Attitudes, awareness, and barriers toward evidence-based practice in orthodontics

ORIGINAL ARTICLE

Attitudes, awareness, and barriers towardevidence-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

aPrivabProfefor AdcAssisEducadProfeBayloThe aucts oReprinlege oDallasSubm0889-Copyrdoi:10

Introduction: The purpose of this study was to evaluate the attitudes, awareness, and barriers toward evidence-based practice. Methods: A survey consisting of 35 questions pertaining to the use of scientific evidence inorthodontics 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 withteaching were ascertained. To minimize bias, the survey questions were phrased as an examination of theuse 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 involvedin teaching were more aware, had a greater understanding, and reported fewer barriers than those notinvolved with teaching. Those with master’s degrees had a greater understanding of evidence-based practicethan those without degrees. Conclusions: Educational initiatives are needed to increase the understandingand use of evidence-based practice in orthodontics. (Am J Orthod Dentofacial Orthop 2011;140:309-16)

Evidence-based practice is an approach that empha-sizes finding and using the best current researchevidence to help make health-care decisions.1 The

goal of evidence-based practice is to give patientsup-to-date treatment that research has shown to besafe, effective, and efficient. Ultimately, the goal ofevidence-based practice is to continuously improvepatient care based on new research developments.2

Evidence-based practice is well established in medi-cine. The Institute of Medicine has designated evidence-based practice as a key feature of high-quality medicine.3

There is awealth of information regarding evidence-basedmedicine, including evidence-based medical journals,evidence-based summaries, and evidence-based practiceguidelines.4 The Agency for Healthcare Research has 12

te practice, St Louis, Mo.ssor and assistant program director, Department of Orthodontics, Centervanced Dental Education, Saint Louis University, St Louis, Mo.tant professor, Department of Orthodontics, Center for Advanced Dentaltion, Saint Louis University, St Louis, Mo.ssor and director of orthodontic research, Department of Orthodontics,r College of Dentistry, Texas A&M University Health Science Center, Dallas.uthors report no commercial, proprietary, or financial interest in the prod-r companies described in this article.t requests to: Peter H. Buschang, Department of Orthodontics, Baylor Col-f Dentistry, Texas A&M University Health Science Center, 3302 Gaston Ave,, TX 75246; e-mail, [email protected], January 2010; revised and accepted, May 2010.5406/$36.00ight � 2011 by the American Association of Orthodontists..1016/j.ajodo.2010.05.023

evidence-based practice centers located in universities inthe United States and Canada that conduct evidence-based medical research.5 In dentistry, evidence-basedpractice is less developed but is quickly gaining momen-tum. The American Dental Association has madea concerted effort to incorporate evidence-based practiceinto the dental field in the United States; its Web site hasan entire section devoted to evidence-based dentistry.6

TheWeb site is an important resource that contains a com-prehensive collection of systematic reviews in all areas ofdentistry. Dental schools are introducing evidence-basedcourses into their curriculums, journals have focused onevidence-based dentistry, 2 centers for evidence-baseddentistry have been established, and the CochraneCollaboration (http://www.cochrane.org) has includedan oral-health database.7 In orthodontics, evidence-based practice is still in its infancy.

Studies on evidence-based practice in medicine havefound that most doctors welcome evidence-based prac-tice and believe that it improves patient care.8-11 Barriersto evidence-based practice include lack of time, over-whelming amount of literature, and difficulties incorpo-rating evidence into practice. Physicians thought thatthe best way to increase evidence-based practice wasby using evidence-based guidelines developed bycolleagues. Dentists have also expressed positive atti-tudes and awareness of evidence-based practice.12,13

However, their understanding of evidence-basedconcepts was poor. The major barriers dentists reported

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http://www.cochrane.org

mailto:[email protected]

310 Madhavji et al

were lack of time, lack of knowledge about evidence-based practice, and financial constraints.12,13 Dentistsbelieved that the development of practical guidelines,journal clubs, and peer-review sessions would help in-crease evidence-based practice in dentistry.12-14 Thereis currently no information about the attitudes andawareness, perceptions, and barriers to evidence-basedpractice in orthodontics.

