Barriers involved in the application of evidence-based dentistry principles

Original Contributions

Systematic Review Barriers involved in the application of evidence-based dentistry principles A systematic review Murilo Fernando Neuppmann Feres, PhD; Marina Guimarães Roscoe, PhD; Solange Alves Job, MSc; Jhony Baltazar Mamani, DDS; Graziela De Luca Canto, PhD; Carlos Flores-Mir, DSc ABSTRACT Background. The authors’ objective in this systematic review was to investigate the barriers involved in the application of evidence-based dentistry principles, as reported by dentists. The authors registered the protocol in the PROSPERO database. Types of Studies Reviewed. Eligible studies included qualitative and quantitative approaches, constituting information about barriers, collected through interviews, questionnaires, or conversation sessions. The authors searched databases and reference lists of preselected studies. After the selection process, the authors evaluated the included studies for potential risk of bias and collected either qualitative or quantitative data. Results. After the selection process, the authors included 35 studies, of which 16 were reported in this article. The authors synthesized and classified the barriers in 4 categories: self-related, evidencerelated, context-related, and patient-related barriers. Shortage of time and financial constraints were the barriers most frequently studied. However, the quantification of these barriers, as well as others, was not possible because of the variability of the results and methodological issues of the included studies. Conclusions and Practical Implications. The authors suggest the development of valid questionnaires and their use in representative samples to quantify the effects of specific barriers. The authors encourage practitioners to participate in educational programs focused on training in evidence-based dentistry abilities, in addition to seeking accessible and synthesized formats of reliable scientific knowledge. Key Words. Dentists; evidence-based dentistry; clinical decision making. JADA 2020:151(1):16-25 https://doi.org/10.1016/j.adaj.2019.08.011

T Copyright ª 2020 American Dental Association. All rights reserved.

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he traditional dental practice historically has been characterized by a great emphasis on the professionals’ training and experience.1 However, this traditional method of practice has been shifting increasingly to a new paradigm (that is, evidence-based practice [EBP]), which investigators have regarded as a practical method of using scientific evidence to elucidate clinical problems.2 This movement originated in the medical field but later was adopted in other health care areas, including dentistry, originating the term evidence-based dentistry (EBD).3 The corresponding literature indicates the potential benefits to be obtained by adopting EBD, such as the improvement of the clinician’s decision-making ability and an increase in confidence about the selected therapeutic approach; in the possibility of providing safer and more effective treatment modalities; and, as a consequence, in both the professional’s and the patient’s level of satisfaction.4 Investigators long have discussed the aspects involved in the access to knowledge and the uptake of technical innovations in the health care field.5-8 In this regard, investigators historically have documented dentists’ access to higher-quality knowledge sources as low9,10 and the implementation JADA 151(1)

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of new scientific advances in daily practice as generally problematic.11,12 The challenges involved in adopting and practicing EBD are still substantial.13-16 Discrepancies between available evidence and its use generally occur in all health care fields.17-24 However, investigations concerning the perceived barriers for EBPs mostly have been conducted in medical25 or public health26,27 fields. Also, in these areas, knowledge translation strategies deliberately conceived to overcome specific and preidentified barriers tended to be more influential in clinicians’ behavior.28,29 Similarly, a systematic analysis of the knowledge concerning the barriers dentists perceive potentially could guide future researchers in the conception, testing, and implementation of customized strategies. Therefore, our objective in this systematic review was to investigate the barriers involved in the application of EBD principles, as reported by dentists. METHODS This article is a partial report of a comprehensive review protocol, which we registered in the PROSPERO database (CRD42017056298). In this first article, we are reporting the results collected from studies that covered barriers involved in the application of EBD principles among dentists. We considered barriers to be any degree of difficulty perceived by dentists, either for themselves or for peers, and the application of EBD principles referred to any of the actions dentists are likely to perform during the application of scientific evidence to make clinical decisions when providing direct patient care in clinical settings. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement checklist.30 Information sources and search Initially, we sought studies of information provided by professionals for the following topics: n barriers involved in the application of EBD principles; n views, opinions, and perceptions of EBD principles, methods, and practices; n awareness of EBD principles, methods, and practices; n perceived and actual knowledge regarding EBD principles, methods, and practices; n EBD-related practice implementation behaviors; n willingness to adopt EBD-related practices. We performed a systematic search up through May 2018 using the following information sources: Cochrane Central Register of Controlled Trials, Embase, PubMed, Scopus, and Web of Science. The Google Scholar search (first 100 hits) and the reference lists of the preselected studies partially covered the gray literature. We used no restrictions concerning year or language of publication. We designed a search strategy first for the PubMed database (Appendix 1, available online at the end of this article), and we adapted it thereafter to the other information sources. Eligibility criteria Inclusion criteria were primary studies in which the investigators presented information collected through interviews, questionnaires, or conversation sessions with dentists. Exclusion criteria were studies including dentists but in which the investigators failed to report their results independently; studies in which the investigators exclusively enrolled dentistry students, dental hygienists, or other health care professionals; narrative or systematic reviews; meta-analyses; editorials; letters; records presenting knowledge translation strategies and initiatives (study protocols); examples of EBP approaches to specific clinical questions (case scenarios); practical guidelines toward EBP implementation; study protocols; and duplicate results. Study selection After we completed the searches, 2 of us (M.F.N.F., M.G.R.) independently preselected the resultant studies, through title and abstract, that supposedly aimed at identifying the previously mentioned topics. Afterward, we obtained the full-text documents of the potentially eligible studies, as well as the studies for which abstracts were at first unavailable or unclear for a definite decision. We discussed disagreements until we reached consensus. For the specific purpose of this article, the same 2 of us identified and separated from the studies included in the comprehensive review protocol those that covered the topic of barriers involved in

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ABBREVIATION KEY CD: Cannot determine. CT: Cannot tell. EBD: Evidence-based dentistry. EBP: Evidence-based practice. HVR: High-value research. NA: Not applicable. NE: Not evaluated. NM: Not mentioned. NR: Not reported. NUD*IST: Non-numerical Unstructured Data Indexing, Searching and Theorizing.

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the application of EBD principles. In case of disagreement, we retrieved full-text documents and discussed until reaching consensus. Data items and collection Two of us (M.F.N.F., M.G.R.) independently, with the use of standardized tables, extracted the characteristics of the included studies and their results regarding perceived barriers. Another one of us (C.F.M.) reviewed the extracted information afterward. We resolved disagreements by reexamining the original documents. If necessary, we contacted the authors of the selected studies and inquired about missing, unclear, or incomplete data Summary measures and synthesis of the results The study outcome was barriers involved in the application of EBD principles. The constant comparative analysis method, which investigators traditionally have used in qualitative primary studies, also are recommended for meta-syntheses (synthesis of findings from different qualitative research studies).31 We used these in this article as a method to synthetize qualitative results and to formulate a classification system of the professionals’ perceived barriers. We collected descriptive data for the quantitative results. We synthesized the data descriptively because we did not consider them adequate to perform meta-analyses because of the large degree of heterogeneity. Risk of bias in individual studies Two of us (S.A.J., J.B.M.) appraised the selected qualitative studies according to the Critical Appraisal Skills Programme.32,33 These same 2 of us used the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies34 to assess the quantitative studies because all of them were observational. We involved a third reviewer (M.G.R.) in case of disagreement. RESULTS Study selection and characteristics The selection process resulted in 35 articles35-69 for the overall comprehensive review protocol. From the overall identified studies, 16 covered barriers (12 quantitative studies37,38,45,49,55,60,64-69; 4 qualitative studies56,58,59,63), and we report them in this article (Figure). Appendix 24,13,24,70 (available online at the end of this article) indicates the specific reasons for exclusions after fulltext readings. eTables 1 and 237,38,45,49,55,56,58-60,63-69 provides detailed characteristics of the studies we report here. Summary of the results The topics that emerged from the analysis of the qualitative studies generated a comprehensive classification system, which we organized in 4 categories (self-related, evidence-related, contextrelated, and patient-related barriers) and subcategories. We also categorized the barriers obtained from quantitative studies according to the same classification system, and we have presented the combined results in the following sections. Self-related barriers Limited EBD Training or Skills According to the results of 1 qualitative study,63 dentists reported unawareness of EBD basics or principles as a limiting factor, which has been confirmed by variable numbers of respondents across one-half of the quantitative studies38,45,64,66,67,69 (14.9%69-69.2%38) (eTable 3).37,38,45,49,55,56,58-60,63-69 In addition, participants from 1 qualitative study reported as a perceived barrier an inability to find scientific documents,63 whereas participants from another cited an inability to appraise or interpret them.56 Although the investigators in 3 quantitative studies (third major barrier55; 3.0 on a 5.0-point scale65; and 5.4%69) presented the former, the investigators in 5 quantitative studies37,64,66,68,69 investigated the latter, with variable frequencies (5.3%69-85.0%66).

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Identification

Records identified through database searching including duplicates (n = 10,523)

Duplicates (n = 4,190)

Screening

Records screened (n = 6,333)

Records excluded (n = 6,214)

Full-text articles assessed for eligibility (n = 119)

Selection

Full-text articles excluded for the following reasons (n = 84) • Narrative or systematic reviews (n = 28) • Records presenting knowledge translation strategies or initiatives—study protocols (n = 14) • Questionnaires, interviews, or conversation sessions unrelated to the review question (n = 12) • Examples of evidence-based practice approach to specific clinical questions—case scenarios (n = 11) • Results derived from dentists’ reports not independently described (n = 4) • Editorials (n = 3) • Results derived from dentistry undergraduate students’ reports (n = 3) • Practical guidelines toward evidence-based practice implementation (n = 3) • No interviews, questionnaires, or conversation sessions were performed (n = 2) • Results derived from dental hygienists’ reports (n = 2) • Longitudinal study with the absence of baseline data (n = 1) • Letter (n = 1)

Postselection

Selected studies (n = 35)

Studies not concerning barriers (n = 19)

Studies included in this systematic review (n = 16) Figure. Flowchart of the study selection process.

