Evidence-Based Prosthodontics.

The practice of evidence-based dentistry has assumed an integral part in today's world. It allows us to achieve self-motivated, problem-based learning, which eventually leads to acquiring clinically sound and relevant information that has a strong backing of evidence on a scientific basis. This would enhance the diagnosis but also the prognoses and treatment that are administered with the highest of ethical standards. Due to the advancement in material studies, dentistry, especially prosthodontics, is getting more intricate and complex due to the dynamic state in the development of new dental materials and equipment. The best evidence is sought through vast empirical literature consisting of controlled trials and reviews. Modern clinical practice should be concurrent with the latest scientific evidence that brings high standards to the treatment options and patient's values. This review highlights the evidence based dentistry on prosthodontics while also addressing the issues it poses in modern day dental practice. Copyright:

INTRODUCTION

In clinical practice, it is imperative that the clinician provides the best treatment option with advanced techniques to their patients while considering the patient's request. Thus, the rendered treatment lives up to the highest of ethical standards. There is an ever-expanding increase in the number of studies being conducted in the medical/dental field and respective reports being published. The majority of the published papers are based on hypotheses that are proven with solid evidence. They strive for achieving a perfect treatment plan, with relatively fewer adverse effects, to conduct research and seek knowledge as a result of which new information and data get outdated very often in the modern world.

Evidence-based practice (EBP) involves utilizing strong scientific evidence that can be applied to queries that arise in daily practice. The concept was framed in 1991 and has been given the definition “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Evidence-based practice involves treating a medical issue, with valid evidence that has been obtained from published studies.[1] Applying evidence-based medicine into practice enables us to correlate individual clinical signs, compare them with the treatment to other cases with similar problems, and take into consideration the best scientific evidence to date. Evidence based Medicine provides a Higher standard of patient care, better treatment with minimal or no side effects, is economical and ultimately gives both the clinician and patient a greater degree of contentment compared to the traditional approaches of care.[2] The field of prosthetic dentistry of prosthodontics specializes in the rehabilitation of edentulous alveolar ridge due to missing teeth with various appliances, ranging from removable to fixed prosthesis and implant-supported dentures. The concepts in denture fabrication have been constructed upon a theoretical basis, many of which lack a strong research foundation. This review sheds the spotlight on evidence-based dentistry with an emphasis on prosthodontics.

Need for evidence-based practice

Traditional practices are based on expert opinions, intuitive thoughts, and what was learned during academia. Because modern medicine is ever-changing, what is new today will tend to become outdated in a couple of months. Expert opinions tend to be biased and incorrect. Instead of depending on such claims that lack critical evidence background, it is imperative that clinicians resort to seeking the latest evidence-based findings and adopt them into their clinical routine for a better outcome.[3] Practicing evidence-based medicine heightens the inquisitive nature of the treating doctor in interrogating oneself about their own treatment and if there is a better way of administering it. As health professionals, it is in our hands to ensure that treatments provided are based on scientific evidence claims. Such practices make the best use of the available resources, especially in scenarios where there is not much at the clinician's disposal.[4]

Advantages of EBP

Practicing evidence-based medicine allows the clinician to improve and individualize the treatment to each patient. It could also replace the treatment of the past with a modern approach, thereby even reducing the cost of a treatment that was previously high. It enhances the validity, reliability, and specificity of various research findings that are built on proven facts rather than just opinions and advice. Without this, the patients tend to be at risk of getting treated with an outdated procedure, the latest of which would be substantially better. EBP helps in making the best-informed clinical decisions.

Role of evidence-based dentistry

Evidence-based dentistry (EBD) takes into account the latest scientific evidence in the form of clinical trials and systematic reviews and implements the learned evidence into clinical practice taking into consideration the patient's oral and medical condition.[5] The American Dental Association (ADA) established a central database that contains relevant information with the latest scientific findings along with their criticism that has to be considered when implementing EBP.

