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Clinical Decision Support Chairside Tools forEvidence-Based Dental Practice

George K. Merijohn, DDSPrivate Practice of Periodontics, San Francisco, CA, USA

James D. Bader, DDS, MPHDepartment of Operative Dentistry, University of North Carolina, Chapel Hill, NC, USA

Julie Frantsve-Hawley, RDH, PhDCenter for Evidence-Based Dentistry, American Dental Association, Chicago, IL, USA

Krishna Aravamudhan, BDS, MSCenter for Evidence-Based Dentistry, American Dental Association, Chicago, IL, USA

Evidence-based clinical decision support (EB-CDS) tools designed for chair-side use, help support the implementation of Evidence-Based Dentistry. EB-CDS tools organize available evidence and risk factors in order to facilitateclinical decision-making as well as to enhance rapid and effective transfer ofknowledge to the patient at the point of care. Gingival recession, root expo-sure, caries, dental sealants, decay prevention and topical fluoride guides arepresented and discussed. The Assess-Advise-Decide Approach, described inthis article, better enables patients to determine which course of action isin line with their preferences and values.

Key Words: clinical decision support tools, evidence-based dental practice, periodontics, gingival recession, rootexposure, caries, dental sealants, decay prevention, topical fluoride

The evidence-based dentistry (EBD) approach offers manyadvantages for clinicians and patients (see Sidebar 1), yetits implementation chairside, at the point-of-care, remainschallenging. Practical and effective aids are needed tohelp clinicians apply the most current scientific evidenceto clinical decision making and therapy. Evidence-basedclinical decision support (EB-CDS) tools designed forchairside use will support implementation of EBD. This ar-ticle briefly reviews concepts important to understanding

Corresponding Author: George K. Merijohn, DDS, 450 Sutter Street, Suite2336, San Francisco CA 94108, tel: 415-986-4664, fax: 415-986-1798;E-mail: [email protected] Evid Base Dent Pract 2008;8:119-1321532-3382/$34.00� 2008 Elsevier Inc. All rights reserved.doi:10.1016/j.jebdp.2008.05.016

EBD, describes a useful approach to clinical decision mak-ing, and introduces 3 EB-CDS tools for clinical practice.

CONCEPTS FOR EVIDENCE-BASEDDENTISTRY

The definition and description of evidence-based medi-cine offered by Sackett et al1 is an appropriate contextfor better understanding evidence-based dental practice(see Sidebar 2). The American Dental Association(ADA) has applied Sackett et al’s description of evi-dence-based medicine to dentistry as: An approach to oralhealth care that requires the judicious integration of systematicassessments of clinically relevant scientific evidence, relating tothe patient’s oral and medical condition and history, with thedentist’s clinical expertise and the patient’s treatment needsand preferences.2

SIDEBAR 1. The Evidence-Based Dental (EBD) Practice Advantage

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE

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SIDEBAR 2. Evidence-Based Medicine: Excerpts from Sackett et al1

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making deci-sions about the care of individual patients. The practice of evidence-based medicine means integrating individualclinical expertise with the best available external clinical evidence from systematic research.Individual clinical expertise is the proficiency and judgment that individual clinicians acquire through clinical ex-perience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective andefficient diagnosis and in the more thoughtful identification and compassionate use of individual patients’ predic-aments [risk factors], rights, and preferences in making clinical decisions about their care.Best External Clinical Evidence is clinically relevant research, often from the basic sciences of medicine, butespecially from patient-centered clinical research into the accuracy and precision of diagnostic tests (includingthe clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative,and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treat-ments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer.Good doctors use both individual clinical expertise and the best available external evidence, and neither alone isenough. Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent externalevidence may be inapplicable to or inappropriate for an individual patient. Without current best evidence, practicerisks becoming rapidly out of date, to the detriment of patients.