The purpose of this study was to determine theattitudes and awareness of evidence-based practice inorthodontics. The term evidence-based practice waspurposefully not used during data collection. To determinethe initiatives that might be needed, barriers to usingscientific evidence were also examined. We hoped thatthis study would identify obstacles and solutions to incor-porating scientific literature into orthodontic practice.

MATERIAL AND METHODS

A survey was designed to examine the perceptions oforthodontists toward evidence-based practice in ortho-dontics. To minimize bias among participants, the termevidence-based practice was not used in the survey. In-stead, the questions were phrased as inquiries regardingthe use of scientific literature in orthodontics. Eachparticipant was asked to respond to a set of demographicquestions, followed by a set of questions pertaining toscientific literature in clinical orthodontics. Most surveyquestions were derived from similar studies conductedin the medical field.8-10,13,15,16 The questions weredivided into 5 categories: attitudes, awareness andcurrent practices, barriers, understanding of terms, andstatements to evaluate the participants’ awareness ofthe literature regarding major orthodontic controversiesand sources for guiding clinical practice. Institutionalreview board approval was granted before starting theresearch project.

The respondent sample was grouped according toage, whether they were currently involved in teachingat a university, and whether they had attained a master’sdegree. The age grouping included those 40 years of ageor younger, those between 41 and 60 years, and those 61years of age and older.

A pilot survey consisting of 45 questions was admin-istered to 7 faculty orthodontists at the Saint LouisUniversity Center for Advanced Dental Education. Thesurvey was discussed with each orthodontist to ensurethat the questions were unambiguous and valid. Thesurvey questions were modified and improved basedon their feedback.

Reliability was assessed by administering the surveyto 20 orthodontic residents on 2 separate occasions, 2weeks apart. The reliability analysis was used to identifyand eliminate problematic questions. The final survey

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(Appendix) consisted of 35 questions, including 6 per-taining to attitudes, awareness, and current practices;10 pertaining to barriers; 10 pertaining to the under-standing of terms; 7 statements on orthodontic issues;and 2 questions on solving clinical problems.

The final version of the survey was submitted to andapproved by the Board of Directors of the AmericanAssociation of Orthodontists (AAO). The board agreedto send the survey to all orthodontists and residents inthe United States with valid e-mail addresses. To main-tain the anonymity and privacy of the respondents, theAAO forwarded the link by e-mail. A reminder e-mailwas sent a week later. Results of the survey were re-corded and maintained anonymously on the SurveyMonkey server (Surveymonkey.com; Portland, Ore).

Statistical analysis

The survey data were analyzed by using SPSS soft-ware (version 14.0, SPSS, Chicago, Ill). Nonparametricstatistics were used to evaluate group differences be-cause the response variables were ordinal. The Mann-Whitney U test was used to test for differences betweenthe dichotomous groupings, and the Kruskal-Wallis Htest was used to compare the 3 age groups. The sourcesfor guiding clinical practice were nominal and evaluatedwith chi-square tests. A P value of\0.05 was consideredsignificant.

RESULTS

The survey was sent to 8455 orthodontists, it wasopened by 4771, and 1517 participated in the study.The response rate was 32%. The modal age group ofthe sample was 41 to 60 years, there were 79% menand 21% women, and the modal number of years inpractice group was 16 to 20 years (Table I). Twenty-eight percent of the respondents were involved in teach-ing; 59% of the respondents had master’s degrees.

Attitudes, awareness, and current practices

The orthodontists were generally positive toward theincorporation of scientific evidence into their practices(Table II). Most agreed that research influenced theirdaily work (80%) and that peer-reviewed journals arethe best source of evidence (82%). The majority alsoexpressed interest in more clinical guidelines (75%)and indicated that they read scientific journals at leastmonthly (91%). The majority of respondents were com-pletely unaware of the Cochrane database (55%), andonly a slight majority of respondents had used PubMedduring the past year (52%).

Those 40 years of age or younger were significantly(P \0.05) more likely to be interested in guidelines,

Journal of Orthodontics and Dentofacial Orthopedics

http://Surveymonkey.com

Table I. Comparison of our sample with the 2008 sur-vey of orthodontists in the United States and ortho-dontic demographics from the AAO in a personalcommunication

This studySurvey of

Keim et al22AAO,

April 2010Age (y) 41–50 (modal

value)52 (median

value)57

Men (%) 79 85 80Women (%) 21 15 20Time inpractice (y)

16–20 (modalvalue)

21 (medianvalue)

24

Mastersdegree (%)

59 NA 51

NA, Not applicable.