Personal Inaccurate Views of EBD Professionals from 3 qualitative studies58,59,63 mentioned negative perceptions of EBD as perceived barriers (eTable 3).37,38,45,49,55,56,58-60,63-69 Dentists viewed EBD skeptically59; they perceived it as excessively academic,59,63 complicated,63 or as having limited value.58,59 Participants from 4 quantitative studies45,67-69 reported negative perceptions of EBD as well; according to results from 1 of the articles,67 EBD nonusers (12.9%-32.7%) perceived limited value in it (eTable 3).37,38,45,49,55,56,58-60,63-69 According to the responses collected from other quantitative studies,45,68,69 clinicians perceived EBD as somehow restricting their clinical freedom (5.2%45), or they considered EBD impractical (5.7%68) or time-consuming (5.0%69). JADA 151(1)

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Resistance to Change or Lack of Interest in EBD Investigators in 1 qualitative study59 mentioned that dentists might feel it difficult to change their routine (eTable 3).37,38,45,49,55,56,58-60,63-69 Investigators in a quantitative study38 investigated this barrier, and one-half of the participants (50.0%) confirmed that resistance to change might be influential. Evidence-related barriers Difficulties Inherent in Research and Literature Interviewees from all qualitative studies56,58,59,63 mentioned that research, or literature itself, might be perceived as a barrier (eTable 4).37,38,45,49,55,56,58-60,63-69 For instance, dentists perceived literature as inaccessible or unavailable (2 studies56,63). Investigators in 6 quantitative studies,38,45,55,65-67 also investigated this barrier, and the resultant frequencies were variable (11.1%45 to 91.7%66). The participants in 2 qualitative studies58,63 also considered research or literature to be insufficient (eTable 4).37,38,45,49,55,56,58-60,63-69 Considering diverse evidence formats, investigators in 3 quantitative studies45,49,69 documented variable frequencies of this barrier (5.5%69-44.0%49). According to results from 1 qualitative study,63 participants also perceived evidence as outdated. Concerning this specific barrier, 6.2% of the respondents from a quantitative study45 confirmed its influence, and professionals from another study assigned a 4.0 to 5.0 level of relevance (5.0-point scale), when referring specifically to guidelines, courses, or new devices.65 Interviewees from 1 qualitative study mentioned unclearness, referring particularly to the perceived subjectivity of outcome measures, research results, and clinical questions63 (eTable 4).37,38,45,49,55,56,58-60,63-69 Respondents from 1 of the quantitative studies65 assigned a 4.0 level of relevance (5.0-point scale) to this barrier. In addition, evidence was characterized as conflicting or ambiguous, according to 1 qualitative study.63 Results from 2 quantitative studies had discrepant frequencies (4.2%45-59.0%49), and dentists from another study attributed a 4.0 to 5.0 level of relevance (5.0-point scale) for this specific barrier.65 The interviewees from 1 qualitative study63 regarded evidence as confusing because of its academic language. Results from a quantitative study65 showed a 3.0 level of relevance (5.0-point scale) for this barrier. Participants of 1 of the qualitative studies,63 as well as from 1 quantitative study (2.9%-3.5%45), regarded evidence as unreliable (eTable 4).37,38,45,49,55,56,58-60,63-69 As detailed in 1 of the qualitative studies,63 some professionals noted a lack of interaction between practitioners and academics as a substantial barrier, for which respondents from 1 quantitative study65 assigned a 3.5 level of relevance (5.0-point scale). The analysis of the qualitative data also disclosed other barriers inherent in research and literature that were not considered in the quantitative studies (eTable 4).37,38,45,49,55,56,58-60,63-69 In this sense, evidence might be perceived as unrealistic or inapplicable (2 studies56,59) or even irrelevant or excessive.59 Difficulties Inherent in the Dental Knowledge Field Interviewees from 1 qualitative study63 reported dentistry, as a knowledge field, to be complex and constantly subject to changes (eTable 4).37,38,45,49,55,56,58-60,63-69 Investigators in 1 quantitative study65 (3.0 on a 5.0-point scale) investigated both barriers. Preference for Other Information Sources Respondents in all of the qualitative studies56,58,59,63 mentioned that clinicians tend to attribute more relevance to other information sources, such as their own experience or expertise, their peers’ advice, or more practice-focused sources (for example, reports of clinical cases,56,59,63 clinical conferences,56 or short-term courses56,59) (eTable 4).37,38,45,49,55,56,58-60,63-69 The investigators in 3 quantitative studies49,64,65 verified that respondents attributed more relevance to their own experience or expertise (eTable 4)37,38,45,49,55,56,58-60,63-69; 23.7%64 to 30.0%49 of the respondents reported being satisfied with their current knowledge and believing that their skills influence the outcomes (3.0 on a 5.0-point scale65). Participants from 2 qualitative studies56,59 mentioned that receiving peers’ advice appeared to be a great opportunity for socialization and networking. Investigators in 1 quantitative study65 measured the influence of this barrier, and the respondents attributed a 3.0 level of relevance to it (5.0-point scale).

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Context-related barriers Practical Issues Participants from all the studies included in this systematic review reported barriers related to practical issues (eTable 5).37,38,45,49,55,56,58-60,63-69 According to the results from the qualitative studies, shortage of time was related to heavy workload58,63 and no time to experiment with new techniques63 or to attend courses or conduct clinical audits.56,59,63 Participants in almost all quantitative studies (11 studies37,38,45,55,60,64-69) evaluated lack of time as a barrier, and the rates were variable (10.6%69-79.5%68). The respondents of 2 quantitative studies55,65 identified its relevance; the respondents ranked lack of time as the first major barrier in 1 study,55 and the participants characterized it with a 3.0 level of relevance (5.0-point scale) in the other study.65 Participants from all qualitative studies56,58,59,63 mentioned financial constraints as a substantial barrier (eTable 5).37,38,45,49,55,56,58-60,63-69 Financial constraints were associated with the perception that new materials and techniques are expected to be costly56,58,59 and with the lack of monetary incentives.63 Respondents in 6 quantitative studies37,38,60,64,68,69 also identified this barrier, with variable general frequencies (16.4%37-45.2%38), and extreme rates when referring specifically to the shortage of monetary incentives (7.7%69) and lack of reimbursement from eventual third-party payers (84.9%60). Unfavorable Work Conditions Participants from 3 qualitative studies56,59,63 reported issues related to public health system practice as obstacles (eTable 5).37,38,45,49,55,56,58-60,63-69 In this regard, the participants mentioned the strong focus on productivity,56,63 constraints set by managers,56,59,63 and issues related to the remuneration or the reimbursement systems.59,63 Regardless of the system (private or public) in which they worked, participants also perceived the work environment (2 studies58,59) as influential, with a motivating environment seeming to be more encouraging for dentists to seek knowledge or change their practices.58,59 Investigators in the quantitative studies did not investigate any of these unfavorable work conditions. Patient-related barriers Attitudes or Conditions Participants in 3 qualitative studies58,59,63 reported barriers related to patient attitudes or conditions (eTable 5).37,38,45,49,55,56,58-60,63-69 Regarding patient attitudes, interviewees from 2 studies59,63 mentioned that current patients sometimes have high expectations with treatment results and with the availability of the dentist.63 Participants also perceived patients’ low compliance with recommendations, including irregular attendance or little concern with oral health, as discouraging for oral health care professionals (2 studies59,63). According to the results from 2 qualitative studies,59,63 patients increasingly have exerted influence over clinical decisions, when they require specific therapeutic approaches59 or favor treatment modalities more liable to be reimbursed63 (eTable 5).37,38,45,49,55,56,58-60,63-69 According to the information extracted from 2 quantitative studies65,67 in which the investigators focused on this particular issue, participants regarded patient satisfaction as having a 3.0 level of relevance (5.0point scale) in 1 study,65, and 90.3% of the respondents cited potential objection to fees in the other study.67 The respondents in 2 qualitative studies58,63 mentioned that patient conditions may be influential, especially when it comes to their unique features, which make it hard to standardize treatments,63 or when they have limited access to oral health care, possibly associated with a decrease in quality of care58 (eTable 5).37,38,45,49,55,56,58-60,63-69 Investigators in the quantitative studies did not investigate these potential barriers. Risk of Bias Within Studies All of the qualitative studies fulfilled 8 of 10 items,32,33 indicating a high overall quality (eTable 6).32,34,37,38,45,49,55,56,58-60,63-69 We evaluated quantitative studies through 14 questions,34 of which 6 were applicable to cross-sectional observational studies with no group comparisons (eTable 6).32,34,37,38,45,49,55,56,58-60,63-69 In general, the studies were of poor quality, with the exception of 2 studies64,66 that fulfilled most of the items (4 of 6). eTable 632,34,37,38,45,49,55,56,58-60,63-69 also presents other features resulting from the quality appraisal of the studies.