Central to evidence-based practice is individualizingtreatment based both on the strongest available evidenceand a patient’s particular risk factors.3 The AmericanDental Association encourages clinicians to use cariesrisk assessment strategies.4 The American Academy ofPeriodontology has recently recommended risk assess-ment for periodontal evaluation and treatment plan-ning.5 Caries Management by Risk Assessment, orCAMBRA, is also based on risk factor assessment.6

Clinical decision support (CDS) is invaluable in imple-menting the evidence-based practice approach at the pointof care (see Sidebar 3). In 2005, the National Coordinatorfor Health Information Technology in the United Statescommissioned the American Medical Informatics Associa-tion to develop a plan that would help advance CDS. Theresult of their efforts was the release, in 2006, of the Road-map for National Action on Clinical Decision Support.7,8

THE ASSESS-ADVISE-DECIDE APPROACHTO CHAIRSIDE CDS TOOL USE IN EBD

Experience with early chairside clinical decision supporttools with respect to both clinician and patient learninghas led to the understanding that when these tools areorganized into a few conceptual building blocks andlearning occurs both verbally and visually, informationoverload risks decrease and learning outcomes in-crease.9-11 The Assess-Advise-Decide Approach is a pa-tient-centered outcomes approach: For patients todecide their best course of action, clinicians’ need to ad-vise based on what is assessed (see Sidebar 4). This ap-proach is designed to simplify and clarify chairsideclinical decision making by organizing the process intoan easy-to-remember and quick-to-adopt 3-step approach:Assess-Advise- Decide.

SIDEBAR 3. A Roadmap for National Action on Clinical Decision Support8

Clinical decision support (CDS) provides clinicians, staff, patients, or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times to enhance health and health care.

It encompasses a variety of tools and interventions such as computerized alerts and reminders, clinical guidelines,order sets, patient data reports and dashboards, documentation templates, diagnostic support, and clinical workflowtools.

CDS has been effective in improving outcomes at some health care institutions and practice sites by makingneeded medical knowledge readily available to knowledge users. Yet at many other sites, CDS has been problematic,stalled in the planning stages, or never even attempted. As a result, relevant medical knowledge that should bebrought to bear is not always available or used for many health care decisions in this country. This is an importantcontributor to the well-documented problems and suboptimal performance of our health care system.

Further, growing consumerism throughout US society, along with efforts to shift the costs of care to patients andexpand patient participation in health care decisions, are driving increasing patient and consumer demand foraccess to reliable medical information. Achieving desirable levels of patient safety, care quality, patient centeredness,and cost-effectiveness requires that the health system optimize its performance through consistent, systematic, andcomprehensive application of available health-related knowledge—that is, through appropriate use of CDS.

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SIDEBAR 4. The Assess-Advise Decide Approach to Chairside CDS Tool Use


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The approach is consistent with the evidence-basedmedicine core concept of enabling patients to make bet-ter decisions.1 EB-CDS chairside tools incorporating theAsses-Advise-Decide Approach are designed to be simpleand easy to use. They support the clinician by facilitatingclinical decision making as well as knowledge transfer tothe patient rapidly and effectively at the point of care.

EVIDENCE-BASED CLINICAL DECISION-MAKING SUPPORT TOOLS

Three EB-CDS tools have been developed for use by clini-cians and their patients in conjunction with the AmericanDental Associations’ 2008 EBD Champion Conference.These tools incorporate the Assess-Advise-Decide Ap-proach to assist in tool adoption and use.

Tool 1: The Dental Chairside Guides tool forattached gingiva conditionsThe Dental Chairside Guide EB-CDS tool: Attached Gingiva isdesigned to organize many common root exposure risksfor individuals with either no attached gingiva or narrowband width of attached gingiva. It helps guide clinician as-sessment and enhances knowledge transfer to the patientat the point of care.

Today there is little strong scientific evidence support-ing the majority of decisions dental clinicians need tomake, including those concerning no attached gingivaor narrow band width of attached gingiva. In these situa-tions where evidence is of insufficient strength to stronglysupport clinical decision making, emphasizing individualrisk factor assessment is consistent with the evidence-based approach.3 Although clinical detection of root

Figure 1. The Dental Chairside Guides� Evidence-Based Clinical Decision Support (EB-CDS) Tool: Attached Gingiva.