The potential benefits of practicing EBD include improved patient health outcomes. In the clinical work setting, it also seems beneficial to the working staff:

Enhancement in the proficiency of clinical treatment procedures.

Significantly better credence in designing treatment outcomes.

Reducing the probability of any risks the treatment present while improving the safety margin.

Individualized approach based on strong evidence with importance given to patient preferences and values.

Patient first approach in the daily practice with well-inspired and knowledgeable clinic staff.

Saving time and energy by utilizing the effective and best resources.

A higher rate of treatment acceptance is gained by explaining to the patient the high quality of evidence the treatment has to offer.

Improved level of mutual understanding between the patient and the clinician.

Expanding the clientele network as patients confide and share with their friends and colleagues about the treatment received.[67]

The approach of evidence-based practice

Integration of evidence-based clinical practice boosts the morale of the patient and the clinician as the best quality of treatment is always administered.[8] There are three crucial factors that firm the pillars of EBD, namely

Obtaining the strongest evidence-based statements up-to-date

Clinical experience and technical skills of the dental professional.

Patient's value and inclination toward a specific treatment.

The approach of evidence based practice starts with finding the foremost and prime evidence of a research topic using research databases on the Internet. Evidence-based practice revolves around finding and applying research that evaluates the expertise of the dentist. This quality reflects the capability to make use of the experience, aptitude to diagnose the disease of patients, and the various treatment options that can be addressed.[9] Patients' first approach is often encouraged when using an evidence-based approach as their preferences, assumptions, and presumptions are given importance.[10]

STEPS IN EBD

To pursue EBD, there are seven key steps that are to be followed, namely

Step 1: Cultivating a spirit of inquiry by questioning the treatment that is to be done, the technique involved as to why? What? How?

Step 2: Framing the thought questions into a structured framework using the PICO format. P: the population, patients in question, Intervention: the type and technique of the treatment to be given. C: compare with a new and modern alternative that is thought to cause less adverse effects, O: whether the new treatment that was administered was true to the evidence that it had been laid on.

Step 3: Search for the best evidence using various online research databases such as PubMed, Google Scholar, Embase, and Cochrane library. Although the literature is cast, they should be meticulously screened to narrow it down to the root tip.

Step 4: Because the literature is vast, it is not feasible to search among millions and millions of studies. Critical appraisal of the evidence obtained is crucial. Priority should be given to randomized control trials (RCTs) and systematic reviews dealing with clinical topics based on diagnoses or interventions, paucity in the literature pertaining to the diagnosis, treatment, and equipment required to execute the said treatment procedure. Software tools such as critical appraisal tools (CATs) are available to guide in evaluating the specificity and sensitivity of clinical trials and further studies.

Step 5: Integrating or translating the learned evidence into daily clinical practice.

Step 6: Assessing the clinical outcome of the treatment that was carried out based on evidence findings.

Step 7: Extrapolation of the search results to the general audiences via publication in a reputed journal and conferences.

However, the most often ignored step in EBP includes the knowledge translation or integration of knowledge into clinical practice as it is hampered by lack of time, expertise to seek out through the vast literature that often makes it complicated and gives the impression that they are engulfed in too much information.[11]

Evidence-based practice vs. traditional practice

Conventional dentistry involves the use of standard dental practice that was learned/thought in undergraduate training with their clinical expertise purely based on theoretical assessments, which create self-doubts when the professional when questioned about his decision-making skills.

In searching for the best evidence, there are studies that provide valuable information but the inception of systematic reviews and meta-analyses has been one of the crowning achievements in the literature as these study designs pinpoint a various number of studies regarding a specific topic, and segregate the ideal and strongest evidence-based research.[12]

One of the problems associated with traditional dentistry is the outdated treatment procedures that have been deemed as commonly accepted practice based on their own observations, and personal and expert opinions. Some dental professionals stick to what was taught to them at dental schools in spite of the modern advancements made in material science. Modern medication, oral hygiene products, and materials provide the patient with better oral hygiene and treatment.