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DISCUSSION We performed this systematic review with the objective of investigating perceived barriers involved in the application of EBD principles among dentists. To do that, we considered both quantitative and qualitative studies. Although we identified only a few qualitative studies,56,58,59,63 their overall methodological level was high. In examining these studies, we identified perceived barriers, which enabled the conception of a comprehensive classification system. We expect that the resultant categories and subcategories we presented here will be capable of including the diversity of barriers that dentists possibly can encounter during practice, and we recommend these categories for investigators to use as a potentially useful framework in future studies. Furthermore, we hope that, once practitioners are confronted with the obstacles listed here, they are encouraged to identify and overcome their own specific barriers. In addition to compiling and organizing perceived barriers, we also attempted in this systematic review to estimate the proportion of professionals who might be affected by specific obstacles, as well as quantifying the extent to which each barrier, if prevalent, might affect clinicians’ behavior. Although the authors of the full body of quantitative studies we have reported here had considered most of the barriers encountered in the qualitative studies, the quantitative studies’ authors did not investigate most of these barriers across these studies. Furthermore, there were still some remaining barriers that the investigators in the quantitative analyses neglected. In this regard, we believe that the negative views of EBD,56,59 unfavorable work conditions,56,58,59,63 preference for practice-focused sources of information,56,58,59,63 and patientrelated barriers58,59,63 deserve further quantitative investigation. Otherwise, some frequently investigated barriers across the quantitative studies referred to limited EBD training or skills,38,66 which also includes unawareness of EBD basics or principles45,64,67,69 and inability to appraise scientific documents.37,64,66,68,69 Despite being relatively more investigated, these barriers were of variable frequencies across the quantitative studies, and we could not determine their effect objectively. Still, against the possible deterrent influence of these barriers for future practitioners, we suggest that educational strategies should be incorporated increasingly in undergraduate curricula of dental schools worldwide.70,71 In addition, training in EBD abilities should be recommended especially for clinicians interested in improving their familiarity with EBDbased practices.72,73 Inaccessibility of evidence is 1 of the barriers that investigators have studied in a relatively more frequent fashion38,45,55,65-67; again, we observed variable frequencies. Concerning scientific knowledge accessibility, there is still serious debate about the free dissemination of science, such as in the case of open-access journals, particularly when “predatory” practices are associated with them.74,75 In addition, the authors of several studies have endorsed the increasing of evidence accessibility via format simplification, such as guidelines,61,65 electronic sources,76,77 summaries of systematic reviews,76,78,79,80,81 and clinical decision support systems.78 Nevertheless, despite the fact that these formats are expected to provide summarized and reviewed versions of the best evidence available, one cannot underestimate the educational importance of training students and practitioners on EBD skills, as previously pointed out. Across all quantitative studies, context-related barriers, such as financial constraints37,38,60,64,68,69 and shortage of time,37,38,45,60,63-69 were the most frequently investigated. Although frequencies for both were still variable, they appeared to reach relatively higher rates than those of the previously mentioned barriers. In this sense, these reinforced the necessity of creating and implementing initiatives to increase access, as well as to turn traditional scientific formats into more straightforward presentations, as previously mentioned. Therefore, researchers propose that systematic reviews are more broadly accessible81 and recommend that authors produce summarized versions,76,79 critical summaries, or guidelines associated with them.78,80,82 These formats, if rigorously composed, might be useful alternatives for practitioners to access, given that higher-quality research findings are expected to be presented in a more synthesized and contextualized way.77,78,79 Although in this study we collected important quantitative data on barriers against the application of EBD principles by dentists, readers must consider these results cautiously, given that most of the selected studies have limitations concerning reduced sample representation;

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therefore, they lack generalizability. Another limitation of this study is that in a relevant number of the included quantitative studies questions were not explicit38,55,60,64; for this reason, we could not determine whether dentists’ reports or opinions were based on their own experiences or related to those of other dentists in general. We could not perform a meta-analysis because the data had large variability. In addition, questionnaire studies might be inherently biased because interviewees tend to provide socially acceptable answers. Therefore, actual barriers might have been underreported. Respondents in most of the reported studies mentioned several barriers that are misconceptions regarding EBD and related topics rather than actual obstacles against its practice. Among some of the inaccurate views dentists seem to share, they see EBD essentially skeptically,59 as having limited value,58,59,67 as impractical,68 or even as a complicating factor.63 Furthermore, some dentists also perceived clinical guidelines as restrictive to their freedom45 and research and literature as somewhat unreliable45,63 or inapplicable.45,56,59 We hypothesize that such preconceived views of EBD might be because of unawareness of EBD basics or principles, as identified in several studies.45,63,64,67,69 These findings should encourage practitioners to attend educational programs specifically focused on EBD73 so they can confront potential biased views of EBD. In this scenario, the next scientific attempts could be directed to the creation and validation of pertinent questionnaires, with consideration of not only the variety of barriers exposed in this study but also the regional peculiarities and variations concerning type of practice (private or public). Once investigators generate reliable and customized assessment tools, we recommend their application in representative samples to identify specific barriers and to quantify their actual importance. Investigators in future studies also should overcome substantial methodological issues and improve generalizability. CONCLUSIONS In this systematic review, we summarized a large number of barriers involved in the application of EBD principles, according to dentists’ reports. Among all of the barriers we identified in this study, shortage of time and financial constraints were the most frequently investigated. However, we could not clearly determine the quantification of their influence, as well as the effect of other barriers, because of the variability of the results and methodological issues of the included studies. n SUPPLEMENTAL DATA Supplemental data related to this article can be found at https://doi.org/10.1016/j.adaj.2019.08.011.

Dr. Feres is an assistant professor, Department of Pediatric Dentistry, Division of Orthodontics, School of Dentistry of Ribeirao Preto, University of São Paulo, Avenida do Café, s/n - Campus da USP, Ribeirão Preto, São Paulo, Brazil CEP: 14040-904, e-mail [email protected]. Address correspondence to Dr. Feres. Dr. Roscoe is an associate professor, Department of Dentistry, Dental Research Division, Division of Orthodontics, Faculty of Dentistry, Guarulhos University, Guarulhos, São Paulo, Brazil. Ms. Job is a Master’s degree student, Department of Dentistry, Dental Research Division, Division of Orthodontics, Faculty of Dentistry, Guarulhos University, Guarulhos, São Paulo, Brazil.

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Mr. Mamani is an undergraduate student, Department of Dentistry, Dental Research Division, Division of Orthodontics, Faculty of Dentistry, Guarulhos University, Guarulhos, São Paulo, Brazil. Dr. Canto is an associate professor, Department of Dentistry, Brazilian Centre for Evidence-Based Research, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil. Dr. Flores-Mir is a professor, School of Dentistry, Division of Orthodontics, University of Alberta, Edmonton Clinic Health Academy, Edmonton, Alberta, Canada. Disclosure. None of the authors reported any disclosures.

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9. Osiobe SA. Use of information resources by health professionals: a review of the literature. Soc Sci Med. 1985; 21(9):965-973. 10. Strother EA, Lancaster DM, Gardiner J. Information needs of practicing dentists. Bull Med Libr Assoc. 1986; 74(3):227-230. 11. Nakata M, Kuriyama S, Mitsuyasu K, Morimoto M, Tomioka K. Transfer of innovation for advancement in dentistry: a case study on pit and fissure sealants’ use in Japan. Int Dent J. 1989;39(4):263-268.

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12. Chapko MK. Time to adoption of an innovation by dentists in private practice: sealant utilization. J Public Health Dent. 1991;51(3):144-151. 13. McGlone P, Watt R, Sheiham A. Evidence-based dentistry: an overview of the challenges in changing professional practice. Br Dent J. 2001;190(12):636-639. 14. Wasiak J, Shen AY, Tan HB, et al. Methodological quality assessment of paper-based systematic reviews published in oral health. Clin Oral Investig. 2016;20(3):399-431. 15. Saltaji H, Armijo-Olivo S, Cummings GG, Amin M, Flores-Mir C. Randomized clinical trials in dentistry: risks of bias, risks of random errors, reporting quality, and methodologic quality over the years 1955-2013. PLoS One. 2017;12(12):e0190089. 16. Wallace J, Byrne C, Clarke M. Improving the uptake of systematic reviews: a systematic review of intervention effectiveness and relevance. BMJ Open. 2014;4(10):e005834. 17. Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ. 2009;181(3-4):165-168. 18. Riley JL 3rd, Gordan VV, Rindal DB, et al.; Dental Practice-Based Research Network Collaborative Group. General practitioners’ use of caries-preventive agents in adult patients versus pediatric patients: findings from the Dental Practice-Based Research Network. JADA. 2010; 141(6):679-687. 19. Riley JL 3rd, Gordan VV, Ajmo CT, Bockman H, Jackson MB, Gilbert GH; Dental PBRN Collaborative Group. Dentists’ use of caries risk assessment and individualized caries prevention for their adult patients: findings from The Dental Practice-Based Research Network. Community Dent Oral Epidemiol. 2011;39(6):564-573. 20. Tellez M, Gray SL, Gray S, Lim S, Ismail AI. Sealants and dental caries: dentists’ perspectives on evidencebased recommendations. JADA. 2011;142(9):1033-1040. 21. Sayagh M, Maniere-Ezvan A, Vernet C, MullerBolla M. Therapeutic decisions in the presence of decayed permanent first molars in young subjects: a descriptive inquiry. Int Orthod. 2012;10(3):318-336. 22. Anabtawi MF, Gilbert GH, Bauer MR, et al.; and The DPBRN Collaborative Group. National Dental Practice-Based Research Network Collaborative Group. Rubber dam use during root canal treatment: findings from The Dental Practice-Based Research Network. JADA. 2013;144(2):179-186. 23. Juntgen LM, Sanders BJ, Walker LA, et al. Factors influencing behavior guidance: a survey of practicing pediatric dentists. Pediatr Dent. 2013;35(7):539-545. 24. Norton WE, Funkhouser E, Makhija SK, et al.; The National Dental Practice-Based Research Network Collaborative Group. Concordance between clinical practice and published evidence: findings from The National Dental Practice-Based Research Network. JADA. 2014;145(1):22-31. 25. Squires JE, Estabrooks CA, Gustavsson P, Wallin L. Individual determinants of research utilization by nurses: a systematic review update. Implement Sci. 2011;5(6):1. 26. Humphries S, Stafinski T, Mumtaz Z, Menon D. Barriers and facilitators to evidence-use in program management: a systematic review of the literature. BMC Health Serv Res. 2014;14(4):171. 27. Oliver K, Innvar S, Lorenc T, Woodman J, Thomas J. A systematic review of barriers to and facilitators of the use of evidence by policymakers. BMC Health Serv Res. 2014;3(14):2. 28. Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ. 1995; 153(10):1423-1431. 29. Grimshaw JM, Shirran L, Thomas R, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001;39(8 suppl 2):II2-II45. 30. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol. 2009;62(10):1006-1012.

