practice centers located in universities in the United States and Canada that conduct evidencebased medical research.5 In dentistry, evidence-based practice is less developed but is quickly gaining momentum. The American Dental Association has made a concerted effort to incorporate evidence-based practice into the dental field in the United States; its Web site has an entire section devoted to evidence-based dentistry.6 The Web site is an important resource that contains a comprehensive collection of systematic reviews in all areas of dentistry. Dental schools are introducing evidence-based courses into their curriculums, journals have focused on evidence-based dentistry, 2 centers for evidence-based dentistry have been established, and the Cochrane Collaboration (http://www.cochrane.org) has included an oral-health database.7 In orthodontics, evidencebased practice is still in its infancy. Studies on evidence-based practice in medicine have found that most doctors welcome evidence-based practice and believe that it improves patient care.8-11 Barriers to evidence-based practice include lack of time, overwhelming amount of literature, and difficulties incorporating evidence into practice. Physicians thought that the best way to increase evidence-based practice was by using evidence-based guidelines developed by colleagues. Dentists have also expressed positive attitudes and awareness of evidence-based practice.12,13 However, their understanding of evidence-based concepts was poor. The major barriers dentists reported 309

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were lack of time, lack of knowledge about evidencebased practice, and financial constraints.12,13 Dentists believed that the development of practical guidelines, journal clubs, and peer-review sessions would help increase evidence-based practice in dentistry.12-14 There is currently no information about the attitudes and awareness, perceptions, and barriers to evidence-based practice in orthodontics. The purpose of this study was to determine the attitudes and awareness of evidence-based practice in orthodontics. The term evidence-based practice was purposefully not used during data collection. To determine the initiatives that might be needed, barriers to using scientific evidence were also examined. We hoped that this study would identify obstacles and solutions to incorporating scientific literature into orthodontic practice.

Statistical analysis

MATERIAL AND METHODS

A survey was designed to examine the perceptions of orthodontists toward evidence-based practice in orthodontics. To minimize bias among participants, the term evidence-based practice was not used in the survey. Instead, the questions were phrased as inquiries regarding the use of scientific literature in orthodontics. Each participant was asked to respond to a set of demographic questions, followed by a set of questions pertaining to scientific literature in clinical orthodontics. Most survey questions were derived from similar studies conducted in the medical field.8-10,13,15,16 The questions were divided into 5 categories: attitudes, awareness and current practices, barriers, understanding of terms, and statements to evaluate the participants’ awareness of the literature regarding major orthodontic controversies and sources for guiding clinical practice. Institutional review board approval was granted before starting the research project. The respondent sample was grouped according to age, whether they were currently involved in teaching at a university, and whether they had attained a master’s degree. The age grouping included those 40 years of age or younger, those between 41 and 60 years, and those 61 years of age and older. A pilot survey consisting of 45 questions was administered to 7 faculty orthodontists at the Saint Louis University Center for Advanced Dental Education. The survey was discussed with each orthodontist to ensure that the questions were unambiguous and valid. The survey questions were modified and improved based on their feedback. Reliability was assessed by administering the survey to 20 orthodontic residents on 2 separate occasions, 2 weeks apart. The reliability analysis was used to identify and eliminate problematic questions. The final survey

September 2011 Vol 140 Issue 3

(Appendix) consisted of 35 questions, including 6 pertaining to attitudes, awareness, and current practices; 10 pertaining to barriers; 10 pertaining to the understanding of terms; 7 statements on orthodontic issues; and 2 questions on solving clinical problems. The final version of the survey was submitted to and approved by the Board of Directors of the American Association of Orthodontists (AAO). The board agreed to send the survey to all orthodontists and residents in the United States with valid e-mail addresses. To maintain the anonymity and privacy of the respondents, the AAO forwarded the link by e-mail. A reminder e-mail was sent a week later. Results of the survey were recorded and maintained anonymously on the Survey Monkey server (Surveymonkey.com; Portland, Ore).

