Oral Health Research Methods Summer Institute: A Systematic Review Methodology Workshop

Evidence-based dentistry (EBD) can only be provided when 3 fundamental factors are considered during a clinical decision process, i) clinical judgment, ii) patient values, and iii) best available clinical evidence. Scientific literature alone should not mandate any specific course of treatment. Instead, an evidence-based, multifactorial approach leads to clinical decisions which provide the best possible care for each patient.¹ Some of the many and far-reaching benefits of evidence-based practices include a reduction in clinical errors, increased patient safety, improvement in patient outcomes, and reduction in treatment variability.^2-5 In addition, studies have illustrated that incorporation of EBD in dental practices improves patient outcomes and their satisfaction, while also securing staff satisfaction.³

A significant variability in the scope and depth of EBD education can be identified not only among Canadian dental schools but also worldwide. There is a need to integrate EBD into dental education as evidenced by its inclusion in the evolving dental school accreditation standards. The Commission on Dental Accreditation of Canada (CDAC) has recently required graduate and undergraduate oral health care programs to implement EBD training.⁶ One specific competency directly linked to EBD is expected among recent graduate dentists: "[to] evaluate the scientific literature and justify management recommendations based on the level of evidence available."

Some barriers to EBD implementation in Canada are:

• Limited teaching of EBD in Canadian dental schools. Although there is a specific competency that is related to EBD,⁶ it is not consistently implemented in Canadian dental education.⁷
• Lack of dental faculty development courses in EBD within Canada. Overall, Canadian dental educators have received limited formal training in EBD compared to dental educators in the U.S., where the EBD Champion Conference⁷ and the ADA/New York University Evidence-Based Dentistry Course (EBD) are available on a yearly basis.⁸

Therefore, there seems to exist an unmet need to improve evidence-based practice (EBP) skills among Canadian oral health care providers. One way to accomplish this is to increase knowledge of EBD among current and future dental faculty members so that future generations of dentists are exposed early in their dental training.

The goals of our 2015 summer workshop were twofold. The first goal was to broaden the knowledge of oral health providers in Canadian dental schools about EBP principles through hands-on activities. The second was to provide workshop participants with hands-on experience in designing, conducting, writing and critiquing health care systematic reviews (SRs). The event was supported by the Network for Canadian Oral Health Research (NCOHR) and held at the University of Alberta in Edmonton.

The target audience and participants

It was essential that the workshop include participants from multiple institutes. To attract participants, we promoted the summer workshop on the NCOHR website and through social media. We worked with the Association of Canadian Faculties of Dentistry (ACFD) to target potential attendees who are or will be faculty members. Our team also contacted Canadian graduate directors about inviting graduate students and early-to-mid career researchers interested in the field.

Oral health care providers in Canada from 4 dentistry schools (University of Manitoba, McGill University, Laval University and University of Alberta) participated in the one-week workshop. We provided accommodation, transportation and catering for 12 participants. In addition, 2 attendees external to Canadian dental schools audited the workshop. One auditor had a strong academic background and previous experience with systematic reviews. The second auditor was a dental hygienist and manager of health policy at the Canadian Dental Hygienists Association, and staff lead on the organization's research advisory committee.

Based on previous experience, we designed the workshop for 12 attendees. This ensured that small groups could be supervised by 1 of 3 workshop facilitators. Applicants were selected if they were an early-to-mid career oral health academic or graduate student with intentions of being involved in dental education or research, either as a part- or full-time faculty member. A first-come, first-served system was used to fill available spots. Pairs of faculty members and graduate students from universities other than the University of Alberta were given priority.

Workshop overview

The workshop was delivered at the Edmonton Clinical Health Academy (ECHA), University of Alberta, from July 13–17, 2015. Each 8-hour day included a combination of lectures, small group discussions, and plenary sessions. The topics covered in the workshop were related to fundamental principles of EBP and the execution and critique of SRs. Concepts were directly applied by critiquing current SRs and working in teams to draft a SR proposal.

The guiding topic focused on pediatric obstructive sleep apnea (OSA) and the impact of oral health providers. We established a specific question: "What are the indications for dentists to identify, refer or treat pediatric OSA?" The organizing team had materials readily available to improve the flow of the workshop and the overall learning experience.

Day 1

The workshop began with a presentation by Dr. Flores-Mir about the fundamental principles of EBD. Two lectures by experts in the OSA field initiated the week: Dr. Rakesh Bhattacharjee, an expert in pediatric sleep medicine, and Dr. Manisha Witmans, an expert in the diagnosis and treatment of pediatric sleep disorders. Examples were provided to showcase how available evidence can change the way medicine is practiced in the field of sleep medicine. Dr. Flores-Mir finished the day by showcasing how his publications regarding pediatric OSA and dentistry have changed the way he approached and handled pediatric patients with OSA.

