For the past several years, I have served on a committee, which has been charged with the responsibility of investigating the writing of guidelines. To begin the process, the committee had to agree upon standardization for formulating guidelines. The initial step was to attend an advanced course at the Forsyth Institute for evidence-based learning at Harvard School of Dental Medicine. Doctor Richard Niederman was the leading instructor for this course. Members of his faculty included doctors and statisticians with the Cochran Group in England. I found the training I received at Forsyth to be some of the most valuable information to which I have been exposed in my career in dentistry.
In today's world of modern dental practice, the practitioner wants information that is easy to access, readily available, reliable, accurate, and relevant. Evidence-based practice is the integration of the best research evidence with clinical expertise and patient values. It combines the best available evidence modified by patients’ circumstances and preferences and is applied to improve the quality of clinical judgments (Figure 1). There are five steps to evidence-based practice: first, we must ask the question; second, review the literature; third, evaluate to help with decision-making; fourth, translate this information into application; and fifth, through this process predict outcomes.
How do you, as a practitioner, search for information that is accurate, reliable, and relevant. There are CE courses for us to attend. There are representatives from manufacturing companies that will visit your office or who present information at meetings. The Internet provides a wonderful source of information. But there is also a wealth of material available through the literature, (i.e., PubMed). We know that the keys to research are centered on asking the right question. In order for us to ask the right question, we have to keep it simple: the more specific the question the more accurate the outcome. But it has to be an answerable question. The foundation of evidence-based practice is asking an answerable question. Clinical questions are often broad, complex, and multi-level. So we need to refine and narrow questions to make them answerable and searchable from the literature. It is often very difficult to translate a clinical question into a form that can be answered from the literature. However, there is a way, and it is called PICO.
PICO is an acronym for Patient or problem, Intervention, Control or comparison, and Outcome (Figure 2). The P can only be one patient, or a group of patients with a particular condition or a health problem. I, represents the intervention of interest, which can be therapeutic, preventive, prognostic, administrative, or related to economic issues. C, control or comparison, is defined as a standard intervention, the most used intervention, or no intervention. O, the outcome, represents the expected result.
Why PICO? It allows us to get the question clearly in our minds. It enables us to identify the information we need to answer the question and to translate the question into searchable terms. PICO further helps to develop and refine our research approach. It looks easy, but it can be tricky. However, it is absolutely invaluable. Minutes spent properly formulating your question will save you hours in searching.
The question that was posed by one of my residents
at a VA hospital for his research project was; “How does the use of the Dynasplint Trismus Appliance (Dynasplint Systems, Inc., Severna Park, MD) affect patients who have had radiation to the head and neck.”
The tips for building this PICO question are as follows; P, starting with your patient ask, “how would I describe the group of patients similar to mine?” The example, “in patients who have undergone radiation therapy to the head and neck”; I, which main intervention am I considering (i.e., “would adding Dynasplint Trismus Appliance”)?; C, ask what is the main alternative to compare with the intervention (i.e., “when compared with tongue-blade exercises or no treatment at all”)?; and O, what can I hope to accomplish or what could this exposure really affect (i.e., “what effect would this have on range of mandibular motion”)?
Now, we have formed a PICO question. The question is, “In patients who have undergone radiation therapy to the head and neck, how does therapy utilizing the Dynasplint Trismus Appliance compare with tongue-blade exercises or no treatment affect the range of mandibular movement?”
In order to compare literature through a systematic review, the articles must be presented in a format, which would allow components of the goals or purpose of study to be searched. Therefore, the PICO question allows us to format the question into searchable terms.
One of the major criticisms of TMD (temporomandibular disorders) and orofacial pain literature has been the concerns about reliability and validity. In 1996, the NIH held a historic conference in which an NIH-appointed committee was to review the literature through presentations by practitioners and educators in the field of TMD and orofacial pain. Based upon the information from this conference, their team of experts began to write guidelines for TMD and orofacial pain. It became evident at the conference that there was a major problem with empirical data and information in the literature. The major outcome of the conference was the need to refocus on research diagnostic criteria for TMD. Since that time, there has been a search for standardization of TMD research. In the late 90s, there emerged the concept of evidence-based practice. Meta analyses of the literature was transformed into systematic reviews of literature in order to focus on the best research evidence.
To date, we are still defining and refining what evidence-based practice really means. It is through the training of researchers, educators, and practitioners in how to accomplish a systematic review that we will be better able to standardize the research method so that there is a level playing field of data presentation for comparison. The first step by which this process is achieved is converting the question or goal of the study into a PICO question.
Ronald C. Auvenshine, D.D.S., Ph.D.
Houston, Texas
Supplemental Material
1. Centre for Evidence -Based Dentistry, Oxford, http://www.cebd.org
2. EBD. Evidence Based Dentistry. Vol.6. No. 2. 2005, www.nature.com/ebd
3. NHS, Critical Appraisal Skills Program, http://www.phru.nhs.uk/casp/
critical_appraisal_tools.htm
4. The Cochrane Collaboration, http:www.Cochrane.org/index0.htm
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