This creates a need to fill the void between what is being practiced at the dental office and the latest scientific evidence available. This can be rectified using online publications and research evidence. Ever since the internet boom, access to online resources has never been easier; however, caution should be exercised in finding studies that are highly reliable.

Establishing clinical guidelines that are based on reliable and latest evidence-based studies is useful because the patient and the clinician can resort to studying them. Following such evidence-based dental practices enables the clinician to obtain the current trend in the desired topic and its current evident findings in dental practice. Such knowledge enables dental professionals to scrutinize the existing treatment procedures for dental problems, and improve current and future treatments.

Evidence-based prosthodontics

Prosthodontics is the discipline of dentistry that deals with the absence of teeth and their subsequent edentulousness by replacing the missing teeth through artificial teeth and prosthesis, thereby restoring the oral, facial, and general health of the patient.[13] The application of EBP in prosthodontics is unlike medical or other disciplines of dentistry. Studies published in the literature dealing with complete dentures, the materials are limited by an uncertain duration of the endpoint; hence, most of the studies are limited in time and the subjects have no defined outcomes of clinical interest, variable follow up period, and inadequate sample size. This creates the need to analyze the concise evidence-based studies published so far in prosthodontics.

Although there is no current definition of evidence-based prosthodontics, the working definition of evidence-based dentistry is “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.”

A researcher is often faced with the arduous task of working around these hurdles. Hence, prosthodontic clinicians consider the latest evidence to meet the patient's expectations even if the evidence is not up to the highest quality.

Although the longevity of the treatment is a crucial factor in determining the success of a prosthodontic procedure, the other important parameters that pose challenges to reporting treatment outcomes include

Time is required to analyze the outcome of a prosthesis.

The number of samples in a study.

Levels of evidence

In traditional medicine, the hierarchy of evidence is a well-renowned scheme that was originally described by the Task Force of Canada in 1979.[14] Although later on expanded by Sackett into five levels based on the likelihood of bias.

Randomized controlled trials (RCT) are at the top of the hierarchy, whereas case reports are at the lowest level. RCTs are often carefully designed to exclude any systematic errors or any probability of bias, whereas case series and expert opinions are at the bottom of the pyramid are, where bias and confounding factors are often uncontrollable.[15] The evidence should always be searched starting at the top of the pyramid, where, based on the availability and the research question, the other levels of evidence are sought. The number of research and studies at the top of the pyramid along with the study's relevance, pertaining to answering the clinical questions increases. Although RCTs are at level 1, this does not make the other publications at levels 2, 3, and 4 by any means not being valid enough. Because not all RCTs may be appropriate for certain treatment procedures, studies at a lower level that are often conducted with well-designed cohort or case–control studies have reliable and valid evidence. Whenever using the hierarchy model, it should be noted that the studies are classified based on the study design. Each study, regardless of its level, should be critically appraised by the reader for its pros and cons, with a cautious approach to be exercised during result interpretation of these randomized trials.

Some of the commonly followed study designs for preventive and therapeutic purposes include meta-analysis, systematic review, and RCTs of single individual cases. To search for evidence pertaining to the diagnosis, prospective cohort study, RCTs are useful as they readily demonstrate the sensitivity and specificity levels. For diagnosis, inception cohort studies are followed as they follow the patients from which the disease primarily manifests. Associating the specific type of answer to its specific study design is a proficient skill required to match the appropriate evidence. It is also observed that ever since their introduction, they have been modified by various fields of medicine with specific research questions pertaining to their field. Burns et al.,[16] presented a schematic representation of the hierarchy of evidence in medicine [Figure 1].