The survey data were analyzed by using SPSS software (version 14.0, SPSS, Chicago, Ill). Nonparametric statistics were used to evaluate group differences because the response variables were ordinal. The MannWhitney U test was used to test for differences between the dichotomous groupings, and the Kruskal-Wallis H test was used to compare the 3 age groups. The sources for guiding clinical practice were nominal and evaluated with chi-square tests. A P value of\0.05 was considered significant. RESULTS

The survey was sent to 8455 orthodontists, it was opened by 4771, and 1517 participated in the study. The response rate was 32%. The modal age group of the sample was 41 to 60 years, there were 79% men and 21% women, and the modal number of years in practice group was 16 to 20 years (Table I). Twentyeight percent of the respondents were involved in teaching; 59% of the respondents had master’s degrees. Attitudes, awareness, and current practices

The orthodontists were generally positive toward the incorporation of scientific evidence into their practices (Table II). Most agreed that research influenced their daily work (80%) and that peer-reviewed journals are the best source of evidence (82%). The majority also expressed interest in more clinical guidelines (75%) and indicated that they read scientific journals at least monthly (91%). The majority of respondents were completely unaware of the Cochrane database (55%), and only a slight majority of respondents had used PubMed during the past year (52%). Those 40 years of age or younger were significantly (P \0.05) more likely to be interested in guidelines,

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Table I. Comparison of our sample with the 2008 sur-

vey of orthodontists in the United States and orthodontic demographics from the AAO in a personal communication

Age (y) Men (%) Women (%) Time in practice (y) Masters degree (%)

This study 41–50 (modal value) 79 21 16–20 (modal value) 59

Survey of Keim et al22 52 (median value) 85 15 21 (median value) NA

AAO, April 2010 57 80 20 24 51

NA, Not applicable.

were more aware of Cochrane, and had used PubMed in the past year to a greater extent than those over 40 years of age. Those 61 years of age and older were significantly more likely to report reading journals than their younger colleagues. Orthodontists involved in teaching were significantly more likely than their nonteaching colleagues to have positive attitudes, awareness, and current practice toward the use of scientific literature in clinical practice. Orthodontists with master’s degrees reported that research influenced their daily work significantly more frequently than those without master’s degrees. Barriers

A large proportion, although not a majority of respondents, thought that the practical demands of work (46%) and insufficient clinical guidelines (44%) were barriers to using scientific evidence in clinical practice (Table III). Most respondents indicated that the literature is ambiguous and conflicting (59%). Those who were less than 40 years of age cited practical demands of work, insufficient clinical guidelines, and ambiguous literature as barriers more often than did their older colleagues. Those between 41 and 60 years of age were significantly more likely to cite the practical demands of work as a barrier than those 61 years and older. Conversely, those 40 years or younger were significantly more likely than their older colleagues to express comfort with their skills to perform a literature review and were more likely to have access to research papers. Orthodontists involved in teaching felt more comfortable with their skills to perform a literature review than did those not involved in teaching. They were also more likely to have access to research papers, and stated that the research is ambiguous and conflicting more often than those not involved in teaching. Orthodontists with a master’s degree were more likely

to be satisfied with their current knowledge than those without degrees. Understanding of terms

Less than a third of the orthodontists understood or could explain the meaning of meta-analysis, odds ratio, sample power, confidence interval, and specificity (Table IV). Only 6% of the respondents understood and could explain the meaning of PICO. However, the vast majority (87%) of respondents had some understanding and wanted to learn more about these terms. Practitioners aged 40 years or less were significantly more likely than their older colleagues to understand all of the evidence-based terms (Table V). Those between 41 and 60 years of age were significantly more likely to understand blinding and confidence interval than those 61 years and older. Orthodontists currently involved in teaching were significantly more likely than those not involved in teaching to understand all terms. Those with a master’s degree were significantly more likely to understand all terms than those without a master’s degree. Statements regarding orthodontic issues

Most respondents (.75%) were consistent with the best, current evidence regarding statements about orthodontic issues (Table VI). Those less than 61 years of age were significantly (P \0.05) more likely than their older counterparts to agree with the current best evidence with regard to the statement “2-phase treatment of Class II Division 1 malocclusion is more efficient than 1-phase treatment in the permanent dentition.” Those less than 40 years of age were significantly (P \0.05) more likely than their older colleagues to agree with the current best evidence with respect to the statement “third molars cause incisor crowding.” Orthodontists currently involved in teaching were significantly more likely to agree with the current best evidence on 4 of the 7 statements than those not involved in teaching. Those with a master’s degree were significantly more likely to agree with the current best evidence on the appropriate timing of a frenectomy than those without degrees. Primary reason for changing practice philosophy

Regardless of their involvement with teaching, number of years in practice, or whether they had a master’s degree, orthodontists were most likely to change their practice philosophy based on “expert advice” (Table VII). Expert advice was followed most closely by clinical journals. Compared with younger orthodontists, those over 40 years of age were more likely to choose “clinical journals” than “colleague advice.” Orthodontists involved in



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Table II. Percentages of respondents and differences related to age groups (group 1, \40 years; group 2, 41–60 years; group 3, $61 years), involvement in teaching (yes or no), and having a master’s degree (yes or no) for questions pertaining to attitudes, awareness, and current practices Percentages of respondents