Madhavji et al 311

were more aware of Cochrane, and had used PubMed inthe past year to a greater extent than those over 40 yearsof age. Those 61 years of age and older were significantlymore likely to report reading journals than their youngercolleagues. Orthodontists involved in teaching were sig-nificantly more likely than their nonteaching colleaguesto have positive attitudes, awareness, and currentpractice toward the use of scientific literature in clinicalpractice. Orthodontists with master’s degrees reportedthat research influenced their daily work significantlymore frequently than those without master’s degrees.

Barriers

A large proportion, although not a majority of re-spondents, thought that the practical demands of work(46%) and insufficient clinical guidelines (44%) werebarriers to using scientific evidence in clinical practice(Table III). Most respondents indicated that the literatureis ambiguous and conflicting (59%).

Those who were less than 40 years of age cited prac-tical demands of work, insufficient clinical guidelines,and ambiguous literature as barriers more often thandid their older colleagues. Those between 41 and 60years of age were significantly more likely to cite thepractical demands of work as a barrier than those 61years and older. Conversely, those 40 years or youngerwere significantly more likely than their older colleaguesto express comfort with their skills to perform a literaturereview and were more likely to have access to researchpapers. Orthodontists involved in teaching felt morecomfortable with their skills to perform a literature re-view than did those not involved in teaching. Theywere also more likely to have access to research papers,and stated that the research is ambiguous and conflict-ing more often than those not involved in teaching.Orthodontists with a master’s degree were more likely

American Journal of Orthodontics and Dentofacial Orthoped

to be satisfied with their current knowledge than thosewithout degrees.

Understanding of terms

Less than a third of the orthodontists understood orcould explain the meaning ofmeta-analysis, odds ratio,sample power, confidence interval, and specificity(Table IV). Only 6% of the respondents understoodand could explain the meaning of PICO. However, thevast majority (87%) of respondents had some under-standing and wanted to learn more about these terms.

Practitioners aged 40 years or less were significantlymore likely than their older colleagues to understandall of the evidence-based terms (Table V). Those between41 and 60 years of age were significantly more likely tounderstand blinding and confidence interval than those61 years and older. Orthodontists currently involved inteaching were significantly more likely than those not in-volved in teaching to understand all terms. Those withamaster’s degree were significantly more likely to under-stand all terms than those without a master’s degree.

Statements regarding orthodontic issues

Most respondents (.75%) were consistent with thebest, current evidence regarding statements about ortho-dontic issues (Table VI). Those less than 61 years of agewere significantly (P\0.05) more likely than their oldercounterparts to agree with the current best evidencewith regard to the statement “2-phase treatment of ClassII Division 1 malocclusion is more efficient than 1-phasetreatment in the permanent dentition.” Those less than40 years of age were significantly (P\0.05) more likelythan their older colleagues to agree with the currentbest evidence with respect to the statement “third molarscause incisor crowding.” Orthodontists currently involvedin teachingwere significantly more likely to agree with thecurrent best evidence on 4 of the 7 statements than thosenot involved in teaching. Those with a master’s degreewere significantly more likely to agree with the currentbest evidence on the appropriate timing of a frenectomythan those without degrees.

Primary reason for changing practice philosophy

Regardless of their involvement with teaching, num-ber of years in practice, or whether they had a master’sdegree, orthodontists were most likely to changetheir practice philosophy based on “expert advice”(Table VII). Expert advice was followed most closely byclinical journals.