Figure 1

Schematic illustration of the hierarchy of evidence (image courtesy ofSchematic illustration of the hierarchy of evidence (image courtesy of Burns PB, Rohrich RJ, Chung KC. The levels of evidence and their role in evidence based medicine. Plast Reconstr Surg. 2011 Jul; 128 (1):305 310[16]

The goals of applying an evidence-based approach to prosthodontics involve finding and compiling the latest scientific information available pertaining to prosthodontics and its techniques, critically analyzing the scientific evidence behind the existing treatment protocol, and seeking improvement in the research, and reporting studies that are at the height of string scientific evidence.

One of the problems with applying an evidence-based approach in prosthodontic lies in the fact that the majority of treated outcomes in this field require a prolonged period of duration to assess the clinical performance of treatment. Most of the articles related to prosthodontics are based on RCTs and large cohort studies, which qualify as weak evidence of the hierarchy of evidence pyramid. Important variables such as duration of the study and sample size are often overlooked in such studies. Although groundbreaking events have been reported through cross-sectional studies, these are still treated as weak evidence. Therefore, an alternative approach seeking evidence-based research in prosthodontics should involve preliminary evidence, substantive evidence, and progressive evidence.[17]

Preliminary evidence studies that are designed based on expert opinions, case reports, theories, and laboratory studies are considered. A classic example of preliminary evidence is the concept of osseointegration put forth by Branemark.

Substantive evidence refers to studies that are proved through cross-sectional studies, case series, and cohort studies and do not require any further validation. They can be direct or circumstantial or both.

Progressive evidence involves studies that have been followed up over a period of duration. Such studies include RCTs, therapeutic studies, and meta-analyses. Various guidelines have been set up that help in sorting the vast literature when a clinician needs to search and report specific evidence. The rationale behind the guidelines is to present an accurate evaluation of the presented evidence. Some of the frequently employed framework protocols are included in Table 1.

Table 1

Frameworks used to carry out and report research

FRAMEWORK	URL
Consolidated Standards of Reporting Trials (CONSORT)[18]	http://www.consort-statement.org/
Transparent Reporting of Evaluations with Nonrandomized Design (TREND)[19]	https://www.cdc.gov/trendstatement/index.html
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)[20]	http://www.prisma-statement.org/
Strength of Recommendation Taxonomy (SORT)[21]	https://www.aafp.org/afp/2004/0201/afp20040201p548.pdf
Assessment of Multiple Systematic Reviews (AMSTAR)	https://amstar.ca/Amstar_Checklist.php
Meta-analysis of Observational Studies in Epidemiology (MOOSE)	https://www.equator-network.org/reporting-guidelines/meta-analysis-of-observational-studies-in-epidemiology-a-proposal-for-reporting-meta-analysis-of-observational-studies-in-epidemiology-moose-group/

Transfer of research findings into clinical practice

Research and development are being processed and published at a high rate, indicating that clinical practice tends to get antiquated.[22] Knowledge translation is a new concept that involves transferring and extrapolating the learned evidence to the population and adopting it into clinical practice. This concept has garnered more attention as it sheds light on the important event where vast amounts of money through grants and fundings are being spent researching without addressing the problem of how the findings are to be incorporated into clinical practice. This needs to be addressed and should be prioritized alongside knowledge creation.[23]

Because not all evidential research is translatable, the studies that are to be translated should be of adequate design, reliable, and have to be relevant to the problem it is being addressed while keeping in mind the barriers that are commonly faced in knowledge extrapolation.[24] This translation should be given more consideration when planning or designing a study at an early stage. In seeking strong evidential information, knowledge distillation should be given importance, where from the thousands and thousands of literature being published, after a strenuous search, the best obtainable research pertaining to a subject is reached.[25]

Knowledge translation and distillation should be re-emphasized and prioritized. Once the goal is achieved, steps should be taken to ensure that the changes made according to evidence-based facts are retained, regardless of a simple clinical setup or a big organization. Ongoing trials and research should also be carefully pursued to find if they contribute to the study as this will make sure information gathered during the search is useful in the future. Knowledge translation can be undertaken with one of the few points listed below[26]

Design a study with the attainable hypothesis in mind

Presenting evidential findings that are useful and curious

Re-emphasizing information exchange and translation

Ensuring longevity of the obtained result

At the heart of successful clinical research that translates into evidence is the changing human behavioral pattern. A clear translation should enable professionals as well as laymen to understand the concept of the new research as this would ensure the long-term sustainability of the study design.

