Dentists' Knowledge, Attitude, and Practice Regarding Evidence-Based Dentistry Practice in Riyadh, Saudi Arabia.

OBJECTIVE: The aim of this study was to assess the existing level knowledge and the use of evidence-based dentistry among dental clinicians. METHODS AND MATERIALS: A cross-sectional questionnaire-based survey was conducted among 400 male and female dental practitioner's working in academic, governmental, and private sectors in Riyadh, Saudi Arabia.
RESULTS: In this study, a total of 400 subjects were recruited of whom 253 (63.3%) were male dental practitioners and 147 (36.8%) were female dental practitioners: 229 (57.3%) subjects belonged to 25-34 age group, 145 (36.3%) to 35-44 age group, 18 (4.5%) to 45-54 age group, and 8 (2%) to >55 age group. Among them, 202 (50.5%) were mixed practice, 91 (22.8%) were working in academics, 76 (19%) belonged to private practice, and 31 (7.8%) belonged to government practice. In addition, 225 (56.3%) were general practitioners and postgraduates, 86 (21.5%) were specialists, 47 (11.8%) were consultants, and 42 (10.5%) had other qualifications. In total, 221 (55.3%) subjects completed their qualification within before 1-5 years, 153 (38.3%) completed their qualification within before 6-10 years, 19 (4.8%) completed their qualification within before 11-15 years, and 7 (1.8%) completed their qualification within 16-20 years.
CONCLUSION: This survey mirrors the necessity to conduct continuing dental education programs on evidence-based practice (EBP), so as to give the dentists of Riyadh better knowledge regarding EBP so that they can administer it in their daily clinical practice and deliver better quality care to their patients. Copyright:

Introduction

The phrase “Practice makes perfect” signifies that the qualified clinician gains additional knowledge and skills as time goes by, ensuing in an enhanced quality of care.[1] Quality enhancement efforts have been an obligatory requisite in each field of health care. Nevertheless, advancement should be scientifically oriented to flourish with the established precedent facts. Dentistry has seen comparable ground-breaking advancement that has allowed it to progress based on evidence. High-quality and sound dental practice depends not only on the wreckage of selected evidence but also on the compilation of the finest obtainable research evidence.[2]

An evidence-based approach has come into view in response to the need to improve the quality of health care and to bridge the gap between practice and research.[3] Evidence-based practice (EBP) is an advancement that highlights the decision and utilizes the finest existing research evidence to assist in formulate health-care decisions. The objective of EBP is to provide patients’ up-to-date treatment that studies have revealed to be secure, efficient, and safe. Eventually, the goal of EBP is to incessantly perk up patient care depending on new research developments.[4] Over the past several decades, a range of events and initiatives have been implemented to improve dental education and clinical practice. Nonetheless, of late, there has been amplified employment of evidence-based dentistry (EBD) in dentistry, with the goal of providing optimal care to the patients.[5]

EBD encourages dental specialists to improve their information and knowledge about science. The American Dental Association defines EBD as “an approach to oral health care 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.” Therefore, the entirety of this contemplation is not only in the elevated levels of proof but also judgment of the clinician with a patient-centered approach.[1] In dentistry, however, EBP is still an up-and-coming conception. Quite a few studies have been conceded to assess the attitude, knowledge, and practice concerning EBP in both the dental and medical fields.[6] EBD is a bridge between clinical research and real-world dental practice. It provides dentists powerful paraphernalia to construe and relate to research findings.[7] Dentists can improve the quality and outcome of treatment by using EBD in harmony with clinical results; moreover, it will help to facilitate judging the advantages and disadvantages of possible treatment methods after examining the reliability of the accessible evidence.[89] As contemporary dentistry is becoming more ubiquitous and demanding owing to the altering lifestyles and increased perception of people in the direction of esthetics and oral care, the understanding of dentists about EBD should be knowledgeable. Thus, the objective of this study was to determine the level of knowledge, attitude, and practice regarding EBP among dentists in Riyadh, Saudi Arabia.

Materials and Methods

Study design and target population

This cross-sectional survey was conducted from January 2017 to March 2018, involving all the dentists working at different academic, governmental, and private sectors in Riyadh, Saudi Arabia. The list of the practicing dentists in Riyadh was obtained from the Saudi Commission for Health Specialties.