Compared with younger orthodontists, those over40 years of age were more likely to choose “clinical jour-nals” 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, 41–60years; group 3,$61 years), involvement in teaching (yes or no), and having a master’s degree (yes or no) for questionspertaining to attitudes, awareness, and current practices

Percentages of respondents Group differences

Stronglydisagree

or disagree Neutral

Agree orstronglyagree Age Involved in teaching Master’s degree

Research influences daily work 5% 15% 80% NS (P 5 0.130) Yes .no (P\0.001) Yes .no (P\0.013)Journals are the best sourceof evidence

3% 15% 82% NS (P 5 0.496) Yes .no (P\0.001) Yes .no (P\0.001)

Interested in more guidelines 6% 19% 75% 1 .2 5 3 (P\0.001) NS (P 5 0.110) NS (P 5 0.385)

Daily Weekly Monthly RarelyFrequency of reading journals 5% 33% 53% 9% 3 .1 5 3 (P\0.022) Yes .no (P\0.001) NS (P 5 0.960)

Unaware Some awareness Fully awareAwareness of Cochrane 55% 20% 25% 1 .2 5 3 (P\0.001) Yes .no (P\0.001) NS (P 5 0.095)

No Yes UncertainUsed Pub/Med in past year 47% 52% 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, 41–60years; group 3,$61 years), involvement in teaching (yes or no), and having a master’s degree (yes or no) for questionspertaining to barriers

Percentages of respondents Group differences

Stronglydisagree ordisagree Neutral

Agreeor strongly

agree Age Involved in teaching Master’s degreePractical demands of work 34% 20% 46% 1 .2 .3 (P\0.001) No .yes (P\0.001) NS (P 5 0.228)Insufficient clinical guidelines 21% 35% 44% 1 .2 5 3 (P\0.001) NS (P 5 0.436) NS (P 5 0.419)Literature is ambiguous/conflicting 15% 26% 59% 1 .2 5 3 (P\0.001) Yes .no (P\0.019) NS (P 5 0.105)Satisfied with current knowledge 45% 25% 30% NS (P 5 0.300) No .yes (P 5 0.006) Yes .no (P 5 0.009)

No Yes UncertainSkills to undertake a literature review 6% 79% 15% 1 .2 5 3 (P\0.001) Yes .no (P\0.001) NS (P 5 0.194)Comfortable performing a literature review 16% 67% 17% 1.2 5 3 (P\0.001) Yes .no (P\0.001) NS (P 5 0.160)I have access to published research papers 5% 85% 10% 1 .2 5 3 (P\0.016) Yes .no (P\0.001) NS (P 5 0.719)

No YesNo access to the Internet 87% 13% NS (P 5 0.317) NS (P 5 0.924) NS (P 5 0.742)Access to the Internet at home 9% 91% NS (P 5 0.999) NS (P 5 0.999) NS (P 5 0.999)Access to the Internet at work 3% 97% NS (P 5 0.922) NS (P 5 0.139) NS (P 5 0.670)

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

312 Madhavji et al

teaching were more likely to select “literature reviews”and less likely to select “colleague advice” than thosenot involved in teaching. Those without a master’s de-gree were more likely to select “colleague advice” thanthose with a master’s degree.

Dealing with clinical uncertainties

When faced with clinical uncertainties, orthodontistsmost often consulted colleagues and least often referredthe patient to another orthodontist (Table VIII).


Orthodontists aged 40 years or younger and those in-volved with teaching were more likely to consult col-leagues and least likely to proceed using their bestjudgment. Having a master’s degree had no effect onthe approach used to manage clinical uncertainties.

DISCUSSION

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


Table IV. Percentages of respondents for questions pertaining to terms used in the scientific literature

Understand andcould explainit to others

Someunderstanding

Don’t understandbut would like to

Don’t understandand don’t want to

Blinding 52% 28% 16% 4%Systematic review 50% 43% 5% 2%Meta-analysis 32% 36% 24% 8%RCT 75% 23% 1% 1%Strength of evidence 49% 43% 7% 1%Odds ratio 21% 40% 32% 7%Sample power 31% 40% 24% 6%Confidence interval 31% 39% 24% 6%Specificity 30% 44% 21% 5%PICO questions 6% 15% 66% 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 Involved in teaching Master’s degreeBlinding 1 .2 .3 (P\0.001) Yes .no (P\0.001) Yes .no (P 5 0.037)Systematic review 1 .2 5 3 (P\0.001) Yes .no (P\0.001) Yes .no (P\0.001)Meta-analysis 1 .2 5 3 (P\0.001) Yes .no (P\0.001) Yes .no (P 5 0.018)RCT 1 .2 5 3 (P\0.001) Yes .no (P\0.001) Yes .no (P\0.001)Strength of evidence 1 .2 5 3 (P\0.001) Yes .no (P\0.001) Yes .no (P\0.001)Odds ratio 1 .2 5 3 (P\0.001) Yes .no (P\0.001) Yes .no (P\0.001)Sample power 1 .2 5 3 (P\0.001) Yes .no (P\0.001) Yes .no (P\0.001)Confidence interval 1 .2 .3 (P\0.001) Yes .no (P\0.001) Yes .no (P\0.001)Specificity 1 .2 5 3 (P\0.001) Yes .no (P\0.001) Yes .no (P\0.001)PICO questions 1 .2 5 3 (P 5 0.022) 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.