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31. Evans D, Pearson A. Systematic reviews of qualitative research. Clin Eff Nurs. 2001;5(3):111-119. 32. Treloar C, Champness S, Simpson PL, Higginbotham N. Critical appraisal checklist for qualitative research studies. Indian J Pediatr. 2000;67(5):347-351. 33. Tong A, Palmer S, Craig JC, Strippoli GF. A guide to reading and using systematic reviews of qualitative research. Nephrol Dial Transplant. 2016;31(6):897-903. 34. National Heart, Lung, and Blood Institute. Quality Assessment Tool for Observational Cohort and CrossSectional Studies. Available at: https://www.nhlbi.nih.gov/ health-topics/study-quality-assessment-tools. Accessed October 2, 2019. 35. Abdelkarim A, Sullivan D. Perspectives of dental students and faculty about evidence-based dental practice. J Evid Based Dent Pract. 2014;14(4):165-173. 36. Afrashtehfar KI, Eimar H, Yassine R, Abi-Nader S, Tamimi F. Evidence-based dentistry for planning restorative treatments: barriers and potential solutions. Eur J Dent Educ. 2017;21(4):e7-e18. 37. Ahad M, Sukumaran G. Awareness, attitude and knowledge about evidence based dentistry among the dental practitioner in Chennai city. Res J Pharm Technol. 2016;9(11):1863-1866. 38. Al-Ansari A, El-Tantawi M. Factors affecting selfreported implementation of evidence-based practice among a group of dentists. J Evid Based Dent Pract. 2014; 14(1):2-8. 39. Allison PJ, Bedos C. Canadian dentists’ view of the utility and accessibility of dental research. J Dent Educ. 2003;67(5):533-541. 40. Bedos C, Allison P. Are the results of dental research accessible to Canadian dentists? J Can Dent Assoc. 2002; 68(10):602. 41. Bedos C, Allison P. Do Canadian dentists find dental research useful? J Can Dent Assoc. 2002;68(9): 540. 42. Bedos C, Allison PJ. Canadian dentists’ willingness to be involved in dental research. Int Dent J. 2004;54(2): 61-68. 43. Botello-Harbaum MT, Demko CA, Curro FA, et al. Information-seeking behaviors of dental practitioners in three practice-based research networks. J Dent Educ. 2013; 77(2):152-160. 44. Ciancio MJ, Lee MM, Krumdick ND, Lencioni C, Kanjirath PP. Self-perceived knowledge, skills, attitudes, and use of evidence-based dentistry among practitioners transitioning to dental educators. J Dent Educ. 2017;81(3):271277. 45. Guncu GN, Nemli SK, Carrilho E, et al. Clinical guidelines and implementation into daily dental practice. Acta Med Port. 2018;31(1):12-21. 46. Hinton RJ, McCann AL, Schneiderman ED, Dechow PC. The winds of change revisited: progress towards building a culture of evidence-based dentistry. J Dent Educ. 2015;79(5):499-509. 47. Iqbal A, Glenny AM. General dental practitioners’ knowledge of and attitudes towards evidence based practice. Br Dent J. 2002;193(10):587-591. 48. Kakudate N, Yokoyama Y, Sumida F, Matsumoto Y, Gordan VV, Gilbert GH. Use of clinical practice guidelines by dentists: findings from the Japanese dental practicebased research network. J Eval Clin Pract. 2017;23(1):96101. 49. Madhavji A, Araujo EA, Kim KB, Buschang PH. Attitudes, awareness, and barriers toward evidence-based practice in orthodontics. Am J Orthod Dentofacial Orthop. 2011;140(3):309.e2-316.e2. 50. Nayak PP, Rao NS, Ali AKS, Thadeethra MJ. Keeping up with dental literature: a study on continuing professional development among dental practitioners in Hubli-Dharwad, India. J Clin Diagn Res. 2017;11(4): ZC27-ZC30. 51. Qureshi A, Bokhari SA, Pirvani M, Dawani N. Understanding and practice of evidence based search

strategy among postgraduate dental students: a preliminary study. J Evid Based Dent Pract. 2015;15(2):44-49. 52. Sabounchi SS, Nouri M, Erfani N, Houshmand B, Khoshnevisan MH. Knowledge and attitude of dental faculty members towards evidence-based dentistry in Iran. Eur J Dent Educ. 2013;17(3):127-137. 53. Saxena P, Gupta SK, Mehrotra D, et al. Assessment of digital literacy and use of smart phones among Central Indian dental students. J Oral Biol Craniofac Res. 2018; 8(1):40-43. 54. Sbaraini A, Carter SM, Evans RW. How do dentists understand evidence and adopt it in practice? Health Educ J. 2012;71(2):195-204. 55. Selvi F, Ozerkan AG. Information-seeking patterns of dentists in Istanbul, Turkey. J Dent Educ. 2002;66(8): 977-980. 56. Stone SJ, Holmes RD, Heasman PA, McCracken GI. Continuing professional development and application of knowledge from research findings: a qualitative study of general dental practitioners. Br Dent J. 2014;216(11): E23. 57. Stout J, Berg J, Riedy C, Scott J, Cunha-Cruz J. Pediatric dentists’ willingness to participate in practicebased research networks. Pediatr Dent. 2014;36(1):39-45. 58. Wårdh I, Axelsson S, Tegelberg A. Which evidence has an impact on dentists’ willingness to change their behavior? J Evid Based Dent Pract. 2009;9(4):197-205. 59. Watt R, McGlone P, Evans D, et al. The facilitating factors and barriers influencing change in dental practice in a sample of English general dental practitioners. Br Dent J. 2004;197(8):485-489. 60. Wilder RS, Bell KP, Phillips C, Paquette DW, Offenbacher S. Dentists’ practice behaviors and perceived barriers regarding oral-systemic evidence: implications for education. J Dent Educ. 2014;78(9):1252-1262. 61. van der Sanden WJ, Mettes DG, Plasschaert AJ, van’t Hof MA, Grol RP, Verdonschot EH. Clinical practice guidelines in dentistry: opinions of dental practitioners on their contribution to the quality of dental care. Qual Saf Health Care. 2003;12(2):107-111. 62. Rabe P, Holmén A, Sjögren P. Attitudes, awareness and perceptions on evidence based dentistry and scientific publications among dental professionals in the county of Halland, Sweden: a questionnaire survey. Swed Dent J. 2007;31(3):113-120. 63. Hannes K, Norré D, Goedhuys J, Naert I, Aertgeerts B. Obstacles to implementing evidence-based dentistry: a focus group-based study. J Dent Educ. 2008;72(6):736744. 64. Yusof ZY, Han LJ, San PP, Ramli AS. Evidencebased practice among a group of Malaysian dental practitioners. J Dent Educ. 2008;72(11):1333-1342. 65. Spallek H, Song M, Polk DE, Bekhuis T, FrantsveHawley J, Aravamudhan K. Barriers to implementing evidence-based clinical guidelines: a survey of early adopters. J Evid Based Dent Pract. 2010;10(4):195-206. 66. Haron IM, Sabti MY, Omar R. Awareness, knowledge and practice of evidence-based dentistry amongst dentists in Kuwait. Eur J Dent Educ. 2012; 16(1):e47-e52. 67. Straub-Morarend CL, Marshall TA, Holmes DC, Finkelstein MW. Toward defining dentists’ evidencebased practice: influence of decade of dental school graduation and scope of practice on implementation and perceived obstacles. J Dent Educ. 2013;77(2):137-145. 68. Gupta M, Bhambal A, Saxena S, Sharva V, Bansal V, Thakur B. Awareness, attitude and barriers towards evidence based dental practice amongst practicing dentists of Bhopal City. J Clin Diagn Res. 2015;9(8):ZC49ZC54. 69. Yamalik N, Nemli SK, Carrilho E, et al. Implementation of evidence-based dentistry into practice: analysis of awareness, perceptions and attitudes of dentists in the World Dental Federation-European Regional Organization zone. Int Dent J. 2015;65(3):127-145.