Research influences daily work Journals are the best source of evidence Interested in more guidelines

Frequency of reading journals

Awareness of Cochrane

Strongly disagree or disagree 5% 3%

Neutral 15% 15%

Agree or strongly agree 80% 82%

6%

19%

75%

Daily 5%

Unaware 55%

Used Pub/Med in past year

Group differences

Weekly 33%

Monthly 53%

Some awareness 20%

No 47%

Yes 52%

Age NS (P 5 0.130) NS (P 5 0.496)

Involved in teaching Yes .no (P \0.001) Yes .no (P \0.001)

Master’s degree Yes .no (P \0.013) Yes .no (P \0.001)

1 .2 5 3 (P \0.001)

NS (P 5 0.110)

NS (P 5 0.385)

Rarely 9%

3 .1 5 3 (P \0.022)

Yes .no (P \0.001)

NS (P 5 0.960)

Fully aware 25%

1 .2 5 3 (P \0.001)

Yes .no (P \0.001)

NS (P 5 0.095)

Uncertain 1%

1 .2 5 3 (P \0.001)

Yes .no (P \0.001)

NS (P 5 0.552)

NS, Not significant; ., more likely to agree with the statement in the question.

Table III. Percentages of respondents and differences related to age groups (group 1, \40 years; group 2, 41–60 years; group 3, $61 years), involvement in teaching (yes or no), and having a master’s degree (yes or no) for questions pertaining to barriers Percentages of respondents Strongly Agree disagree or or strongly disagree Neutral agree Practical demands of work 34% 20% 46% Insufficient clinical guidelines 21% 35% 44% Literature is ambiguous/conflicting 15% 26% 59% Satisfied with current knowledge 45% 25% 30% Skills to undertake a literature review Comfortable performing a literature review I have access to published research papers

No access to the Internet Access to the Internet at home Access to the Internet at work

No 87% 9% 3%

No 6% 16% 5%

Yes 79% 67% 85%

Uncertain 15% 17% 10%

Yes 13% 91% 97%

Group differences

Age 1 .2 .3 (P \0.001) 1 .2 5 3 (P \0.001) 1 .2 5 3 (P \0.001) NS (P 5 0.300)

Involved in teaching No .yes (P \0.001) NS (P 5 0.436) Yes .no (P \0.019) No .yes (P 5 0.006)

1 .2 5 3 (P \0.001) 1.2 5 3 (P \0.001) 1 .2 5 3 (P \0.016) NS (P 5 0.317) NS (P 5 0.999) NS (P 5 0.922)

Master’s degree NS (P 5 0.228) NS (P 5 0.419) NS (P 5 0.105) Yes .no (P 5 0.009)

Yes .no (P \0.001) Yes .no (P \0.001) Yes .no (P \0.001) NS (P 5 0.924) NS (P 5 0.999) NS (P 5 0.139)

NS (P 5 0.194) NS (P 5 0.160) NS (P 5 0.719) NS (P 5 0.742) NS (P 5 0.999) NS (P 5 0.670)

NS, Not significant; ., more likely to agree with the statement in the question.

teaching were more likely to select “literature reviews” and less likely to select “colleague advice” than those not involved in teaching. Those without a master’s degree were more likely to select “colleague advice” than those with a master’s degree.

Orthodontists aged 40 years or younger and those involved with teaching were more likely to consult colleagues and least likely to proceed using their best judgment. Having a master’s degree had no effect on the approach used to manage clinical uncertainties.

Dealing with clinical uncertainties

DISCUSSION

When faced with clinical uncertainties, orthodontists most often consulted colleagues and least often referred the patient to another orthodontist (Table VIII).

The response rate in this study was 32%; this is lower than evidence-based surveys conducted in other fields.9,10,15-17 The studies in medicine attributed their



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Table IV. Percentages of respondents for questions pertaining to terms used in the scientific literature Understand and could explain it to others 52% 50% 32% 75% 49% 21% 31% 31% 30% 6%

Blinding Systematic review Meta-analysis RCT Strength of evidence Odds ratio Sample power Confidence interval Specificity PICO questions

Some understanding 28% 43% 36% 23% 43% 40% 40% 39% 44% 15%

Don’t understand but would like to 16% 5% 24% 1% 7% 32% 24% 24% 21% 66%

Don’t understand and don’t want to 4% 2% 8% 1% 1% 7% 6% 6% 5% 13%

RCT, Randomized controlled trial.