Day 2

Day 2 of the workshop was dedicated to learning about SR methods. Dr. De Luca Canto lectured about study design, question formulation, selection process, inclusion and exclusion criteria and SR protocol. Dr. De Luca Canto and Dr. Pachêco-Pereira also organized a hands-on search for published SRs and briefly discussed the questions: Can the SR be improved? Can another SR be justified? In the afternoon, Liza Chan, a librarian with expertise in health research, talked about developing key research questions.

Day 3

Dr. Flores-Mir discussed the hierarchy of evidence and the importance of evidence-based guidelines. In the afternoon, Dr. Pachêco-Pereira conducted an exercise about data collection and table building. She also lectured on reference management and how to present the results of an SR.  

Day 4

Dr. Saltaji lectured about assessing risk of bias of studies included in SRs. This lecture presented information about which assessment tools should be used to assess study quality and sources of bias in clinical trials. Use of the Cochrane Risk of Bias Tool was provided as an example of a widely used quality assessment tool in SRs. Dr. Saltaji also lectured about analysing data and undertaking meta-analyses. This lecture was intended to present information about meta-analysis: fundamental principles, when to do one in an SR, and what is involved. The lecture also provided information about addressing clinical and statistical heterogeneity and identifying publication bias when conducting an SR. In the afternoon, Dr. De Luca Canto conducted a hands-on session using meta-analysis software.

Day 5

The workshop started with a discussion about methodological tools to assess the quality of SRs and was followed by lectures about the publication process and a lunch-and-learn activity based on plans for future research. Final evaluations were completed.

Available resources during workshop

Fourteen poster boards of systematic and scoping reviews were displayed during the week.  Participants also had an opportunity to develop and discuss their own research protocols.

Feedback of participants

In general, participants provided very positive feedback. Generally, their written comments were based on the enthusiasm of the team, organization of the workshop and the sharing of personal experiences while working on this specific methodology. All participants agreed that the applied knowledge will impact their academic life and aimed to see the speakers in the future. Some of them would have liked more time to critique SRs and do hands-on exercises. They acknowledged the quality of information provided during the workshop and the importance of doing well conducted and structured SRs, and of putting their new knowledge into practice.

The participants also expressed interest in developing research questions within their field of specialty to conduct an SR based on knowledge obtained from the workshop. This positive feedback opens doors for future cooperation in research and evidence-based teaching among teams from different Canadian dental programs.

Impact of the workshop

The outcomes of this training program for oral health professionals were enhanced critical thinking skills, increased knowledge of EBP, improved skills in conducting and/or critiquing SRs, and a new ability to incorporate the learned material into their classroom lectures or clinical bedside teaching. Dental health care providers, researchers and policy makers are inundated with unmanageable amounts of information. They need SRs to integrate efficiently existing information and provide data for rationale decision-making. Ultimately, it is our expectation that this effort should result in more oral health professionals practising EBP (practising with less geographic variation in treatment, less clinical decision-making errors, better patient outcomes, and improved patient satisfaction).

Conclusion

This workshop reviewed basic and general principles of clinical research methodology and evidence-based practice in health care. Attendees gained skills in conducting efficient searches and in the evaluation and knowledge translation of published evidence. Additionally, attendees developed core competencies in preparing a systematic review manuscript for consideration in a peer-reviewed scientific journal.

Following the workshop, there were email exchanges and planned teleconferences with participants to develop research strategies and identify and apply to funding opportunities. In summary, there appears to be ample opportunity for further collaborations among Canadian dentistry schools.

THE AUTHORS

	Carlos Flores-Mir is professor and division head of orthodontics, school of dentistry, University of Alberta, Edmonton, AB
	Camila Pachêco-Pereira is assistant clinical professor and MSc student, school of dentistry, University of Alberta, Edmonton, AB
	Graziela De Luca Canto is associate professor, department of dentistry, Federal University of Santa Catarina, Florianópolis, Brazil, and adjunct assistant professor, school of dentistry, University of Alberta, Edmonton, AB
	Maryam Elyasi is MSc student, school of dentistry, University of Alberta, Edmonton, AB
	Humam Saltaji, is PhD student and graduate orthodontic student, school of dentistry, University of Alberta, Edmonton, AB

Acknowledgements

The authors thank and acknowledge the tireless efforts of Heather Good and Pat LaPointe for their administrative support, before and during the event; Dr. Maryam Amin for sharing her experience in the preparation meetings; Peggy Scade and Daniel Kwok for financial and technical support; Kerry West and James Yacyshyn for their support of continuing education accreditation of this event. Finally, we are grateful to Dr. Paul Major for hosting the event as the chair of the School of Dentistry at the University of Alberta.

An NCOHR grant funded this summer workshop in collaboration with the School of Dentistry at the University of Alberta.