Study approval

The study proposal was submitted the Research Center of Riyadh Elm University, Riyadh, Saudi Arabia and the ethical approval was obtained (IRB No: RC/IRB/2018/1000).

Study procedure

The survey questionnaire was prepared after a thorough review of the literature. The questions were customized to fit into the criteria of this study. The questionnaire was then faced and content validated by five subject experts. A pilot study was conducted in Riyadh Elm University among 30 participants, who were not included in the final survey. The survey was analyzed using Cronbach’s reliability coefficient (α = 0.75). Minor changes were incorporated before using for the larger sample.

The questionnaire was composed of two parts: Part A that had demographic details and Part B that had 24 questions based on EBD questionnaire proper. The questionnaire was personally distributed to all the participating dentists and the objectives of the study were explained. Written informed consent was obtained from each subject. The filled questionnaire was then collected back with a single round of follow-up. Only completely filled questionnaire was considered for the study.

Statistical analysis

After the collection of the data, the data were entered in Statistical Package for the Social Sciences software version 22. Descriptive statistics were applied to summarize the demographic information. Pearson’s chi-squared test was applied to find the correlation between gender, age, practice type, level of education, and a number of years’ dentistry practice experience. A value of P ≤ 0.05 was considered statistically significant.

Results

In this study, a total of 400 subjects were recruited of whom 253 (63.3%) were male dental practitioners and 147 (36.8%) were female dental practitioners [Figure 1]. Among them, 229 (57.3%) subjects belonged to the 25–34 age group, 145 (36.3%) to the 35–44 age group, 18 (4.5%) to the 45–54 age group, and 8 (2%) to >55 age group [Figure 2]. In addition, 202 (50.5%) subjects were mixed practice, 91 (22.8%) were working in academics, 76 (19%) belonged to private practice, and 31 (7.8%) belonged to government practice [Figure 3]. 225 (56.3%) were general practitioners and PGs, 86 (21.5%) were specialists, 47 (11.8%) were consultants, and 42 (10.5%) had other qualifications in Figure 4. In total, 221 (55.3%) subjects completed their qualification within before 1–5 years, 153 (38.3%) within before 6–10 years, 19 (4.8%) within before 11–15 years, and 7 (1.8%) within 16–20 years [Figure 5]. The comparison of answers given by subjects with their qualifications with the questions asked is given in Table 1.

Figure 1

Distribution of participants by gender

Figure 2

Distribution of participants by age

Figure 3

Distribution of participants by practice type

Figure 4

Distribution of participants by level of education

Figure 5

Distribution of participants by dentistry practice experience

Table 1

Comparison between answered given by subject with different qualification

Sl. no.	Questions	P
1	Are you aware of EBP?	0.699
2	Where did you come across the word EBP	0.227
3	Do you practice EBP in your decision-making about your patients?	0.630
4	Do you agree that without EBP, your practice is inefficient?	0.197
5	Do you think that EBP is obligatory	0.076
6	Do you critically evaluate/appraise the evidence obtained?	0.344
7	Are you aware of evidence-based pyramid	0.626
8	EBD improve patient outcomes.	0.379
9	EBD improve patient care.	0.143
10	Do you feel the need to be trained regarding the application of EBP	0.536
11	Do you Regularly Read Journal?	0.559
12	Have you ever used the EBD approach in ordering tests or treatment?	0.833
13	If yes, the reason for the obligation	0.682
14	When faced with clinical uncertainty, your source of information is	0.334
15	What is your preference for printed source	0.865
16	Among the electronic source, the preference	0.013
17	Reason for preference	0.892
18	Which studies formed the base of the evidence-based pyramid	0.241
19	Which studies form the apex of the evidence-based pyramid	0.316
20	What do you consider the most important barriers to your using EBD in your clinical practice?	0.361
21	If you discover that recent evidence contradicts your clinical judgment what would you do?	0.943
22	The concept of Evidence-based Dentistry is not applicable to my culture	0.775
23	Patients are willing to participate in clinical decision-making	0.497
24	What percentage of your patients do you believe would be capable of participating in clinical decision-making?	0.141
25	If you reading a scientific article they usually read	0.053

Discussion

This study assessed the knowledge, attitude, and practices involving all the dentists working at different academic, governmental, and private sectors in Riyadh, Saudi Arabia in relation to EBD. In this study, almost all the dentists (91.8%) were aware of the term EBP, which is higher than the study conducted by Pratap et al.[10] (50.7%) and Gupta et al.[11] (70.5%). On the contrary, in a study by Khami et al.[12] it was observed that 80% of the student’s had feeble awareness and knowledge in this area and more than 85% of them had diminutive knowledge on the databases used in EBD.