Table V. Differences in the understanding of terms related to age groups (group 1, \40 years; group 2, 41–60 years;

group 3, $61 years), involvement in teaching (yes or no), and having a master’s degree (yes or no) Age

Blinding Systematic review Meta-analysis RCT Strength of evidence Odds ratio Sample power Confidence interval Specificity PICO questions

1 .2 .3 1 .2 5 3 1 .2 5 3 1 .2 5 3 1 .2 5 3 1 .2 5 3 1 .2 5 3 1 .2 .3 1 .2 5 3 1 .2 5 3

(P \0.001) (P \0.001) (P \0.001) (P \0.001) (P \0.001) (P \0.001) (P \0.001) (P \0.001) (P \0.001) (P 5 0.022)

Involved in teaching Yes .no (P \0.001) Yes .no (P \0.001) Yes .no (P \0.001) Yes .no (P \0.001) Yes .no (P \0.001) Yes .no (P \0.001) Yes .no (P \0.001) Yes .no (P \0.001) Yes .no (P \0.001) Yes .no (P \0.001)

Master’s degree Yes .no (P 5 0.037) Yes .no (P \0.001) Yes .no (P 5 0.018) Yes .no (P \0.001) Yes .no (P \0.001) Yes .no (P \0.001) Yes .no (P \0.001) Yes .no (P \0.001) Yes .no (P \0.001) Yes .no (P 5 0.036)

NS, Not significant; RCT, randomized controlled trial; ., more likely to agree with the statement in the question.

high response rates to short, concise surveys, anonymity, the support of professional leaders, and professional membership.9,15,17 Because this was the first survey of its kind in orthodontics, it was designed to be comprehensive and therefore longer. This study also involved a much larger overall number of respondents (n 5 1517) than other studies; anonymity and AAO support were used to maximize the response rate. The response rate in this survey fell within the 10% to 58% range reported for other surveys conducted in orthodontics.18-20 It has also been suggested that the response rate among health-care professionals is decreasing.21 Importantly, the composition of our sample closely matched the 2008 survey sample of Keim et al22 and, especially, current orthodontic demographics reported by the AAO (Table I). This supports the notion that our sample represented the orthodontic population as a whole. Most respondents had positive attitudes toward scientific evidence in clinical practice and reported current practices that were encouraging. However, the majority of respondents’ lack of awareness of Cochrane highlights an important resource that needs more exposure among orthodontists. This agreed with studies in general

dentistry, which also found that most respondents were unaware of Cochrane.13,16 Cochrane provides systematic reviews pertaining to all aspects of health care and is therefore an important source of the best current literature.13,16 Moreover, most respondents reported only partial or no understanding of 6 of the 10 terms used in the scientific literature. A survey conducted in 1998 also showed that most physicians reported only some or no understanding of evidence-based terms.9 Failure to understand these terms could hinder interpretation of evidence, a vital aspect the evidence-based approach.9 Without a clear understanding of the basic terminology, it is unlikely that evidence-based concepts can be accurately incorporated into clinical practice. For example, PICO was well understood by only 6% of the respondents, even though it is a major underpinning of evidence-based research. PICO is an acronym for the process of specifying a scientific question based on the problem (P), intervention (I), comparison (C), and outcome (O). It forms the basis of the evidence-based protocol. Nonetheless, it was encouraging that most orthodontists reported either some understanding of or



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Table VI. Percentages of respondents and differences related to age groups (group 1, \40 years; group 2, 41–60

years; group 3, $61 years), involvement in teaching (yes or no), and having a master’s degree (yes or no) for questions pertaining to major orthodontic controversies

2-phase tx more efficient than 1-phase tx Occlusion causes TMD Third molars cause incisor crowding Frenectomy performed before tx Premolar extraction smiles are less esthetic Extraction tx causes TMD Casts should be mounted for diagnosis

Strongly agree or agree 12%

Neutral 11%

Disagree or strongly disagree 77%

Age 3 .2 5 1 (P 5 0.027)

Involved in teaching NS (P 5 0.206)

Master’s degree NS (P 5 0.314)

10% 4%

8% 10%

82% 86%

NS (P 5 0.117) 3 5 2 .1 (P \0.001)

No .yes (P 5 0.001) NS (P 5 0.243)

NS (P 5 0.336) NS (P 5 0.051)

3%

5%

92%

NS (P 5 0.088)

NS (P 5 0.208)

No .yes (P 5 0.030)

9%

10%

81%

NS (P 5 0.219)

No .yes (P 5 0.001)

NS (P 5 0.645)

1% 7%

2% 10%

97% 83%

NS (P 5 0.273) NS (P 5 0.201)

No .yes (P 5 0.022) No .yes (P 5 0.013)

NS (P 5 0.483) NS (P 5 0.482)

NS, Not significant; tx, treatment; TMD, temporomandibular disorders; ., more likely to agree with the statement in the question.