Madhavji et al 313

high response rates to short, concise surveys, anonymity,the support of professional leaders, and professionalmembership.9,15,17 Because this was the first survey ofits kind in orthodontics, it was designed to becomprehensive and therefore longer. This study alsoinvolved a much larger overall number of respondents(n 5 1517) than other studies; anonymity and AAOsupport were used to maximize the response rate. Theresponse rate in this survey fell within the 10% to 58%range reported for other surveys conducted inorthodontics.18-20 It has also been suggested that theresponse rate among health-care professionals is decreas-ing.21 Importantly, the composition of our sample closelymatched the 2008 survey sample of Keim et al22 and, es-pecially, current orthodontic demographics reported bythe AAO (Table I). This supports the notion that our sam-ple represented the orthodontic population as a whole.

Most respondents had positive attitudes toward sci-entific evidence in clinical practice and reported currentpractices that were encouraging. However, the majorityof respondents’ lack of awareness of Cochrane highlightsan important resource that needs more exposure amongorthodontists. This agreed with studies in general


dentistry, which also found that most respondentswere unaware of Cochrane.13,16 Cochrane providessystematic reviews pertaining to all aspects of healthcare and is therefore an important source of the bestcurrent literature.13,16

Moreover, most respondents reported only partial orno understanding of 6 of the 10 terms used in the scien-tific literature. A survey conducted in 1998 also showedthat most physicians reported only some or no under-standing of evidence-based terms.9 Failure to under-stand these terms could hinder interpretation ofevidence, 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 accu-rately incorporated into clinical practice. For example,PICO was well understood by only 6% of the respon-dents, even though it is a major underpinning ofevidence-based research. PICO is an acronym for theprocess of specifying a scientific question based on theproblem (P), intervention (I), comparison (C), and out-come (O). It forms the basis of the evidence-based pro-tocol. Nonetheless, it was encouraging that mostorthodontists reported either some understanding of or


Table VI. Percentages of respondents and differences related to age groups (group 1,\40 years; group 2, 41–60years; group 3,$61 years), involvement in teaching (yes or no), and having a master’s degree (yes or no) for questionspertaining to major orthodontic controversies

Stronglyagree oragree Neutral

Disagreeor stronglydisagree Age Involved in teaching Master’s degree

2-phase tx more efficientthan 1-phase tx

12% 11% 77% 3 .2 5 1 (P 5 0.027) NS (P 5 0.206) NS (P 5 0.314)

Occlusion causes TMD 10% 8% 82% NS (P 5 0.117) No .yes (P 5 0.001) NS (P 5 0.336)Third molars cause incisorcrowding

4% 10% 86% 3 5 2 .1 (P\0.001) NS (P 5 0.243) NS (P 5 0.051)

Frenectomy performedbefore tx

3% 5% 92% NS (P 5 0.088) NS (P 5 0.208) No .yes (P 5 0.030)

Premolar extraction smilesare less esthetic

9% 10% 81% NS (P 5 0.219) No .yes (P 5 0.001) NS (P 5 0.645)

Extraction tx causes TMD 1% 2% 97% NS (P 5 0.273) No .yes (P 5 0.022) NS (P 5 0.483)Casts should be mountedfor diagnosis

7% 10% 83% NS (P 5 0.201) No .yes (P 5 0.013) 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” relatedto age groups, involvement in teaching, and having a master’s degree

Age* (P\0.001) Involved in teaching* (P\0.001) Master’s degree* (P 5 0.033)

#40 y 41–60 y $61 y No Yes No YesColleague advice 24% 12% 9% 17% 10% 18% 14%Expert advice 32% 35% 36% 36% 29% 36% 33%Clinical journals 15% 26% 29% 22% 25% 21% 23%Literature reviews 18% 13% 11% 12% 22% 14% 15%Other 11% 14% 15% 13% 14% 11% 15%Total 100% 100% 100% 100% 100% 100% 100%

*P\0.05.