Prabhu et al. evaluated PG dental students’ knowledge, outlook, and obstacles pertaining to the practice of EBD. The results showed that even though they were familiar with EBD sources, they had an inadequate understanding of the terms related to EBD.[13] In a cross-sectional study in Jeddah by Bahammam et al.,[14] it was found that the knowledge and attitudes among the dental students on EBD did not reach the required competency standards. Conferences and continuing dental educations (CDEs) are the stages where practitioners are introduced to new terms or concepts. It was noted that most of the respondents had come across the term EBD at conferences/CDEs.[6] This was in harmony with this study. About 75.5% of subjects came across the term at conferences, which indicated that most of the dentists kept themselves updated by attending conferences.

In our study, the majority (84.8%) of the dentists practiced EBP in their decision-making about the patients; however, 59% of among them agreed that their practice was inefficient without EBP. This was in agreement with the study by Bhate et al.,[6] in which 56.4% of the dentists believed that their practice was inefficient without EBP. On the contrary, the results of the study by Eslamipour et al.[15] indicated that dental students were unwilling to use the evidence-based approach and inclined to use the lessons and experiences of their teachers. Almost 53.5% of the dentists agreed that EBP was obligatory. Among them, 29.8% of the subjects answered ethically and 26.3% answered professionally. Nevertheless, in the study conducted by Gavgani and Mohan,[16] the two main reasons quoted for obligation by dentists were professional (81.6%) and ethical (79.6%).

When faced with clinical uncertainty, our 48.8% of the dentists used electronic source and 32% used both electronic and printed sources. Only11.3% of the dentists preferred asking to a friends or colleagues. This was in agreement with the study by Bhate et al.,[6] in which more than one-third of the respondents chose the electronic source and 31.5% used both electronic and printed sources. Only 23.8% preferred asking to their friends or colleagues. These findings are not in line with those obtained by Iqbal and Glenny,[7] in which 60% of general dental practitioners preferred asking to their colleagues and friends for assistance and advice for handling complicated cases. In a study by Nader et al.[8] 77.2% believed of consulting a colleague as a way to rectify their clinical dilemma. In contrast to the above studies, a high percentage (90.2%) of the dentists in the study depended on their own decision for clinical problems concerned with their practice.[17] Hay et al.,[18] in a pilot study, revealed that most doctors in their treatment approach uses their own and their colleague’s clinical experiences and rarely use evidence-based medicine and scientific resources.

Among the various electronic sources, 44.5% of the subjects answered free web, which was much greater than that answered by the subjects (16.3%) in the study by Bhate et al.[6] It was observed that only 5.5% of the dentists used Cochrane Database, which was much less than that answered by the subjects (69.2%) in the study by Prabhu et al.[13] Yusof et al.[19] revealed that the majority of the students were not even familiar with the Cochrane Library. This was in agreement with the study by Sabounchi et al.,[20] in which the Cochrane Library was the minimum source of evidence used by dental instructors. In spite of being familiar with the EBD approach and having access to the Cochrane Library, students did not use this approach in their diagnostic and treatment procedures.[21] This signifies deprived knowledge of practitioners about the diverse sources accessible for evidence-based literature.

The evidence-based pyramid gives a hierarchy structure for ranking evidence that examines health-care interventions and specifies which studies should be given more importance. The base of the pyramid was formed by background information/expert opinion and the systematic reviews form the apex.[6] When asked about the awareness of the evidence-based pyramid, half of the respondents were aware of it and 24.8% of the dentists correctly knew which studies formed the base and apex of the evidence-based pyramid. This was noted in a study in which 38.5% of them were aware and very few dentists correctly knew which studies formed the base (6.8%) and apex (12.8%) of the evidence-based pyramid.[6]

In this study, the majority of dentists (76.5%) said that they critically evaluated the evidence obtained, which is similar to the study conducted by Nazir et al.,[5] in which 70.3% evaluated the evidence obtained. When asked about do you feel the need to be trained in the application of EBP, the majority of the (80%) of dentists said “Yes,” which is similar to study conducted by Iqbal et al.,[7] in which 80% of the respondents were further engrossed to find more about EBP. The results of the studies by Eslamipour et al.[15] and Sabounchi et al.[20] specified students positive attitudes toward obtaining EBD skills and their interest in attending training workshops.