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75. Beall J. Predatory publishers are corrupting open access. Nature. 2012;489(7415):179. 76. Bohannon J. Who’s afraid of peer review? Science. 2013;342(6154):60-65. 77. Chalmers I, Haynes B. Reporting, updating, and correcting systematic reviews of the effects of health care. BMJ. 1994;309(6958):862-865. 78. Song M, Spallek H, Polk D, Schleyer T, Wali T. How information systems should support the information needs of general dentists in clinical settings: suggestions from a qualitative study. BMC Med Inform Decis Mak. 2010;2(10):7. 79. Chambers D, Wilson PM, Thompson CA, Hanbury A, Farley K, Light K. Maximizing the impact of systematic reviews in health care decision

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making: a systematic scoping review of knowledgetranslation resources. Milbank Q. 2011;89(1):131156. 80. Perrier L, Mrklas K, Lavis JN, Straus SE. Interventions encouraging the use of systematic reviews by health policymakers and managers: a systematic review. Implement Sci. 2011;27(6):43. 81. Tricco AC, Cardoso R, Thomas SM, et al. Barriers and facilitators to uptake of systematic reviews by policy makers and health care managers: a scoping review. Implement Sci. 2016;12(11):4. 82. Lapinsky SE, Wax R, Showalter R, et al. Prospective evaluation of an internet-linked handheld computer critical care knowledge access system. Crit Care. 2004; 8(6):R414-R421.

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Appendix 1. Description of the PubMed search strategy. KEY WORDS Search Group No. 1

Search Group No. 2

dentist science OR dental practitioner AND OR knowledge OR dental professional OR research OR evidence

Search Group No. 3

Search Group No. 4

attitude* OR awareness OR perception* OR perceive* incorporat* OR implement* OR application AND OR apply OR applies OR utilization OR utilize* AND OR view* OR opinion* OR understanding OR behavior* OR behaviour* OR habit* OR facilitat* OR barrier* OR uptake* OR disseminat* OR diffuse* OR obstacle* OR challeng* OR adopt* OR transfer* OR translat* OR use*

Appendix 2. Articles excluded after full-text evaluation and reasons for exclusion. REFERENCE

REASON FOR EXCLUSION

Dorsey M, Overman P, Hayden WJ, Mayberry W, Requa-Clark B, Krust K. Relationships among and demographic predictors of dentists’ self-reported adherence to national guidelines. Soc Sci Med. 1991;32(11):1263-1268.

Example of EBP* approach to specific clinical questionsdcase scenario

Levine RA, Shanaman RH. Translating clinical outcomes to patient value: an evidence-based treatment approach. Int J Periodontics Restorative Dent. 1995;15(2):186-200.

Record presenting knowledge translation strategy or initiativedstudy protocol

Benn DK, Clark TD, Dankel DD 2nd, Kostewicz SH. Practical approach to evidence-based management of caries. J Am Coll Den. 1999;66(1):27-35.

Record presenting knowledge translation strategy or initiativedstudy protocol

Deahl ST 2nd. Conditions and tools for evidence-based dental practice. J Am Coll Dent. 1999;66(1):13-16.

Narrative or systematic review

Monaghan N. Human nature and clinical freedom: barriers to evidence-based practice? Br Dent J. 1999;186(5):208-209.

Editorial

Manski RJ. Translating clinical practice into evidence-based research through the use of technology. J Am Coll Dent. 2000;67(2):30-32.

Narrative or systematic review

Sutherland SE. The building blocks of evidence-based dentistry. J Can Dent Assoc. 2000;66(5):241-244.

Narrative or systematic review

McGlone P, Watt R, Sheiham A. Evidence-based dentistry: an overview of the challenges in changing professional practice. Br Dent J. 2001;190(12):636-639.

Narrative or systematic review

White BA, Maupomé G. Clinical decision-making for dental caries management. J Dent Educ. 2001;65(10): 1121-1125.

Record presenting knowledge translation strategy or initiativedstudy protocol

Benn DK. Applying evidence-based dentistry to caries management in dental practice: a computerized approach. JADA. 2002;133(11):1543-1548.

Record presenting knowledge translation strategy or initiativedstudy protocol

Forrest JL, Miller SA. Evidence-based decision making in action, part 1: finding the best clinical evidence. J Contemp Dent Pract. 2002;3(3):10-26.

Example of EBP approach to specific clinical questionsdcase scenario

Bonetti D, Johnston M, Pitts NB, et al. Can psychological models bridge the gap between clinical guidelines and clinicians’ behaviour? A randomised controlled trial of an intervention to influence dentists’ intention to implement evidence-based practice. Br Dent J. 2003;195(7):403-407.

Questionnaire, interview, or conversation sessions unrelated to the review question

Walker AE, Grimshaw J, Johnston M, Pitts N, Steen N, Eccles M. PRIME: PRocess modelling in ImpleMEntation researchdselecting a theoretical basis for interventions to change clinical practice. BMC Health Serv Res. 2003;3(1):22.

Record presenting knowledge translation strategy or initiativedstudy protocol

White BA. On translating new biologic-based interventions into dental practice. J Am Coll Dent. 2003;70(4): 30-34.

Narrative or systematic review

Bahrami M, Deery C, Clarkson JE, et al. Effectiveness of strategies to disseminate and implement clinical guidelines for the management of impacted and unerupted third molars in primary dental care: a cluster randomised controlled trial. Br Dent J. 2004;197(11):691-696.

Results derived from dentists’ reports not independently described

Clarkson JE. Getting research into clinical practice: barriers and solutions. Caries Res. 2004;38(3):321-324.

Narrative or systematic review

Cobban SJ. Evidence-based practice and the professionalization of dental hygiene. Int J Dent Hyg. 2004;2(4): 152-160.

Narrative or systematic review

Ismail A, Bader JD; ADA Council on Scientific Affairs and Division of Science. Evidence-based dentistry in clinical practice. JADA. 2004;135(1):78-83.

Example of EBP approach to specific clinical questionsdcase scenario

Armitage GC. Value of the evidence-based consensus conference. J Am Coll Dent. 2005;72(4):28-31.

Record presenting knowledge translation strategy or initiativedstudy protocol

* EBP: Evidence-based practice.

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Appendix 2. Continued REFERENCE

REASON FOR EXCLUSION

Ohrn K, Olsson C, Wallin L. Research utilization among dental hygienists in Sweden: a national survey. Int J Dent Hyg. 2005;3(3):104-111.

Results derived from dental hygienists’ reports

Bauer J, Chiappelli F, Spackman S, Prolo P, Stevenson R. Evidence-based dentistry: fundamentals for the dentist. J Calif Dent Assoc. 2006;34(6):427-432.

Narrative or systematic review

Bonetti D, Pitts NB, Eccles M, et al. Applying psychological theory to evidence-based clinical practice: identifying factors predictive of taking intra-oral radiographs. Soc Sci Med. 2006;63(7):1889-1899.

Questionnaire, interview, or conversation sessions unrelated to the review question

Kao RT. The challenges of transferring evidence-based dentistry into practice. J Calif Dent Assoc. 2006;34(6): 433-437.

Narrative or systematic review

Kao RT. The challenges of transferring evidence-based dentistry into practice. J Evid Based Dent Pract. 2006;6(1):125-128.

Narrative or systematic review

MacVicar R, Cunningham D, Cassidy J, McCalister P, O’Rourke JG, Kelly DR. Applying evidence in practice through small group learning: a Scottish pilot of a Canadian programme. Educ Prim Care. 2006;17(5):465-472.

Results derived from dentists’ reports not independently described

Merijohn GK. Implementing evidence-based decision making in the private practice setting: the 4-step process. J Evid Based Dent Pract. 2006;6(4):253-257.

Practical guideline toward EBP implementation

Wagenberg BD. Practice-based research: is it worthwhile? A clinician’s view. J Evid Based Dent Pract. 2006;6(2):164-166.

Editorial

Ballini A, Capodiferro S, Toia M, et al. Evidence-based dentistry: what’s new? Int J Med Sci. 2007;4(3):174-178.

Narrative or systematic review

Faggion CM Jr, Tu YK. Standard operating procedures approach for the implementation of the evidence-based dentistry concept in dental practice. J Evid Based Dent Pract. 2007;7(3):102-107.

Record presenting knowledge translation strategy or initiativedstudy protocol

Fontana M, Zero D. Bridging the gap in caries management between research and practice through education: the Indiana University experience. J Dent Educ. 2007;71(5):579-591.

Record presenting knowledge translation strategy or initiativedstudy protocol

Newman MG. Clinical decision support complements evidence-based decision making in dental practice. J Evid Based Dent Pract. 2007;7(1):1-5.

Narrative or systematic review

Van der Sanden WJ, Nienhuijs ME, Mettes TG. The role of guidelines and systematic reviews in oral healthcare [in Dutch]. Ned Tijdschr Tandheelkd. 2007;114(4):179-186.

Narrative or systematic review

Clarkson JE, Turner S, Grimshaw JM, et al. Changing clinicians’ behavior: a randomized controlled trial of fees and education. J Dent Res. 2008;87(7):640-644.

No interview, questionnaire, or conversation sessions were performed

DeRouen TA, Hujoel P, Leroux B, et al; Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry. Preparing practicing dentists to engage in practice-based research. JADA. 2008;139(3):339-345.

Record presenting knowledge translation strategy or initiativedstudy protocol

Frantsve-Hawley J, Meyer DM. The evidence-based dentistry champions: a grassroots approach to the implementation of EBD. J Evid Based Dent Pract. 2008;8(2):64-69.

Record presenting knowledge translation strategy or initiativedstudy protocol

Hadley J, Hassan I, Khan KS. Knowledge and beliefs concerning evidence-based practice amongst complementary and alternative medicine health care practitioners and allied health care professionals: a questionnaire survey. BMC Complement Altern Med. 2008;8:45.

Results derived from dentists’ reports not independently described

Spielman AI, Wolff MS. Overcoming barriers to implementing evidence-based dentistry. J Dent Educ. 2008;72(3):263-264.

Letter

Bonetti D, Johnston M, Clarkson J, Turner S. Applying multiple models to predict clinicians’ behavioural intention and objective behaviour when managing children’s teeth. Psychol Health. 2009;24(7):843-860.