314 Madhavji et al

expressed a desire to learn about these terms. This sug-gests that evidence-based learning initiatives would beuseful and welcome.

The responses to statements on orthodontic issueswere encouraging because they were in accordancewith the current best evidence. The majority of ortho-dontists agreed with the evidence-based stance on theissues examined. This suggests that most orthodontistshave some understanding of the current best evidenceon major topics of interest in orthodontics. Most ofthe issues examined are topics that are commonly dis-cussed at major conferences such as the AAO annualconference and other orthodontic society meetings.This might help explain why most respondents wereaware of the best current evidence even though theyare not necessarily practicing with an evidence-basedapproach. Furthermore, since most of these topics havebeen issues that have been around for many years, it isnot surprising that respondents could have had exposureto them without making a concerted effort to self-research the literature.


Identifying the barriers is an important step towardincreasing evidence-based practice in orthodontics. Fororthodontists, barriers include the ambiguous andconflicting nature of the literature, demands of work,and insufficient clinical guidelines. General dental prac-titioners, as well as nurses and physicians, also havereported uncertainty created by conflicting researchresults as the most frequently reported barrier.8,15

Literature that is ambiguous or conflicting makes itdifficult for practitioners to identify the most accurateanswer to a clinical question. This might be theimpetus for desiring more clinical guidelines.Systematic reviews have the potential to clarifyuncertainty pertaining to conflicting results and are animportant tool in the evidence-based approach.13,15

Systematic reviews follow explicit, documentedprotocols to reduce bias and aim to provide anobjective and thorough review of the literature.13,23

Because of the demands of clinical practice, ortho-dontists reported being too overburdened to sortthrough conflicting literature. Studies in medicine and


Table VIII. Percentages of respondents to the statement “when faced with clinical uncertainties, I usually” related toage groups, involvement in teaching, and having a master’s degree

Age* (P\0.001)Involved in teaching*

(P 5 0.015)Master’s degree(P 5 0.275)

#40 y 41–60 y $61 y No Yes No YesConsult colleagues 63% 41% 47% 49% 52% 52% 49%Consult textbooks 5% 2% 2% 4% 3% 4% 3%Consult the literature 21% 28% 26% 23% 29% 23% 26%Proceed using my best judgment 11% 29% 25% 24% 16% 21% 22%Refer 0% \1% \1% \1% 0% \1% 0%Total 100% 100% 100% 100% 100% 100% 100%

*P\0.05.

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dentistry have previously shown that clinicians do nothave the time or inclination to appraise the research ev-idence themselves.9,10,13,16 This suggests that researchevidence needs to be presented in formats that areeasier for orthodontists to appraise and understand.13

The introduction of guidelines and protocols developedby peers skilled in the evidence-based process might helpto overcome many of the barriers cited.9,15

Younger orthodontists were more interested in andaware of evidence in practice and understood the termsexamined better than did their older colleagues. However,those aged 40 years or less also reported more barriersthan their older colleagues, suggesting that they morefully understood the requirements of this approach.Those aged 40 years or less were more likely to agreewith the evidence-based stance on orthodontic issues ex-amined than their older colleagues. The recent introduc-tion of evidence-based courses to the curriculum and theshorter time span since finishing formal education mightexplain why the younger respondents are more in touchwith the evidence than their older colleagues.

Orthodontists currently involved in teaching hadmore positive attitudes toward evidence in practice andgreater awareness of evidence in practice, and reportedcurrent practices that were more consistent with the ev-idence. Those involved in teaching also perceived fewerbarriers and were less likely to report the demands ofwork as a barrier, perhaps because research is often em-phasized in teaching institutions. Teachers also reportedgreater understanding of the terms examined and weremore likely to adopt an evidence-based stance on the or-thodontic issues examined. Furthermore, their increasedaccess to papers and increased skills of assessing researchperhaps led them to be more skeptical of the current lit-erature. As expected, it appears that those involved witha teaching institution are more likely to be in touch withthe current best evidence.