Research can be extrapolated via efforts made by major healthcare organizations and private practice centers through posters and banners at hospitals and clinic premises, establishing guidelines by authorities.

An outstanding prototypical example is the model titled “Promoting Action on Research Implementation in Health Services Framework, or PARIHS Framework”[27] that correlates elementals that are influential in the integration of changes in medical practice. However, the framework needs further validation.[28] Some of the useful knowledge translation databases are included in Table 2.

Table 2

Knowledge translation databases

Databases	URL Links
Cumulative Index to Nursing and Allied Health Literature (CINAHL)	www.ebscohost.com/biomedical-libraries/the-cinahl-database
Atlantic Health Promotion Research Centre Knowledge Translation Library, Dalhousie University	www.ahprc.dal.ca/kt/default.asp
Canadian Health Services Research Foundation (CHSRF)	http://www.cfhi-fcass.ca/WhatWeDo/AppliedResearchandPolicyAnalysis.asp
Cochrane Effective Practice and Organisation of Care Group, University of Ottawa	www.epoc.cochrane.org/en/index.html
Knowledge Translation + (KT+)	http://plus.mcmaster.ca/kt/Default.aspx
Keenan Research Centre – Research Programs Joint Program in Knowledge Translation	www.stmichaelshospital.com/research/ktclearinghouse.php
New York Academy of Medicine	www.nyam.org/library/pages/grey_literature_repor

Once the evidence-based research has been completed, for a successful implementation, dental professionals in the private sector should confer the latest findings to their staff. The importance of following evidence-based research protocols should be educated and informed to all the staff from receptionists to assistants in a way that excites and motivates them. It should be re-emphasized that following evidence-based medicine is a crucial and integral part of making clinical decisions. Such steps would make the clinic personnel equipped with high knowledge and a great sense of awareness in what is being rendered to the patient is of the highest quality that can be given.[29]

New skills to acquire evidence-based prosthodontics

Such skills can be implemented by following the five vital steps that are referred to as the 5 As

Asking the pertinent research question for a particular subject of interest.

Acquiring new knowledge and facts by resorting to reading scientific literature.

Appraisal of the gained information in a critical manner.

Applying the information to clinical practice with a patient- first approach.

Assessing the clinical outcome when the new evidence is applied in a presenting clinical scenario.

Evidence-based fixed partial denture

Fixed partial dentures (FPDs) have been long considered as the choice of replacing the missing tooth. The longevity of dentures relies on the intactness of the fixed tooth. Based on an evidence-based search, tooth-supported FPDs presented with a 89% survival rate and a clinical performance rate of 71% over the course of 10 years compared to cantilever and end-abutment-supported FPDs.[30]

The effectiveness of gingival retraction during tooth preparation for FPDs between corded or cordless techniques was studied by Veitz-Keenan et al.[31] It was observed that gingival paste achieved better hemostasis during the procedure; however, the tissue displacement was minimal. Thick gingival tissues were best retracted by impregnated gingival cords in the posterior teeth, while the gingiva in the anterior teeth where displacement is minimal, were retracted by gingival paste.