Table VII. Percentage of respondents to the statement “I change my practice philosophy primarily based on” related to age groups, involvement in teaching, and having a master’s degree Age* (P \0.001) Colleague advice Expert advice Clinical journals Literature reviews Other Total

#40 y 24% 32% 15% 18% 11% 100%

41–60 y 12% 35% 26% 13% 14% 100%

Involved in teaching* (P \0.001) $61 y 9% 36% 29% 11% 15% 100%

No 17% 36% 22% 12% 13% 100%

Yes 10% 29% 25% 22% 14% 100%

Master’s degree* (P 5 0.033) No 18% 36% 21% 14% 11% 100%

Yes 14% 33% 23% 15% 15% 100%

*P \0.05.

expressed a desire to learn about these terms. This suggests that evidence-based learning initiatives would be useful and welcome. The responses to statements on orthodontic issues were encouraging because they were in accordance with the current best evidence. The majority of orthodontists agreed with the evidence-based stance on the issues examined. This suggests that most orthodontists have some understanding of the current best evidence on major topics of interest in orthodontics. Most of the issues examined are topics that are commonly discussed at major conferences such as the AAO annual conference and other orthodontic society meetings. This might help explain why most respondents were aware of the best current evidence even though they are not necessarily practicing with an evidence-based approach. Furthermore, since most of these topics have been issues that have been around for many years, it is not surprising that respondents could have had exposure to them without making a concerted effort to selfresearch the literature.


Identifying the barriers is an important step toward increasing evidence-based practice in orthodontics. For orthodontists, barriers include the ambiguous and conflicting nature of the literature, demands of work, and insufficient clinical guidelines. General dental practitioners, as well as nurses and physicians, also have reported uncertainty created by conflicting research results as the most frequently reported barrier.8,15 Literature that is ambiguous or conflicting makes it difficult for practitioners to identify the most accurate answer to a clinical question. This might be the impetus for desiring more clinical guidelines. Systematic reviews have the potential to clarify uncertainty pertaining to conflicting results and are an important tool in the evidence-based approach.13,15 Systematic reviews follow explicit, documented protocols to reduce bias and aim to provide an objective and thorough review of the literature.13,23 Because of the demands of clinical practice, orthodontists reported being too overburdened to sort through conflicting literature. Studies in medicine and


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Table VIII. Percentages of respondents to the statement “when faced with clinical uncertainties, I usually” related to age groups, involvement in teaching, and having a master’s degree Involved in teaching* (P 5 0.015)

Age* (P \0.001) Consult colleagues Consult textbooks Consult the literature Proceed using my best judgment Refer Total

#40 y 63% 5% 21% 11% 0% 100%

41–60 y 41% 2% 28% 29% \1% 100%

$61 y 47% 2% 26% 25% \1% 100%

No 49% 4% 23% 24% \1% 100%

Yes 52% 3% 29% 16% 0% 100%

Master’s degree (P 5 0.275) No 52% 4% 23% 21% \1% 100%

Yes 49% 3% 26% 22% 0% 100%

*P \0.05.

dentistry have previously shown that clinicians do not have the time or inclination to appraise the research evidence themselves.9,10,13,16 This suggests that research evidence needs to be presented in formats that are easier for orthodontists to appraise and understand.13 The introduction of guidelines and protocols developed by peers skilled in the evidence-based process might help to overcome many of the barriers cited.9,15 Younger orthodontists were more interested in and aware of evidence in practice and understood the terms examined better than did their older colleagues. However, those aged 40 years or less also reported more barriers than their older colleagues, suggesting that they more fully understood the requirements of this approach. Those aged 40 years or less were more likely to agree with the evidence-based stance on orthodontic issues examined than their older colleagues. The recent introduction of evidence-based courses to the curriculum and the shorter time span since finishing formal education might explain why the younger respondents are more in touch with the evidence than their older colleagues. Orthodontists currently involved in teaching had more positive attitudes toward evidence in practice and greater awareness of evidence in practice, and reported current practices that were more consistent with the evidence. Those involved in teaching also perceived fewer barriers and were less likely to report the demands of work as a barrier, perhaps because research is often emphasized in teaching institutions. Teachers also reported greater understanding of the terms examined and were more likely to adopt an evidence-based stance on the orthodontic issues examined. Furthermore, their increased access to papers and increased skills of assessing research perhaps led them to be more skeptical of the current literature. As expected, it appears that those involved with a teaching institution are more likely to be in touch with the current best evidence. Overall, there were few significant differences between those with and those without a master’s degree.