Overall, there were few significant differences be-tween those with and those without a master’s degree.


However, those with a master’s degree were more likelyto report that research had a greater influence on theirpractice, and they had a greater understanding of theterms examined. Because a master’s degree requiresa hands-on approach to research, it might be expectedthat those with a master’s degree have a solid under-standing of the scientific method involved in conductingresearch.

The most frequently selected reason for changinga practice philosophy was expert advice; this is inconsis-tent with evidence-based practice. Although expertsgenerally have much experience, they can be biased.Without considering other sources of less biasedinformation as well, practitioners risk changing theirpractice philosophy on erroneous and unsubstantiatedinformation.24 This might lead to less efficient treat-ment, increased costs of treatment, or unnecessaryinconvenience to the patient.

The majority of orthodontists responded that theywould consult colleagues when faced with clinicaluncertainties. This is consistent with general dentalpractitioners, who tend to select friends and colleaguesas the primary source of advice when facing clinicaluncertainties.13,16 Whereas colleagues are a quick,inexpensive, and convenient source of advice, theycan have biases and conflicts of interest.16,24

Furthermore, colleagues’ advice might reflectexperience within their practices rather than bestpractices.13 Ideally, clinicians should consult electronicdatabases, such as PubMed and Cochrane, and seek ev-idence from systematic reviews or meta-analyses ofrandomized control trials when possible to identifythe best current evidence that can help guide decisionmaking.13 However, these sources are not always as ac-cessible as colleagues and might not cover the relevanttopic of interest.16 We hope that, with time and in-creased attention to these resources, more areas of clin-ical uncertainty will be addressed. When systematicreviews are not available, the hierarchy of evidence


316 Madhavji et al

will help to identify the best level of appropriate evi-dence that should be considered.

This study was not without limitations. Conductinga survey that requires self-completion of a questionnaireis not the most accurate method of gathering theperceptions of health-care professionals on a complexsubject.10,25 Furthermore, it has been shown thatrespondents’ verbal explanations of terms can differfrom written responses. However, it would have beendifficult to gather information from such a largenumber of people with a method other than a survey.

It was also possible that there are inconsistencies be-tween the respondents’ true vs reported attitudes,awareness, current practices, and understanding ofterms. Another problem was that respondents mighthave tried to make a good impression rather thandeclaring their true views on the subject, even thoughthe surveys were anonymous.

Although it is possible that the sample did not repre-sent the orthodontic population as a whole, it closelymatches current orthodontic demographics in terms ofage, sex, years in practice, and percentages with master’sdegrees (Table I). Nevertheless, those who were not insupport of using evidence in clinical practice couldhave chosen not to participate in the survey. If thiswere true, the results might have been skewed towarda more positive outlook on the use of evidence in clinicalpractice than was actually the case. Lastly, due to the im-mense breadth of evidence-based practice in orthodon-tics, it was not possible to explore all areas of thiscomprehensive subject. Further exploration is war-ranted, especially to identify solutions to increase theuse of literature in scientific practice.

CONCLUSIONS

Orthodontists expressed awareness and positive atti-tudes toward evidence-based practice. However, aware-ness of the Cochrane database was low, andunderstanding of evidence-based practice terminologywas poor. Most respondents currently seek advice fromcolleagues when faced with clinical uncertainties, andexpert advice was the most frequently selected reasonfor changing a practice philosophy. Conflicting andambiguous literature, lack of clinical guidelines, andpractical demands of work were the major barriersidentified in this study.

Because of the interest orthodontists have expressedin evidence-based practice, it appears to be an optimaltime to initiate educational programs that will enhancetheir knowledge, understanding, and use of it inorthodontics.


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

Question Abbreviation

Answer choices(assigned numeric

value in parentheses)Research influences my daily work. Research influences

daily workStrongly agree (2) Agree (1) Neutral (0) Disagree (�1) Strongly

disagree (�2)Peer-reviewed journals providethe best current evidencefor me to incorporate intomy practice.