Much evidence based research suggests that Pontics with a surface area measuring of 6–9 mm2 in all ceramic fixed partial prosthesis, because most of the fractures that were reported had occurred from the major connector which travelled up to the Pontic midpoint.[32]

A systematic review in which evidence-based literature compared impressions taken digitally and using conventional methods, it was observed FPDs made from digital impressions had a better marginal and internal fit compared to dentures made with conventional techniques[33]

Many designs used in the prosthodontic literature, revealed no standardized measurement for finish lines and how much incisal reduction is needed for the fabrication of ceramic veneers. The use of butt joint preparation had transferred little or no stress on the tooth structure, contrasting to the chamfered finish line which makes the tooth more susceptible to fracture.[34]

Longitudinal studies spanning more than 10 years have demonstrated porcelain-fused metal (PFM) restorations tend to exhibit a 97% survival rate, whereas leucite-reinforced restoration demonstrated a 99% survival rate after 3.5 years, which reduced minimally to 95% survival after 11 years. Veneered ceramic over zirconia restorations has shown survival rates of 96% and 94% after 2 years and 4 years, respectively. Studies have shown 93% survival rates for zirconia over 5 years, and all-ceramic restoration shows 89% survival rates over the course of 5 years.[35]

Evidence-based removable denture

Denture fabrication, molding techniques, teeth setting, occlusal principles and their concepts, jaw relations, and the type of material to be used are discussed in detail in textbooks; however, none have discussed the strength of scientific evidence these techniques would have allegedly developed upon. All these have been subjected to extreme scrutiny in recent times by academics and clinicians alike.

To this day, there is no strong scientific evidence to prove that one single impression satisfies all the criteria required for the fabrication of complete dentures. Instead, at a dental school level, a two-step process is thought. When it comes to clinical practice, preferences vary much among dentists. Carlsson described that there was no significant difference between dentures fabricated using border molding and those fabricated without. Face bow registration and transfer also met the same fate.[36]

A study found that patients had preferred dentures fabricated from elastomeric impressions over irreversible hydrocolloid materials, as the former were more comfortable, had less distortion, and felt satisfied on an overall basis after wearing the dentures.[37]

One of the key roles of prosthodontics is to restore the stomatognathic function to preserve the arch and health of the dentition a role that is well thought out throughout dental schools across the world. It was then considered by the ADA that described it as “preserving what was left was much better than replacing them.” Kayser et al.[38] put forth his theory on the shortened dental arch where there is insufficient adaptive capacity on patients with white dental arch and such people had no problem with replacing their teeth.

During complete denture fabrication, jaw relation is used to establish a maxillomandibular relationship with the maximum intercuspation of the patient's teeth to maintain the condyle–fossa relationship. Evidence states that deliberate alterations in the jaw positions and condyle–fossa relationships could end up causing discomfort and pain in the temporomandibular joint over the years.[39]

Arrangement of teeth contacts between the anatomic teeth was placed on the deflective inclines, which led to stress forces to be placed directly upon the alveolar ridge.[40] During teeth setting, occlusal schemes such as conventional bilaterally balanced occlusion (CBBO) and lingualized bilaterally balanced occlusion (LBBO) were developed as they arranged the teeth in a monoplane; however, there was no scientific justification as to why monoplane attributes such advantage.

Justification of balanced occlusion and its benefits led to the development of mathematical models and engineering abstract models. These eventually led to the designing and development of numerous articulators that we now see.[4142434445] They not only tried to replicate the temporomandibular and maxillomandibular jaw movements but also different forms of teeth forms and surfaces that best fit the balanced occlusion model.[21]

Kapur et al.[42] had described that denture efficiency was in no way dependent on masticatory efficiency. Although unproven in their scientific justification, it is very clear that there is a multitude of ways to achieve clinical success pathways to clinical success in complete denture occlusion. This statement was justified by Jacob et al. who stated that pending scientific justification, these methods were now considered to be vital in clinical practice today.[46] It can be taken into account that instead of establishing strong evidence behind the principles of denture fabrication, more research should be focused on the paucity.

Evidence-based dental implants

Dental implants have revolutionized prosthetic rehabilitation of missing teeth. It has been estimated that almost 100,000–300,000 dental implants are used to replace missing teeth in a single year.[44] Research and development in this field are in constant motion, with new implant surface materials, textures, and topography being produced to prolong longevity. However, an occlusal concept used is still the same theory as in removable dentures because there is an ample amount of evidence to suggest that there is very little evidence to support a relationship between occlusal factors and biological outcomes.