However, those with a master’s degree were more likely to report that research had a greater influence on their practice, and they had a greater understanding of the terms examined. Because a master’s degree requires a hands-on approach to research, it might be expected that those with a master’s degree have a solid understanding of the scientific method involved in conducting research. The most frequently selected reason for changing a practice philosophy was expert advice; this is inconsistent with evidence-based practice. Although experts generally have much experience, they can be biased. Without considering other sources of less biased information as well, practitioners risk changing their practice philosophy on erroneous and unsubstantiated information.24 This might lead to less efficient treatment, increased costs of treatment, or unnecessary inconvenience to the patient. The majority of orthodontists responded that they would consult colleagues when faced with clinical uncertainties. This is consistent with general dental practitioners, who tend to select friends and colleagues as the primary source of advice when facing clinical uncertainties.13,16 Whereas colleagues are a quick, inexpensive, and convenient source of advice, they can have biases and conflicts of interest.16,24 Furthermore, colleagues’ advice might reflect experience within their practices rather than best practices.13 Ideally, clinicians should consult electronic databases, such as PubMed and Cochrane, and seek evidence from systematic reviews or meta-analyses of randomized control trials when possible to identify the best current evidence that can help guide decision making.13 However, these sources are not always as accessible as colleagues and might not cover the relevant topic of interest.16 We hope that, with time and increased attention to these resources, more areas of clinical uncertainty will be addressed. When systematic reviews are not available, the hierarchy of evidence



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will help to identify the best level of appropriate evidence that should be considered. This study was not without limitations. Conducting a survey that requires self-completion of a questionnaire is not the most accurate method of gathering the perceptions of health-care professionals on a complex subject.10,25 Furthermore, it has been shown that respondents’ verbal explanations of terms can differ from written responses. However, it would have been difficult to gather information from such a large number of people with a method other than a survey. It was also possible that there are inconsistencies between the respondents’ true vs reported attitudes, awareness, current practices, and understanding of terms. Another problem was that respondents might have tried to make a good impression rather than declaring their true views on the subject, even though the surveys were anonymous. Although it is possible that the sample did not represent the orthodontic population as a whole, it closely matches current orthodontic demographics in terms of age, sex, years in practice, and percentages with master’s degrees (Table I). Nevertheless, those who were not in support of using evidence in clinical practice could have chosen not to participate in the survey. If this were true, the results might have been skewed toward a more positive outlook on the use of evidence in clinical practice than was actually the case. Lastly, due to the immense breadth of evidence-based practice in orthodontics, it was not possible to explore all areas of this comprehensive subject. Further exploration is warranted, especially to identify solutions to increase the use of literature in scientific practice. CONCLUSIONS

Orthodontists expressed awareness and positive attitudes toward evidence-based practice. However, awareness of the Cochrane database was low, and understanding of evidence-based practice terminology was poor. Most respondents currently seek advice from colleagues when faced with clinical uncertainties, and expert advice was the most frequently selected reason for changing a practice philosophy. Conflicting and ambiguous literature, lack of clinical guidelines, and practical demands of work were the major barriers identified in this study. Because of the interest orthodontists have expressed in evidence-based practice, it appears to be an optimal time to initiate educational programs that will enhance their knowledge, understanding, and use of it in orthodontics.