Figure 2. Increasing root exposure. Courtesy G. K. Merijohn, DDS

exposure, no attached gingival, and/or narrow bandwidth of attached gingiva is often considered routine inthe practice setting, clinical decision making guided byindividual risk factor assessment is not common (see Fig-ures 1-7).

The Dental Chairside Guide EB-CDS tool: Attached Gingivais an example of an EB-CDS tool developed for clinical sit-uations where:

1. The strength of evidence available to guide clinicaldecision making is weak

Figure 3. No root exposure and no attached gingiva.Courtesy G. K. Merijohn, DDS

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2. Etiology is not well understood3. There are multiple risk factors4. The clinical presentation is common

The attached gingiva EB-CDS tool was developed forchairside use based on the September 2007 article pub-lished in the Journal of Evidence-Based Dental Practice titled‘‘Evidence-Based Clinical Decision Support Guide: Muco-gingival/Esthetics.’’3 It provides background referencesupport not covered in this article. This chairside tool isnot intended to assist the clinician in selecting a specificsurgical revision procedure. There exists a wide body ofevidence to support various surgical interventions.12-14

Figure 4. Root exposure: data are not available re-garding recession history or rate of change. CourtesyG. K. Merijohn, DDS

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Figure 5. The Dental Chairside Guides� Evidence-Based Clinical Decision Support (EB-CDS) Tool: AttachedGingiva.


This tool is designed to be used as a visual and verbalchairside aid that can streamline the process of advisingthe patient about the decision options for managingGroup 1 risks and deciding among surgical revision, sur-gical revision consultation, or wait and watch options(see Figures 1, 6, and 7). Clinician experience and judg-ment guided the organization of the most common risksinto Group 1 and Group 2 (see Figures 1, 6, and 7). Treat-ment recommendation decision pathways are based onrisk factor assessment and, when possible, risk manage-ment. An important feature of this chairside tool is theclinical decision support it provides when root exposurehistorical data are not available regarding teeth present-ing with root exposure and no attached gingiva or narrowband width of attached gingiva (see Figures 4 and 7).Dentists will find this tool useful for restorative caseplanning when cosmetic outcomes are critical. The DentalChairside Guide EB-CDS tool: Attached Gingiva can support

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the clinician in forecasting risks for exposure of restora-tion margins and/or root surfaces in restorative and or-thodontic cases. Additionally, it can enhance treatmentacceptance for prerestoration and preorthodontic inter-ventions aimed at preventing exposure of restorationmargins and/or root surfaces.

The Dental Chairside Guide EB-CDS tool: Attached Gingivais recommended to be used whenever no attached gingivaor a narrow band width of attached gingiva is detected. In-structions for use and implementation recommendationsare found in Figures 5, 6, and 7.

Tool 2: Current evidence for managing earlyenamel lesions and suspicious dentinal lesionsThis caries management tool address 2 different, butequally problematic treatment decisions that cliniciansoften encounter on occlusal surfaces. One is an early

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Figure 6. The Dental Chairside Guides� Evidence-Based Clinical Decision Support (EB-CDS) Tool: AttachedGingiva.


enamel lesion, (Figure 8) and the other is a suspiciousdentinal lesion (Figure 9). Deciding how to treat either ofthese lesions involves selecting a treatment approach torecommend from among several possible options. Rec-ommending the most appropriate option for a specificpatient requires consideration of several patient factorsas well as knowledge of the effectiveness of each of the op-tions. The tool is intended to help clinicians make theserecommendations by summarizing (1) the clinical pre-sentation of the lesion, (2) the evidence for effectivenessof each of 4 possible treatment options, and (3) patientfactors that should be considered in making the treat-ment recommendation (see Figures 8 and 9). These 3steps are presented in a left-to-right procession on themanagement tool using the rubric of ‘‘Assess-Advise-Decide.’’ The evidence for effectiveness of the treatmentoptions is adapted from a 2006 review of systematicreviews, updated to January 2008.15