Questionnaire, interview, or conversation sessions unrelated to the review question

Bonetti D, Johnston M, Pitts NB, et al. Knowledge may not be the best target for strategies to influence evidencebased practice: using psychological models to understand RCT effects. Int J Behav Med. 2009;16(3):287-293.

Questionnaire, interview, or conversation sessions unrelated to the review question

Bonetti D, Young L, Black I, Cassie H, Ramsay CR, Clarkson J. Can’t do it, won’t do it! Developing a theoretically framed intervention to encourage better decontamination practice in Scottish dental practices. Implement Sci. 2009;4:31.

Questionnaire, interview, or conversation sessions unrelated to the review question

Gillette J. Answering clinical questions using the principles of evidence-based dentistry. J Evid Based Dent Pract. 2009;9(1):1-8.

Example of EBP approach to specific clinical questionsdcase scenario

Gillette J, Matthews JD, Frantsve-Hawley J, Weyant RJ. The benefits of evidence-based dentistry for the private dental office. Dent Clin North Am. 2009;53(1):33-45.

Narrative or systematic review

Moskowitz EM. Evidence-based dentistry for you and me: the challenge of using a new educational tool. N Y State Dent J. 2009;75(6):48-51.

Narrative or systematic review

Soheilipour S, Dunne SM, Newton JT, Jabbarifar SE. Implementation of clinical practice guidelines in dental settings. J Evid Based Dent Pract. 2009;9(4):183-193.

Example of EBP approach to specific clinical questionsdcase scenario

Bonetti D, Johnston M, Clarkson JE, et al. Applying psychological theories to evidence-based clinical practice: identifying factors predictive of placing preventive fissure sealants. Implement Sci. 2010;5:25.

Questionnaire, interview, or conversation sessions unrelated to the review question

Chambers DW. Evidence-based dentistry. J Am Coll Dent. 2010;77(4):68-80.

Narrative or systematic review

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Appendix 2. Continued REFERENCE

REASON FOR EXCLUSION

Clarkson JE, Ramsay CR, Eccles MP, et al. The translation research in a dental setting (TRiaDS) programme protocol. Implement Sci. 2010;5:57.

Record presenting knowledge translation strategy or initiativedstudy protocol

Perrier L, Mrklas K, Shepperd S, Dobbins M, McKibbon KA, Straus SE. Interventions encouraging the use of systematic reviews in clinical decision-making: a systematic review. J Gen Intern Med. 2011;26(4):419-426.

Narrative or systematic review

Virtanen JI, Tseveenjav B, Wang NJ, Widström E. Nordic dental hygienists’ willingness to perform new treatment measures: barriers and facilitators they encounter. Scand J Caring Sci. 2011;25(2):311-316.

Results derived from dental hygienists’ reports

Abt E, Bader JD, Bonetti D. A practitioner’s guide to developing critical appraisal skills: translating research into clinical practice. JADA. 2012;143(4):386-390.

Practical guideline toward EBP implementation

Kreulen CM, Mettes TG, Van der Sanden WJ, de Rijk AJ. The integration of science in the clinical dental programme at the University of Nijmegen [in Dutch]. Ned Tijdschr Tandheelkd. 2012;119(6):307-311.

Narrative or systematic review

Morténius H, Marklund B, Palm L, Fridlund B, Baigi A. The utilization of knowledge of and interest in research and development among primary care staff by means of strategic communication: a staff cohort study. J Eval Clin Pract. 2012;18(4):768-775.

Longitudinal study with the absence of baseline data

Forrest JL, Overman P. Keeping current: a commitment to patient care excellence through evidence based practice. J Dent Hyg. 2013;87(suppl 1):33-40.

Narrative or systematic review

Gordan VV; National Dental PBRN Collaborative Group. Translating research into everyday clinical practice: lessons learned from a USA dental practice-based research network. Dent Mater. 2013;29(1):3-9.

Record presenting knowledge translation strategy or initiativedstudy protocol

O’Donnell JA, Modesto A, Oakley M, Polk DE, Valappil B, Spallek H. Sealants and dental caries: insight into dentists’ behaviors regarding implementation of clinical practice recommendations. JADA. 2013;144(4):e24-e30.

Example of EBP approach to specific clinical questionsdcase scenario

Sbaraini A, Carter SM, Evans RW, Blinkhorn A. How do dentists and their teams incorporate evidence about preventive care? An empirical study. Community Dent Oral Epidemiol. 2013;41(5):401-414.

Example of EBP approach to specific clinical questionsdcase scenario

Teich ST, Demko CA, Lang LA. Evidence-based dentistry and clinical implementation by third-year dental students. J Dent Educ. 2013;77(10):1286-1299.

Results derived from dentistry undergraduate students’ reports

Bahammam MA, Linjawi AI. Knowledge, attitude, and barriers towards the use of evidence based practice among senior dental and medical students in western Saudi Arabia. Saudi Med J. 2014;35(10):1250-1256.

Results derived from dentists’ reports not independently described

Bonetti DL. Evidence not practised: the underutilisation of preventive fissure sealants. Br Dent J. 2014;216(7):409413.

Narrative or systematic review

Govindaiah S, Bhoopathi V. Dentists’ levels of evidence-based clinical knowledge and attitudes about using pitand-fissure sealants. JADA. 2014;145(8):849-855.

Questionnaire, interview, or conversation sessions unrelated to the review question

Kishore M, Panat SR, Aggarwal A, Agarwal N, Upadhyay N, Alok A. Evidence based dental care: integrating clinical expertise with systematic research. J Clin Diagn Res. 2014;8(2):259-262.

Narrative or systematic review

Norton WE, Funkhouser E, Makhija SK, et al.; National Dental Practice-Based Research Network Collaborative Group. Concordance between clinical practice and published evidence: findings from The National Dental Practice-Based Research Network. JADA. 2014;145(1):22-31.

Questionnaire, interview, or conversation sessions unrelated to the review question

Appleby B, Roskell C, Daly W. What are health professionals’ intentions toward using research and products of research in clinical practice? A systematic review and narrative synthesis. Nurs Open. 2015;3(3):125-139.

Narrative or systematic review

Braspenning JC, Mettes TG, Van der Sanden WJ, Wensing MJ. Evidence-based clinical oral healthcare guidelines, 4: adherence requires an implementation strategy [in Dutch]. Ned Tijdschr Tandheelkd. 2015;122(3):148-155.

Narrative or systematic review

Brignardello-Petersen R, Carrasco-Labra A, Glick M, Guyatt GH, Azarpazhooh A. A practical approach to evidence-based dentistry, III: how to appraise and use an article about therapy. JADA. 2015;146(1):42.e1-49.e1.

Practical guideline toward EBP implementation

Elouafkaoui P, Bonetti D, Clarkson J, Stirling D, Young L, Cassie H. Is further intervention required to translate caries prevention and management recommendations into practice? Br Dent J. 2015;218(1):E1.

Questionnaire, interview, or conversation sessions unrelated to the review question

van Dam BA, Oosterkamp BC, den Boer JC, Bruers JJ. Evidence-based clinical practice guidelines in oral care, 3: support for the development of clinical practice guidelines [in Dutch]. Ned Tijdschr Tandheelkd. 2015;122(2):8592.

Narrative or systematic review

Van der Sanden WJ, Gorter R, Tams J. Evidence-based clinical guidelines in dental practice, 6: guidelines for clinical practice in dental education [in Dutch]. Ned Tijdschr Tandheelkd. 2015;122(9):475-482.

Narrative or systematic review

Carrilho E, Dianiskova S, Guncu GN, Karakoca Nemli S, Melo P, Yamalik N. Practical implementation of evidencebased dentistry into daily dental practice through a short time dependent searching method. J Evid Based Dent Pract. 2016;16(1):7-18.

No interview, questionnaire, or conversation sessions were performed

Coleman BG, Johnson TM, Erley KJ, Topolski R, Rethman M, Lancaster DD. Preparing dental students and residents to overcome internal and external barriers to evidence-based practice. J Dent Educ. 2016;80(10): 1161-1169.

Narrative or systematic review

Isham A, Bettiol S, Hoang H, Crocombe L. A systematic literature review of the information-seeking behavior of dentists in developed countries. J Dent Educ. 2016;80(5):569-577.

Narrative or systematic review

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Appendix 2. Continued REFERENCE

REASON FOR EXCLUSION

Nalliah RP. Clinical decision making: choosing between intuition, experience and scientific evidence. Br Dent J. 2016;221(12):752-754.

Editorial

Straub-Morarend CL, Wankiiri-Hale CR, Blanchette DR, et al. Evidence-based practice knowledge, perceptions, and behavior: a multi-institutional, cross-sectional study of a population of U.S. dental students. J Dent Educ. 2016;80(4):430-438.

Results derived from dentistry undergraduate students’ reports

Dawett B. DCPs and research in general dental practice. Br Dent J. 2017;222(4):307-309.

Narrative or systematic review

Marshall TA, Straub-Morarend CL, Guzmán-Armstrong S, Handoo N. Evidence-based dentistry: assessment to document progression to proficiency. Eur J Dent Educ. 2017;21(4):207-213.

Record presenting knowledge translation strategy or initiativedstudy protocol

Mertz E, Wides C, White J. Clinician attitudes, skills, motivations and experience following the implementation of clinical decision support tools in a large dental practice. J Evid Based Dent Pract. 2017;17(1):1-12.

Questionnaire, interview, or conversation sessions unrelated to the review question

Morténius H, Twetman S. Creating research and development awareness among dental care professionals by use of strategic communication: a 12-year intervention study. BMC Oral Health. 2017;17(1):164.