REFERENCES 1. Sackett D, Rosenberg W, Gray J, Haynes R, Richardson W. Evidence based medicine: what it is and what it isn’t. Br Med J 1996;312:71-2. 2. Rinchuse D, Kandasamy S, Ackerman M. Deconstructing evidence in orthodontics: making sense of systematic reviews, randomized clinical trials, and meta-analyses. World J Orthod 2008;9:167-76. 3. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academy Press; 2001. 4. White B. Making evidence-based medicine doable in everyday practice. Fam Pract Manage 2004;11:51-8. 5. Agency of Healthcare Research. Evidence-based practice centers; 2009. 6. American Dental Association. Systematic reviews and summaries. Center for Evidence-Based Dentistry; 2009. 7. Rabb-Waytowich D. Evidence-based dentistry: part 1. An overview. J Can Dent Assoc 2009;75:27-8. 8. De Smedt A, Buyl R, Nyssen M. Evidence-based practice in primary health care. Stud Health Tech Inform 2006;124:651-6. 9. McColl A, Smith H, White P, Field J. General practitioners’ perceptions of the route to evidence based medicine: a questionnaire survey. Br Med J 1998;316:361-5. 10. O’Donnell CA. Attitudes and knowledge of primary care professionals towards evidence-based practice: a postal survey. J Eval Clin Pract 2004;10:197-205. 11. Coleman P, Nicholl J. Influence of evidence-based guidance on health policy and clinical practice in England. Br Med J 2001;10:229-37. 12. Rabe P, Holmen A, Sj€ ogren P. Attitudes, awareness and perceptions on evidence based dentistry and scientific publications among dental professionals in the county of Halland, Sweden: a questionnaire survey. Swed Dent J 2007;31:113-20. 13. Yusof Z, Han L, San P, Ramli A. Evidence-based practice among a group of Malaysian dental practitioners. J Dent Educ 2008;72:1333-42. 14. Allison P, Bedos C. Canadian dentists’ view of the utility and accessibility of dental research. J Dent Educ 2003;67:533-41. 15. McKenna H, Ashton S, Keeney S. Barriers to evidence-based practice in primary care. J Adv Nurs 2004;45:178-89. 16. Iqbal A, Glenny A. General dental practitioners’ knowledge of and attitudes towards evidence based practice. Br Dent J 2002;193:587-91. 17. Heywood A, Mudge P, Ring I, Sanson-Fisher R. Reducing systematic bias in studies of general practitioners: the use of a medical peer in the recruitment of general practitioners in research. Fam Pract 1995;12:227-31. 18. Gentry S. Extraction decision-making in Class I malocclusions: a survey identifying values for definite extraction and non-extraction therapy [thesis]. St. Louis, MO: Saint Louis University; 2009. 19. O’Connor B. Contemporary trends in orthodontic practice: a national survey. Am J Orthod Dentofacial Orthop 1993;103:163-70. 20. Yang E, Kiyak H. Orthodontic treatment timing: a survey of orthodontists. Am J Orthod Dentofacial Orthop 1998;113:96-103. 21. McAvoy B, Kaner E. General practice postal surveys: a questionnaire too far? Br Med J 1996;313:732-4. 22. Keim RG, Gottlieb EL, Nelson AH, Vogels DS 3rd. 2008 JCO study of orthodontic diagnosis and treatment procedures, part 1: results and trends. J Clin Orthod 2008;42:625-40. 23. Mulrow C. Systematic reviews: rationale for systematic reviews. Br Med J 1994;309:597-9. 24. Slawson D, Shaughnessy A. Obtaining useful information from expert based sources. Br Med J 1997;314:947-9. 25. Young J, Ward J. Evidence-based medicine in general practice: beliefs and barriers among Australian GPs. J Eval Clin Pract 2001;7:201-10.


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Appendix. Survey questions pertaining to attitudes, awareness, and current practices, abbreviated questions, and answer choices with assigned numeric values used for data analysis

Question Research influences my daily work.

Abbreviation Research influences daily work Journals are the best source of evidence

Peer-reviewed journals provide the best current evidence for me to incorporate into my practice. I would be interested in more Interested in more clinical practice guidelines guidelines that help guide treatment decision making. I read scientific peer-reviewed journals. Frequency of reading journals Please evaluate your awareness Awareness of of the Cochrane Collaboration. Cochrane I have used PubMed/Medline in the past year to answer a clinical question. The practical demands of work make it difficult for me to keep up to date with current best evidence relating to practice. There are not enough clinical practice guidelines in the literature. The literature is often conflicting and ambiguous. I am satisfied with my current knowledge and practice and feel it is sufficient.

Strongly agree (2) Agree (1)

Neutral (0)

Disagree ( 1) Strongly disagree ( 2)

Daily (4)

Weekly (3)

Monthly (2)

Rarely (1)

Fully aware (2)

Aware of Not aware ( 1) only by name (1) No ( 1) Uncertain (0)

Not at all (0)

Used Pub/Med in past year

Yes (1)

Practical demands of work

Strongly agree (2) Agree (1)

Neutral (0)


Insufficient Strongly agree (2) Agree (1) clinical guidelines

Neutral (0)


Literature is Strongly agree (2) Agree (1) ambiguous/ conflicting Strongly agree (2) Agree (1) Satisfied with current knowledge

Neutral (0)


Neutral (0)


Question I have the skills to undertake a comprehensive literature review. I feel comfortable performing a comprehensive literature review. I can obtain copies of published research papers relating to my clinical practice. I have no access to the Internet. I have access to the Internet at home. I have access to the Internet at work.