Early enamel lesions

Identification (Assess). Early enamel lesions are rela-tively common findings in children and adolescents,

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and less common but not unknown in adults. The clini-cal presentation (see Sidebar 5) is summarized on theleft (Assess) section of the management tool (Figure 8).These lesions are often referred to as ‘‘incipient lesions’’but that designation is confusing because there are 2 dis-tinct clinical presentations that traditionally have beendescribed as ‘‘incipient’’ lesions, and it is important todistinguish between them. One presentation is the earlyenamel lesion described in the sidebar. The other pre-sentation is the ‘‘stick’’ of a probe in a pit or fissure.The ‘‘sticky fissure’’ is not necessarily a lesion, as fre-quently the resistance of the probe to withdrawal froma fissure is due to friction of the side of the probe againstthe fissure wall into which it has been wedged.16 Becauseof the possibility for false-positive identification of le-sions, as well as the possibility of damage to demineral-ized but as yet noncavitated enamel,17 vigorous probingof occlusal surfaces is no longer considered to be an ap-propriate diagnostic procedure.18 Thus, early enamel le-sions are detected entirely from visual inspection ofa thoroughly dried occlusal surface. The drying, 5 sec-onds or longer, is essential to visualize early stages of de-mineralization. The typical clinical presentation is

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Figure 7. The Dental Chairside Guides� Evidence-Based Clinical Support (EB-CDS) Tool: Attached Gingiva.


summarized on the left side of the EB-CDS managementtool, and it is expected that this description will be usefulas an occasional reference for clinicians not used tosearching for these lesions.

Effectiveness of treatment options (Advise). The mid-dle (Advise) section of the card summarizes the evidenceconcerning the effectiveness of 4 approaches to manag-ing individual early enamel lesions. The purpose of thesummary is to remind the clinician of what is known,and to help convey this information to a patient. The ev-idence is not plentiful for any of these options; it consistsat best of 2 or 3 studies. However, in most instances theavailable evidence is reasonably consistent. The ‘‘moni-tor’’ approach illustrates that progression of untreatedlesions is relatively slow, with between 5% and 16% ad-vancing within the space of a year following identifica-

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tion. It is not known, however, what proportion of suchlesions will ever progress. The effectiveness of attemptsto remineralize occlusal lesions is poorly understood,with a wide range of progression proportions, from 0%to 37% in the year following identification. In contrast,sealant effectiveness using light or autopolymerized resinhas been better well documented. Progression is low forthe first 3 years after treatment, rising to 11% after 5 yearswithout repair. Finally, restoration effectiveness has notbeen studied extensively for early enamel lesions, butthe available studies show a range of replacement ratesfor such restorations from 0% to 20% at 5 years, whichplaces it in the same ‘‘ball park’’ as sealants with respectto progression.

Patient factors (Decide). The right (Decide) side of theEB-CDS management tool presents patient factors

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Figure 8. Tool for management of early enamel lesions.


thought to be associated with the risk of lesion progres-sion, as well as initiation. These factors have not been spe-cifically associated with the progression of early enamellesions. The purpose of listing these factors is to remindthe clinician that their presence or absence, ie, a patient’scaries risk, should be considered in the process of recom-mending a treatment to a patient. If a patient’s caries risklevel is low, it is assumed that the risk of progression ofa given early enamel lesion is also reduced, and a lessinvasive treatment option may be considered with lesslikelihood of progression in the long term. Also, if themanagement tool is used to help the clinician inform pa-tients of treatment options and the rationale for the clini-cian’s recommendation, the presence of these risk factorsmay facilitate a discussion of appropriate treatment to re-duce a patient’s overall risk of caries. It must be noted thatthe focus of the management tool is on the treatment ofthe individual lesion, but a complete intervention shouldinclude attention to reducing caries risk as well.19 A pa-tient’s desire to maintain intact tooth structure, whilenot a ‘‘risk’’ factor, is also an important consideration.