Questionnaire, interview, or conversation sessions unrelated to the review question

Nieminen P, Virtanen JI. Information retrieval, critical appraisal and knowledge of evidence-based dentistry among Finnish dental students. Eur J Dent Educ. 2017;21(4):214-219.

Results derived from dentistry undergraduate students’ reports

Akbar AA, Al-Sumait N, Al-Yahya H, Sabti MY, Qudeimat MA. Knowledge, attitude, and barriers to fluoride application as a preventive measure among oral health care providers. Int J Dent. 2018;2018:8908924.

Example of EBP approach to specific clinical questionsdcase scenario

Alanzi A, Faridoun A, Kavvadia K, Ghanim A. Dentists’ perception, knowledge, and clinical management of molar-incisor-hypomineralisation in Kuwait: a cross-sectional study. BMC Oral Health. 2018;18(1):34.

Example of EBP approach to specific clinical questionsdcase scenario

Goodwin TL, Brocklehurst PR, Williams L. The knowledge mobilisation challenge: does producing evidence lead to its adoption within dentistry? Br Dent J. 2018;224(3):136-139.

Record presenting knowledge translation strategy or initiativedstudy protocol

Polk DE, Weyant RJ, Shah NH, Fellows JL, Pihlstrom DJ, Frantsve-Hawley J. Barriers to sealant guideline implementation within a multi-site managed care dental practice. BMC Oral Health. 2018;18(1):17.

Example of EBP approach to specific clinical questionsdcase scenario

Schwendicke F, Foster Page LA, Smith LA, Fontana M, Thomson WM, Baker SR. To fill or not to fill: a qualitative cross-country study on dentists’ decisions in managing non-cavitated proximal caries lesions. Implement Sci. 2018;18(1):54.

Example of EBP approach to specific clinical questionsdcase scenario

van der Zande MM, Gorter RC, Bruers JJM, Aartman IHA, Wismeijer D. Dentists’ opinions on using digital technologies in dental practice. Community Dent Oral Epidemiol. 2018;46(2):143-153.

Questionnaire, interview, or conversation sessions unrelated to the review question

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eTable 1. Characteristics of the qualitative studies reported in the systematic review. STUDY

PRACTICE SITE

Qualitative Watt and Colleagues,59 2004

SAMPLE Participants, No.

United Kingdom North of England: 51.6% Midlands: 11.6% South of England: 36.6%

60

Characteristics Dentist Male: 72.0% Age > 40 years: 55.0% Practice: Associate 20.0% Sole owner 50.0% Single handed 32.0% Experience: NR*

ASSESSMENT TOOL Recruitment

Characteristics

Analysis

Purposive sampling

Format: individual interviews

Collection: audio record with transcription

Criteria: variability in age, sex, practice features, qualification, changing practice behaviors, and geographic location

Conduction: NR

Content analysis: constant comparative analysis

Guide: semistructured interview guide (based on 6 previous pilot interviews)

Codes, themes, labels, categories: NR

Software: NUD*IST† Topics: barriers, resistance and (Version 4) predisposition to change

Hannes and Colleagues,63 2008

Belgium Brabant: 38.0% Antwerp: 21.5% East Flanders: 20.3% West Flanders: 19.0% Limburg: 1.2%

79

Dentist Female: 57.0% Age: mean 42 y (range, 27-62 y) Practice: Individual: 60.8% Full time: 62.0% University or scientific organization: 21.5% Experience: mean 18 y

Time: z 60 minutes

Reliability: NR

Theoretical sampling

Format: 6 focus groups (> 12 participants each)

Collection: audio record and transcription

Criteria: variability in interest, expertise in EBD,‡ and geographic location

Conduction: 1 Content analysis: constant independent moderator comparative analysis

Guide: semistructured interview guide

Codes, themes, labels, categories: 2 independent investigators and 1 investigator for disagreements

Topics: specific barriers Software: ATLAS-ti§ to implement EBD

Wårdh and Colleagues,58 2009

Sweden Västmanland County

15

Dentist Sex: NR Age: NR Practice: NR Experience: NR

Time: 90-120 min

Reliability for coding: 70.0%-96.0%

Strategic (purposive) sampling

Format: 3 focus group discussions (5 participants each)

Collection: audio record with transcription

Criteria: variability in age, sex, experience of practice, and geographic location

Conduction: 1 investigator

Content analysis: constant comparative analysis

Guide: semistructured Codes, themes, labels, interview guide (based categories: NR on a previous objective questionnaire) Topics: seeking and implementing new and actual knowledge

Software: NR

Time: 60-120 min

Reliability: NR

* NR: Not reported. † Nonnumerical Unstructured Data Indexing, Searching and Theorizing, QSR International. ‡ EBD: Evidence-based dentistry. § Scientific Software Development.

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PRACTICE SITE

SAMPLE

Qualitative

Participants, No.

Stone and Colleagues,56 2014

England Northeast

11

Characteristics Dentist Male: 63.3% Age: NR Practice: NR 1-28 y of experience (range, 5-10 y): 46%

ASSESSMENT TOOL Recruitment Purposive sampling

Characteristics Format: 4 individual interviews and 1 focus group discussion (11 participants)

Criteria: variability in sex Conduction: 1 investigator and experience of practice

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Analysis Collection: audio record with transcription

Content analysis: constant comparative analysis

Guide: semistructured interview guide (based on previous literature review)

Codes, themes, labels, categories: 2 independent investigators

Topics: potential barriers to translating research findings into clinical dental practice

Software: None

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eTable 2. Characteristics of the quantitative studies reported in the systematic review. STUDY

PRACTICE SITE

SAMPLE Participants, No.

Quantitative

ASSESSMENT TOOL

Characteristics

Representativeness

Characteristics

Yes, No, or Questionable

Yes or No Selvi and Ozerkan,55 2002

Turkey City of Istanbul

133

Yes

Dentists Sex: NR Age: 24-35 y: 45.0% Experience: NR Specialty: NR Work setting: NR

Validated/Pilot Tested

Self-administered questionnaire

Developed based on previous studies

Response rate: 35.0%

No/Questionable

Question orientation: undetermined Yusof and Colleagues,64 2008

Malaysia State of Selangor

193

Dentists Male: 52.3% Age: NR
20 y of experience: 36.8% Specialty: NR Work setting: NR Others: Chinese 53.9%

Yes

Self-administered questionnaire

Developed based on previous studies

Question orientation: undetermined Collected at a local conference or sent by post

Content validation by 3 dental public health academicians

Response rate: 50.3%

Pilot tested with 3 practitioners Modifications performed accordingly Yes/Yes

Spallek and Colleagues,65 2010

United States

38

Dentists Male: 67.4% Age: 25-65 y (most
45 y) Experience: graduation range, 7-46 y (most:  29 y) General dentists: 75.0% Private practice: 61.0%

Data collected from dentists previously attending an EBD conference 7 months before

Self-administered online questionnaire

Developed based on previous studies and the expertise of the research team

Question orientation: dentist himself or herself No

Sent by e-mail

No/Questionable

Response rate: 34.0% Madhavji and Colleagues,49 2011

United States

1,517

Dentists Male: 79.0% Age: 41-60 y (modal) 16-20 y in practice group (modal) Orthodontists: 100.0% Teaching: 28.0% Others: master’s degrees 59.0%

Sample totally from the American Association of Orthodontists

Self-administered online questionnaire

Developed based on previous studies

Question orientation: dentist himself or herself Most of the dentists had master’s degrees

No

Sent by e-mail

Pilot tested with 7 teaching staff members and 20 orthodontic residents

Response rate: 32.0%

Modifications performed accordingly

* FDI World Dental Federation European Regional Organization (FDI-ERO) Working Group.

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PRACTICE SITE

SAMPLE Participants, No.

Quantitative

Characteristics

ASSESSMENT TOOL

Representativeness

Characteristics

Validated/Pilot Tested Yes, No, or Questionable

Yes or No

Questionable/Yes Haron and Colleagues,66 2012

120

Kuwait Kuwait City: 31.7% Hawalli: 16.7% Farwaniya: 23.3% Ahmadi: 12.5% Jahra: 15.8%

Dentists Male: 63.3% Age < 30 y: 43.3%  10 y of experience 67.5% General dentists: 55.8% Ministry of Health: 100.0%

Data only from dentists who worked in the public health service

Self-administered questionnaire

Developed based on some questions from previously tested questionnaires

Question orientation: dentists, in general No

Distributed and collected personally

Pilot tested with 7 teaching staff members

Response rate: 80.0%

Modifications performed accordingly Questionable/Yes

StraubMorarend and Colleagues,67 2013

United States Iowa

518

Dentists Sex: NR Age: NR Graduation: 4-68 y (most > 24 y: 68.8%) General dentists: 84.7% Private practice: 97.8% Others: not faculty members

Yes

Self-administered questionnaire

Developed based on the expertise of the research team

Question orientation: dentist himself or herself Sent by mail

Pilot tested with 48 faculty members

Response rate: 38.4%

Modifications performed accordingly

Self-administered online questionnaire

Developed based on previous studies

Questionable/Yes Saudi Arabia

Al-Ansari and El-Tantawi,38 2014

201

Dentists Male: 61.7% Age: 24-35 y: 52.0% Graduation previous 10 y: 48.7% General dentists: 58.5% Governmental positions: 72.7% Others: Saudi 54.5%

Saudi Dental Society, estimated to have 3,000 dentists

Available on Web sites and networking sites Question orientation: undetermined Potential response overlap

Response rate: not applicable

Pilot tested with 9 teaching staff members Modifications performed accordingly

No

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Questionable/Yes

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eTable 2. Continued STUDY

PRACTICE SITE

SAMPLE Participants, No.