Question Blinding

Answer choices (assigned numeric value in parentheses) Strongly agree (2) Agree (1) Neutral (0) Disagree ( 1) Strongly disagree ( 2) Strongly agree (2) Agree (1) Neutral (0) Disagree ( 1) Strongly disagree ( 2)

Abbreviation Blinding

Abbreviation Skills to undertake a literature review Comfortable performing a literature review I have access to published research papers No access to the Internet Access to the Internet at home Access to the Internet at work

Understand and could explain it to others (2)

Yes (1)

Answer choices (assigned numeric value in parentheses) No ( 1)

Yes (1)

No ( 1)

Uncertain (0)

Yes (1)

No ( 1)

Uncertain (0)

Yes (1)

No (0)

Yes (1)

No (0)

Yes (1)

No (0)

Answer choices (assigned numeric value in parentheses) Some Don’t understand understanding (1) but would like to ( 1)


Uncertain (0)

Don’t understand and don’t want to ( 2)


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Appendix. Continued

Question Systematic review

Abbreviation Systematic review

Meta-analysis

Meta-analysis

RCT

RCT

Strength of evidence

Strength of evidence

Odds ratio

Odds ratio

Sample power

Sample power

Confidence interval

Confidence interval

Specificity

Specificity

PICO questions

PICO questions

Question Two-phase treatment of Class II Division 1 malocclusion is more efficient than 1-phase treatment in the permanent dentition. Occlusion is a primary etiologic factor in TMD. Third molar eruption causes mandibular incisor crowding. A frenectomy should be performed before orthodontic treatment. Premolar extraction smiles are rated significantly less esthetic than nonextraction smiles. Extraction treatment causes TMD. All casts should be mounted to improve diagnosis and treatment. I change my practice philosophy based primarily on: When faced with clinical uncertainties, I usually:

Understand and could explain it to others (2) Understand and could explain it to others (2) Understand and could explain it to others (2) Understand and could explain it to others (2) Understand and could explain it to others (2) Understand and could explain it to others (2) Understand and could explain it to others (2) Understand and could explain it to others (2) Understand and could explain it to others (2)

Abbreviation 2-phase tx more efficient than 1-phase tx

Answer choices (assigned numeric value in parentheses) Some understanding (1) Don’t understand but would like to ( 1) Some understanding (1) Don’t understand but would like to ( 1) Some understanding (1) Don’t understand but would like to ( 1) Some Don’t understand understanding (1) but would like to ( 1) Some Don’t understand understanding (1) but would like to ( 1) Don’t understand Some but would like understanding (1) to ( 1) Some understanding (1) Don’t understand but would like to ( 1) Some understanding (1) Don’t understand but would like to ( 1) Some Don’t understand understanding (1) but would like to ( 1) Answer choices (assigned numeric value in parentheses) Neutral (0) Disagree ( 1)

Strongly agree (2)

Agree (1)

Strongly agree (2) Strongly agree (2) Strongly agree (2) Strongly agree (2)

Agree (1)

Neutral (0)

Disagree ( 1)

Agree (1)

Neutral (0)

Disagree ( 1)

Agree (1)

Neutral (0)

Disagree ( 1)

Agree (1)

Neutral (0)

Disagree ( 1)

Extraction tx Strongly causes TMD agree (2) Casts should be Strongly mounted for diagnosis agree (2)

Agree (1)

Neutral (0)

Disagree ( 1)

Agree (1)

Neutral (0)

Disagree ( 1)

Occlusion causes TMD Third molars cause incisor crowding Frenectomy performed before tx Premolar ext smiles are less esthetic

I change my practice philosophy based primarily on When faced with clinical uncertainties, I usually


Don’t understand and don’t want to ( 2) Don’t understand and don’t want to ( 2) Don’t understand and don’t want to ( 2) Don’t understand and don’t want to ( 2) Don’t understand and don’t want to ( 2) Don’t understand and don’t want to ( 2) Don’t understand and don’t want to ( 2) Don’t understand and don’t want to ( 2) Don’t understand and don’t want to ( 2)

Strongly disagree ( 2)

Strongly disagree ( Strongly disagree ( Strongly disagree ( Strongly disagree (

2) 2) 2) 2)

Strongly disagree ( 2) Strongly disagree ( 2)

Other (5) Literature Reading review (4) clinical journals (3) Consult with Consult Consult the Proceed with Refer (5) colleagues (1) textbooks (2) literature (3) my best judgment (4) Colleague advice (1)

Expert advice (2)