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Suspicious dentinal lesions

Identification (Assess). There is no definitive descrip-tion of a suspicious dentinal lesion, each suspected lesionis just that, a specific location on an occlusal surface werea clinician thinks, but is not sure that a dentinal lesionexists (see Sidebar 6 and Figure 9). The very few studiesof suspicious lesions have demonstrated that whenopened, roughly half prove to be carious lesions extendingto, or into dentin. Thus, clinicians seem to be demonstrat-ing a reasonably balanced sense of uncertainty in designat-ing this kind of clinical appearance as suspicious. It isworth noting that these are not ‘‘hidden caries lesions,’’where visual inspection shows no suspicion of the cariesprocess, but radiographic examination reveals a dentinallesion. Here, there is no radiographic evidence of dentinalcaries.

Effectiveness of treatment options (Advise). The mid-dle of the EB-CDS management tool summarizes the ex-tremely scanty evidence on effectiveness of 4 alternativetreatment approaches. Monitoring leads to uncertain

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Figure 9. Tool for management of suspicious dentinal lesions.


outcomes, with studies reporting between 16% and 77% ofsuspicious lesions progressing in 2 or more years of obser-vation. There are no studies of attempts to remineralizesuspicious lesions, and ozone is ineffective. Sealants showgood effectiveness, with progression occurring in lessthan 20% of lesions in 2-, 3-, and 5-year studies. When sus-picious lesions are restored, the restoration replacementrate is less than 20% for 3 years and 25% or less for 5 years.

Patient factors (Decide). The patient factors thatshould be considered in making a recommendation arethe same as those listed for early enamel caries. Again,these risk factors have not been associated specificallywith progression of suspicious dentinal lesions, Ratherthey are associated with the rate of the initiation andprogression of caries lesions generally, and serve asreminders that the choice of intervention should

SIDEBAR 5. Early Enamel Lesions

Early occlusal enamel lesions are areas of initial demineralization associated with pits and fissures on occlusal sur-faces. They are usually characterized as a white or light brown discoloration along the edge of a fissure, with somesurface extension. The discoloration is a surface phenomenon; there is no underlying shadow. These lesions are notdetected by probing, although vigorous probing can prevent their remineralization. In some instances, a slightchange in the texture of the discolored surface may be detected using a very light sweeping stroke with an explorer.These lesions represent the first clinically detectable developmental stage of a caries lesion. At this stage there iseither no, or minimal demineralization of dentin, and the prismatic structure of the enamel is largely intact. Thereusually is no radiolucency apparent, but if present, it is confined to the enamel. These lesions may be detected usinglaser reflectance methods, depending on the detection threshold employed.


SIDEBAR 6. Suspicious Dentinal Lesions

Suspicious occlusal dentinal lesions are areas on occlusal surfaces where an examining clinician suspects a lesion ispresent, but cannot identify any definitive clinical signs, ie, frank cavitation or radiolucency. There are no standardcriteria that define such lesions; clinicians will respond to slightly different presentations as ‘‘suspicious’’ such as‘‘sticky’’ fissures, color, or dentinal shadow under the enamel.


consider the patients caries risk. Less invasive treatmentoptions become more attractive as the general cariesrisk, and hence the assumed risk of progression, declines.

Tool 3: Clinical decision support forprofessionally applied topical fluorideThe highest level of evidence available to clinicians forclinical decision making is an evidence-based clinical rec-ommendation or guideline. Such evidence is developedby an expert panel that follows a specific process to iden-tify systematic reviews on a topic, critically assess the sys-tematic reviews, and provide guidance as to how thecumulative body of evidence can be considered bythe clinician as part of the decision-making process.