In this study, 57.8% of the respondents said they regularly read journals. This was in agreement with the study of Fedorowicz et al.,[22] in which 39% of the dental students were reading dental journals. On the contrary, deprived follow-up of journals and updates were seen in a study by Bahammam et al.[14] Further, nearly 82% of the participants agreed that they used the EBD approach in ordering tests or treatment. However, 60% of the students in the study by Bahammam et al. did not use EBP in ordering tests or treatment. Such attitudes may elucidate their inadequate awareness of the importance of incorporating EBP into their clinical practice.[14]

The main barrier to the use of EBD, as reported in this study, was that they did not believe that evidence is universally applicable, no ready access to EBD resources, and difficulty in understanding the concept. Time constraints were also a significant barrier, as noted in the study by Bahammam et al.,[14] in which the complexity in understanding the concept and time was the important barriers. In the study by Nahid et al.,[23] respondents reported lack of time, money, internet access, and interest as a foremost barrier in applying EB in their practice. Lack of EBM workshops and training courses were also the main barrier to practicing EBM by physicians in Doha.[24]

In the study by Bahammam et al.,[14] the majority of the dental students reported that EBP is not applicable to their culture. This was in agreement with this study, in which 32.3% of the participants agreed that EBD was not applicable to their culture. A significant difference was noted in answers given by subjects having different educational qualification on question number 24. Nearly 48.5% of respondents agreed that the vast majority of their patients are capable of participating in clinical decision-making, and 12.3% of the participants agreed that all of their patients were willing to be involved in clinical decision-making, which was similar to the study by Bahammam et al.,[14] in which more than half of the dental students agreed that the vast majority of their patients were able to participate in clinical trials, and a high percentage of the students predicted that patients were willing to be involved in clinical decision-making.

Majority of the respondents (74.5%) reported an agreement on the fact that applying EBP will improve patients’ care. This was in line with the study by Nahid et al.,[23] in which both dental and medical practitioners agreed on the verity that applying EBP will improve patients’ care. In another study, the respondent’s overall attitude was encouraging concerning the benefits of EBP toward patient care.[25]

The noteworthy disparity in knowledge scores depending on degree level obtained indicates that additional education may give added opportunities to achieve EBP knowledge. Significant differences were renowned owing to the knowledge and practice of EBD when general dentists and specialist practitioner were compared; this disparity could be due to the training in the specialty, where the specialists were skilled to incorporate EBP into clinical practice which is not thought in undergraduate level.

Limitations of the study

This study has certain limitations that must be mentioned. As with any survey, there is the risk of response bias. Rating of knowledge by oneself amid dentists may result in overestimation of genuine knowledge and even elevated self-reported utilization of resources of evidence. Respondents may incline to over delineate their use of textbooks and journals and hide their actual dependence on their friends or colleagues. Thus, our finding of low self-reported dependence on colleagues may even be an underrated image in real practice. Another limitation is that prejudice in volunteerism may subsist as those who agreed to participate may acquire basically dissimilar EBP knowledge and attitudes than those who did not participate. Furthermore, the use of “Yes/No” questions may restrict the questionnaire in evaluating actual knowledge of respondents as it is effortless to guess properly on many items, albeit topic has not been mastered.

Conclusion

This survey is carried out in a single city––Riyadh; it cannot be generalized to an entire nation like Saudi Arabia. EBD is comparatively a new archetype in dentistry and therefore may not be a well-known notion to each and every dentist. Developing awareness regarding EBD is imperative to be highlighted in the UG curriculum to guarantee cultural changes. Educating the patient might also be a promising strategy for promoting an EBP cultural environment. Thus, this survey mirrors the necessity to conduct continuing dental education programs on EBP, so as to give the dentists of Riyadh better knowledge regarding EBP so that they can administer it in their daily clinical practice and deliver better quality care to their patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.