It was conceived that non-axial forces on implants created areas that exhibited high stress without uniform dissipation of these forces due to the absence of periodontal ligament, thereby showing a high rate of failure of fatigue; however, the evidence to this notion is lacking as studies failed to prove that non-axial forces lead to failure of the Implant restoration.[4546]

Also, progressive loading of implants did not affect tactile sensation due to the lack of proprioception as this was the previous notion that patients with implants would notice the difference between the masticatory force exerted by a natural tooth and an implant.[4748] This is in contrast to the current observation that claims no association between occlusion and disease processes, with the evidence already present on the subject being of weak hierarchical evidence.

Evidence-based fixed dentures

Techniques of fixed prosthetics rely on theories of physical and biomechanical properties of the materials being used because these materials influence the outcome of aesthetic and functional goals. It is imperative that treatment options and treatment administered are held up to a higher standard. Most of the studies on fixed prosthodontics are categorized as laboratory studies or clinical studies. The studies can be classified further based on different criteria such as retrospective or prospective, cross-sectional or longitudinal, observational or experimental.

Jokstad in 2018 framed a protocol that enabled evidence-based decision-making in fixed prosthodontics.[13]

The patient's problem and identification of need should be recognised

Therapeutic aims as in what is to be achieved by giving the fixed unit on an outcome basis should be determined

Procedures for producing fixed partial dentures using the latest advancements in mind, from abutment teeth and material used for casting of the fixed unit.

Judging the outcome as in whether the expected outcome has been met.

Limitations of evidence-based prosthodontics

Despite the availability of evidence-based findings in prosthodontics, there are various hurdles that hamper their integration into clinical practice such as finding a specific treatment protocol for patients, skewed research, outdated material value, and ethical inclinations. In trials and clinical studies, the present complaint of patients is completely different from those who are presenting in a dental clinic. This specialty of dentistry requires total translation and distillation of knowledge in the current literature, which at this stage might seem impossible. In spite of this, following an EBP in this field is of utmost importance for the future. Even though there is no rule that states the mandatory following of evidence-based protocol, ethical values should be kept in mind along with patients' welfare.

Summary

In the modern era of the dental practice, the Internet is at the disposal of the dentist and patient to learn the latest innovative techniques and procedures pertaining to dentistry. This could be used to bridge the void between clinical trials and the integration of found results into clinical practice. Randomized trials and meta-analyses form the epitome of hierarchical evidence. Future studies pertaining to prosthetic dentistry have to be designed with prolonged follow-up durations and the implementation of newfound knowledge into chair-side practice. High-quality patient care utilizing the best EBP should always be prioritized.

CONCLUSION

Dental professionals should always be focused on presenting the latest evidence-based therapy to their patients. Although it might seem a bit overwhelming at first in seeking such information, modern databases and online sources have made it easier to access such information. In this review, we outlined the steps needed to be taken to adopt evidence-based findings into our clinical practice, and a keen eye should be kept on ongoing developments and clinical trials to improve the study itself and our own dental practice.

ABBREVIATIONS

EBP – Evidence-based practice

EBD – Evidence-based dentistry

ADA - American Dental Association

CAT – Critical assessment tool

SR – Systematic review

RCT – Randomized control trial

PICO – Population, intervention, control, outcome

CONSORT - Consolidated Standards of Reporting Trials

TREND - Transparent Reporting of Evaluations with Nonrandomized Design

PRISMA - Preferred Reporting Items for Systematic Reviews and Meta-Analyses

MOOSE - Meta-analysis of Observational Studies in Epidemiology

SORT - Strength of Recommendation Taxonomy (SORT)

AMSTAR - Assessment of Multiple Systematic Reviews

PARIHS - Promoting Action on Research Implementation in Health Services Framework

CBBO - Conventional bilaterally balanced occlusion

LBBO - Lingualized bilaterally balanced occlusion

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.