In 2005, the ADA Council on Scientific Affairsconvened an expert panel to develop evidence-based clin-ical recommendations on professionally applied topicalfluoride. The expert panel critically assessed the evidenceand developed specific recommendations for the use oftopical fluorides as a primary preventive approach. Therecommendations are stratified by both age and cariesrisk. The ADA Council on Scientific Affairs approvedthe panel’s recommendations, which were published inthe August 2006 issue of the Journal of the American DentalAssociation (JADA).4 An executive summary of the fullreport also appeared in the issue.20 For detailed informa-tion, the reader is encouraged to consult both the fullreport4 and the executive summary.20

An evidence-based clinical decision support (EB-CDS)tool based on the topical fluoride clinical recommenda-tions has been developed (Figures 10 and 11). This toolis not intended to replace either the full report or theexecutive summary that appeared in JADA. Rather, thisEB-CDS tool is intended as a chairside aid that addressesthe key points to be considered in the decision-makingprocess.

The topical fluoride tool involves 3 steps: Assess, Ad-vise, and Decide. The first step is to assess the patientbased on 2 factors: age and caries risk status. There aremany systems to determine caries risk. One system, shownin Figure 11, considers both caries risk factors and carieshistory within the previous 3 years.

The second step is to advise the patient about evidencecurrently available on the topic. In this step, the clinicianshould consider the patient’s age and caries risk, and theevidence supporting the frequency and modality of topicalfluoride application (gel or varnish). Additionally, the rec-ommendations of the expert panel are summarized. The

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strength of each recommendation, which is based on thecorresponding evidence, is represented in a color spec-trum. In this spectrum, blue represents recommendationbased on the highest level of evidence, and the gradingsystem gradually decreases to red, representing recom-mendations based substantially on extrapolations or sub-jective opinions. Three additional factors also should beconsidered: (1) current evidence supports a 4-minute ap-plication for fluoride gel and foam; there is no clinicalevidence for the effectiveness of 1-minute applications;(2) there is limited evidence differentiating sodium fluo-ride (NaF) and acidulated phosphate fluoride (APF)gels; and (3) the recommendations have not been extrap-olated to foam because of limited evidence.

The third and final step of the topical fluoride tool isdecision making. Through the application of EBD, thisstep involves incorporating the scientific evidence, thepractitioner’s clinical judgment, and the patient’s needsand preferences. Ultimately, it is the patient’s role tomake final treatment decisions. The assess and advisesteps are key to providing information and recommenda-tions to be used by the patient in making decisions abouthis or her own treatment.

The first decision should determine if a topical fluoridetreatment is indicated. If treatment is indicated, the nextdecision should determine both the most appropriatetype of fluoride for the patient and its frequency of applica-tion. Because risk factors and the patient’s needs and pref-erences may change with time, the final decision shoulddetermine how often the patient should be reevaluated.

CONCLUSION

The 3 EB-CDS tools organize available evidence and riskfactors to facilitate clinical decision making as well asrapid and effective knowledge transfer to the patient atthe point of care. These tools are intended to augmentclinicians’ professional expertise, not replace it. EB-CDStools are not expected to triage each and every clinical sit-uation; however, they cover most common risk factors andprovide guidance, serving as practical chairside tools.Treatment recommendation decision pathways are basedon risk factor assessment and, when possible, risk man-agement.3

When CDS tools are organized into a few conceptualbuilding blocks and learning occurs both verbally andvisually (for both the clinician and the patient), informa-tion overload risks decrease and learning outcomes

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Figure 10. Professionally applied topical fluoride: evidence-based clinical recommendations—Assess, Advise, Decide.


increase.11 The Assess-Advise-Decide Approach better en-ables patients to decide which course of action is in linewith their preferences and values. EB-CDS chairside toolsincorporating this approach are designed to be simpleand easy to use. They support the clinician by facilitatingclinical decision making as well as knowledge transfer tothe patient rapidly and effectively at the point of care.As dentistry’s evidence base continually improves andknowledge transfer methodology advances, practicaland effective EB-CDS tools must continually be broughtup-to-date to reflect these developments.