Journals are thebest source ofevidence

Strongly agree (2) Agree (1) Neutral (0) Disagree (�1) Stronglydisagree (�2)

I would be interested in moreclinical practice guidelinesthat help guide treatmentdecision making.

Interested in moreguidelines


I read scientific peer-reviewed journals. Frequency ofreading journals

Daily (4) Weekly (3) Monthly (2) Rarely (1) Not at all (0)

Please evaluate your awarenessof the Cochrane Collaboration.

Awareness ofCochrane

Fully aware (2) Aware ofonly byname (1)

Not aware (�1)

I have used PubMed/Medlinein the past year to answera clinical question.

Used Pub/Medin past year

Yes (1) No (�1) Uncertain (0)

The practical demands of workmake it difficult for me to keepup to date with current bestevidence relating to practice.

Practicaldemands ofwork


There are not enough clinicalpractice guidelines in theliterature.

Insufficientclinical guidelines


The literature is often conflictingand ambiguous.

Literature isambiguous/conflicting


I am satisfied with mycurrent knowledgeand practice and feel it is sufficient.

Satisfied withcurrent knowledge




value in parentheses)I have the skills to undertake acomprehensive literature review.

Skills to undertakea literature review


I feel comfortable performing acomprehensive literature review.

Comfortable performinga literature review


I can obtain copies of publishedresearch papers relating tomy clinical practice.

I have access topublished researchpapers


I have no access to the Internet. No access tothe Internet

Yes (1) No (0)

I have access to the Internet at home. Access to theInternet at home

Yes (1) No (0)

I have access to the Internet at work. Access to theInternet at work

Yes (1) No (0)



value in parentheses)Blinding Blinding Understand and

could explainit to others (2)

Someunderstanding (1)

Don’t understandbut would liketo (�1)

Don’t understandand don’t wantto (�2)

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Madhavji et al 316.e1

Appendix. Continued



value in parentheses)Systematic review Systematic review Understand and

could explainit to others (2)

Some understanding (1) Don’t understandbut would liketo (�1)


Meta-analysis Meta-analysis Understand andcould explainit to others (2)



RCT RCT Understand andcould explainit to others (2)



Strength ofevidence

Strength ofevidence

Understand andcould explainit to others (2)




Odds ratio Odds ratio Understand andcould explainit to others (2)




Sample power Sample power Understand andcould explainit to others (2)




Confidence interval Confidence interval Understand andcould explainit to others (2)



Specificity Specificity Understand andcould explainit to others (2)



PICO questions PICO questions Understand andcould explainit to others (2)






value in parentheses)Two-phase treatment ofClass II Division 1 malocclusionis more efficient than 1-phasetreatment in the permanentdentition.

2-phase tx moreefficient than1-phase tx

Stronglyagree (2)

Agree (1) Neutral (0) Disagree (�1) Stronglydisagree (�2)

Occlusion is a primary etiologicfactor in TMD.

Occlusion causes TMD Stronglyagree (2)


Third molar eruption causesmandibular incisor crowding.

Third molars causeincisor crowding

Stronglyagree (2)


A frenectomy should be performedbefore orthodontic treatment.

Frenectomy performedbefore tx

Stronglyagree (2)


Premolar extraction smiles arerated significantly less estheticthan nonextraction smiles.

Premolar ext smilesare less esthetic

Stronglyagree (2)


Extraction treatment causes TMD. Extraction txcauses TMD

Stronglyagree (2)


All casts should be mounted toimprove diagnosis andtreatment.

Casts should bemounted for diagnosis

Stronglyagree (2)


I change my practice philosophybased primarily on:

I change my practicephilosophy basedprimarily on

Colleagueadvice (1)

Expertadvice (2)

Readingclinicaljournals (3)

Literaturereview (4)

Other (5)

When faced withclinical uncertainties,I usually:

When faced withclinicaluncertainties,I usually

Consult withcolleagues (1)

Consulttextbooks (2)

Consult theliterature (3)

Proceed withmy bestjudgment (4)

Refer (5)

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316.e2 Madhavji et al

Documents

Attitudes, awareness, and barriers toward evidence-based practice in orthodontics