REFERENCES

1. Sackett DL, Rosenberg WMC, Muir Gray JA, Haynes RB,Richardson WS. Evidence based medicine: what it is and what itisn’t. BMJ 1996;312:71-2.

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2. American Dental Association Web site. Evidence-based dentistry:

a glossary of terms. Available at: http://www.ada.org/prof/resources/

ebd/glossary.asp. Accessed July 19, 2008.3. Merijohn GK. The evidence-based clinical decision support guide:

mucogingival/esthetics. J Evid Base Dent Pract 2007;7:94.4. American Dental Association Council on Scientific Affairs. Profes-

sionally applied topical fluoride. Evidence-based clinical recommen-dations. J Am Dent Assoc 2006;137(8):1151-9.

5. Featherstone J, Adair S, Anderson M, Berkowitz R, Bird W, Crall J,

et al. Guidelines for the management of patients with periodontal

diseases. J Periodontol 2006;727:1608.6. Featherstone JDB, et al. Caries management by risk assessment: con-

sensus statement. J Calif Dent Assoc 2003;31(3):257-69.7. Newman MG. Clinical decision support complements evidence-

based decision making in dental practice. J Evid Base Dent Pract

2007;7:1-5.8. Osheroff JA, Teich, JM, Middleton BF, Steen EB, Wright A, Detmer

DE. A roadmap for national action on clinical decision support.

June 13, 2006. Available at: www.amia.org/inside/initiatives/cds/.

Accessed May 11, 2007.

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http://www.ada.org/prof/resources/ebd/glossary.asp

http://www.ada.org/prof/resources/ebd/glossary.asp

http://www.amia.org/inside/initiatives/cds/

Figure 11. Professionally applied topical fluoride: evidence-based clinical recommendations—Caries Risk Assessment.


9. Merijohn GK. Perio Access� Periodontal Decision-Making, Therapyand Record Keeping System. San Francisco, 1986.

10. Hall W, Merijohn GK, et al. Decision making in periodontology. Fac-tors influencing prognosis. Toronto: B.C.Decker, Inc.; 1988.

11. Mayer RE. Multi-media learning. Cambridge, MA: CambridgeUniversity Press; 2007.

12. Abrams A, Barringston E, Caton J, Genco R, Goodman S,Hildebrand C, et al. Ad Hoc Committee on the Parameters ofCare. Parameter on mucogingival conditions. Parameters of caresupplement. J Periodontol 2000;71(5):861-2.

13. Research, Science and Therapy Committee. Oral reconstructive andcorrective considerations in periodontal therapy. Academy Report.J Periodontol 2005;76(9):1588-99.

14. Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plasticsurgery for treatment of localized gingival recessions: a systematic re-view. J Clin Periodontol 2002;29(suppl. 3):178-94.

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15. Bader J, Shugars D. The evidence supporting alternative manage-ment strategies for early occlusal caries and suspected occlusal den-tinal caries. J Evid Base Dent Pract 2006;6:91-100.

16. Lussi A. Validity of diagnostic and treatment decisions of fissurecaries. Caries Res 1991;25:296-303.

17. Ekstrand K, Qvist V, Thylstrup A. Light microscope study of the effectof probing in occlusal surfaces. Caries Res 1987;21:368-74.

18. Stookey G. Should a dental explorer be used to probe suspectedcarious lesions: No—use of an explorer can lead to misdiagnosisand disrupt remineralization. J Am Dent Assoc 2005;36:1526-32.

19. Young D, Featherstone J, Roth J, Anderson M, Autio-Gold J,Christensen G, et al. Caries management by risk assignment: imple-mentation guidelines. J Calif Dent Assoc 2007;35:799-804.

20. ADA Council on Scientific Affairs. Professionally applied topicalfluoride: executive summary of evidence-based clinical recommen-dations. J Am Dent Assoc 2006;137(8):Special JADA Insert.

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