Quantitative

Characteristics

ASSESSMENT TOOL

Representativeness

Characteristics

Yes, No, or Questionable

Yes or No Wilder and Colleagues,60 2014

Gupta and Colleagues,68 2015

United States North Carolina

India Bhopal City

667

200

Dentists Male: 77.0% Age:
40 y: 27.0% Experience: NR Specialty: NR Private practice: 59.0% Others: practicing 31 to 40 hours per week 71.0%

Dentists Male: 62.5% Age: 26-30 y: 61.5% 1-5 y of experience: 69.0% General dentists: 58.5% Private practice: 100.0%

Yes

Data only from dentists who reported to be familiar with EBP

Validated/Pilot Tested

Self-administered questionnaire

Developed based on the expertise of the research team

Question orientation: undetermined

Pilot tested with 10 dentists

Sent by mail

Modifications performed accordingly

Response rate: 49.0%

Questionable/Yes

Self-administered questionnaire

Developed based on previous studies

Question orientation: dentists, in general Not including dentists practicing in a government setting

Distributed and collected personally

Pilot tested with 10% of the sample

Not including dentists involved in academic field

Response rate: 80.0%

Modifications performed accordingly

Not including dentists with < 1 y of experience No Yamalik and Colleagues,69 2015

Europe France: 6.1% Georgia: 3.3% Portugal: 41.4% Slovakia: 7.5% Turkey: 24.6% Poland: 17.1%

850

Dentists Female: 52.9% Age: 31-40 y: 28.1% 0-10 y of experience: 39.3% General practitioners: 81.6% Private practice: 77.5%

Uneven distribution among countries

Questionable/Yes Self-administered online questionnaire

Developed by experts*

Question orientation: dentists, in general No

Posted on Web sites or No/Questionable sent by e-mail to the member dentists by the relevant national dental associations Response rate: NR

Ahad and Sukumaran,37 2016

India Chennai City

35

Dentists Male: 60.0% Age: < 35 y: z 77.0% 1-5 y of practice: 43.0% Dental surgeons: 63.0%

Small sample size

Self-administered questionnaire

Developed based on previous studies

Question orientation: dentists, in general No

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Response rate: 87.5%

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eTable 2. Continued STUDY

PRACTICE SITE

SAMPLE Participants, No.

Quantitative

Characteristics

ASSESSMENT TOOL

Representativeness

Characteristics

Yes, No, or Questionable

Yes or No 910

Europe Turkey: 32.5% Portugal: 28.8% Russia: 11.8% Italy: 11.3% Georgia: 10.1% Switzerland: 5.5%

Guncu and Colleagues,45 2018

Dentists Female: 53.4% Age 31-40 y: 30.5% 0-10 y of experience: 35.8% General practitioners: 65.8% Private practice: 75.5% Others: solo practice 42.1%

Uneven distribution among countries

Validated/Pilot Tested

Self-administered online questionnaire

Developed by FDI World Dental Federation European Regional Organization Working Group

Question orientation: dentists, in general Posted on Web sites or sent by e-mail to the member dentists by the relevant national dental associations No

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Response rate: NR

No/Questionable

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eTable 3. Summary of the results concerning self-related barriers in the qualitative and quantitative studies. STUDY

SELF-RELATED BARRIERS

Qualitative

Limited EBD* Training or Skills

Watt and colleagues,59 2004

Hannes and colleagues,63 2008

Wårdh and colleagues,58 2009 Stone and colleagues,56 2014

NM†

Unawareness of EBD basics or principles Concept of EBD is new Inability to find scientific documents Lack of familiarity with information retrieval technology NM

Personal Inaccurate Views of EBD

Resistance to Change or Lack of Interest in EBD Resistance to change Difficulty in changing the routine

Negative perception of EBD EBD seen with skepticism EBD as excessively academic EBD as having limited relevance Negative perception of EBD EBD as a complicating factor EBD as excessively academic

NM

Negative perception of EBD EBD as having limited value

NM

Inability to appraise or interpret scientific documents

NM

NM

Selvi and Ozerkan,55 2002

Inability to find scientific documents To use electronic device or computer: ranked third (percentage not reported)

NE‡

NE

Yusof and colleagues,64 2008

Unawareness of EBD basics or principles: 28.1% (n ¼ 135) Inability to appraise or interpret scientific documents: 22.2% (n ¼ 135)

NE

NE

Spallek and colleagues,65 2010

Inability to find scientific documents: median 3.0 (range, 0.0-5.0)

NE

NE

NE

NE

NE

NE

Quantitative

Madhavji and colleagues,49 2011 66

Haron and colleagues,

2012

NE Limited EBD training or skills In general: 66.7% Inability to appraise or interpret scientific documents: 85.0%

Straub-Morarend and colleagues,67 2013

Unawareness of EBD basics or principles In general: 50.5% (n ¼ 39)dmore than 1 answer allowed 25.6%d1 answer allowed

Al-Ansari and El-Tantawi,38 2014

Limited EBD training or skills In general: 69.2% Unfamiliarity with English language: 28.2%

Wilder and colleagues,60 2014

NE

Negative perception of EBD Limited perceived value: 32.7% (n ¼ 39)dmore than 1 answer allowed 12.9%d1 answer allowed NE

NE

Resistance to change: 50.0%

NE

NE

Gupta and colleagues,68 2015

Inability to appraise or interpret scientific documents: 73.1% agree

Negative perception of EBD Impractical: 5.7% agree

Lack of interest: 33.3% agree

Yamalik and colleagues,69 2015

Unawareness of EBD basics or principles In general: 14.9% (n ¼ 469) Lack of awareness of EBD: 8.5% (n ¼ 469) Lack of continuing education courses on EBD: 6.5% (n ¼ 469) Inability to find scientific documents: 5.4% (n ¼ 469) Inability to appraise or interpret scientific documents: 5.3% (n ¼ 469)

Negative perception of EBD Time consuming: 5.0%

NE

Ahad and Sukumaran,37 2016

Inability to appraise or interpret scientific documents: 26.6%

Guncu and colleagues,45 2018

Unawareness of EBD basics or principles Lack of awareness of clinical guidelines: 29.0%

NE

NE

Negative perception of EBD Clinical guidelines restrict clinical freedom: 5.2%

NE

* EBD: Evidence-based dentistry. † NM: Not mentioned. ‡ NE: Not evaluated.

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eTable 4. Summary of the results concerning evidence-related barriers in the qualitative and quantitative studies. STUDY

EVIDENCE-RELATED BARRIERS Difficulties Inherent in Research and Literature

Qualitative

Watt and colleagues,59 Irrelevant 2004 Excessive Information overload Unrealistic or inapplicable Most of the evidence-based therapies are technique sensitive

Hannes and colleagues,63 2008

Inaccessible or unavailable Journal subscriptions Insufficient Lack of information about negative effects of interventions Outdated Time delay between scientific knowledge and application in practice Unclear Lack of clear answers to clinical questions and outcome measures Potentially subjective research results Contradictory, subjective information Academic language Unreliable Commercial interests from companies (sponsors) Influence of sales representatives Economic attitude of investigators No accuracy check Limited interaction between academics and clinicians

Wårdh and colleagues,58 2009

Insufficient Research or literature provides a glance of possibilities

Stone and colleagues,56 Inaccessible or unavailable 2014 Journal and Web site subscriptions Unrealistic or inapplicable Subjects and interventions perceived as being excessively academic

Difficulties Inherent in Dental Knowledge Field

Preference for Other Information Sources

NM*

Own experience or expertise Reliance on past experiences Formal audit processes seen as unnecessary Peers’ or experts’ advice Dependence on colleagues and networks Reliance on those who are in position to interpret the evidence Practice-focused information sources Hands-on courses

Complex Various treatment choices Fast changing

Own experience or expertise Peers’ or experts’ advice Practice-focused information sources Clinical cases reported in handbooks

NM

Own experience or expertise Reliance on personal abilities

NM

Own experience or expertise Peers’ or experts’ advice Opportunity for socialization and networking Practice-focused information sources Conferences aimed at generalists Short-term courses Continuing professional education

NE†

NE

Quantitative Selvi and Ozerkan,55 2002

Inaccessible or unavailable Difficulty of transportation (local traffic): ranked second (percentage not reported)

Yusof and colleagues,64 2008

NE

Spallek and colleagues,65 2010

Inaccessible or unavailable Expensive academic journals: median 3.0 (0.0-5.0) Outdated For devices and products: median 5.0 (range, 0.0-5.0) For continuing dental education courses: median 4.0 (range, 0.0-5.0) Unclear Lack of clear answers to clinical questions: median 4.0 (range, 0.0-5.0) Conflicting or ambiguous: median 4.0 (range, 0.0-5.0) Academic language: median 3.0 (range, 0.0-5.0) Limited interaction between academics and clinicians Lack of information exchange: median 3.5 (range, 0.0-5.0)

NE Complex: median 3.0 (range, 0.0-5.0) Fast changing: median 3.0 (range, 0.0-5.0)

Own experience or expertise Satisfied with current knowledge: 23.7% Own experience or expertise Skills strongly influence outcomes with patients: median 3.0 (range, 0.0-5.0) Peers’ or experts’ advice: median 3.0 (range, 0.0-5.0)

* NM: Not mentioned. † NE: Not evaluated.

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eTable 4. Continued STUDY Qualitative

EVIDENCE-RELATED BARRIERS Difficulties Inherent in Research and Literature

Difficulties Inherent in Dental Knowledge Field

Preference for Other Information Sources

Madhavji and colleagues,49 2011

Unclear: 59.0% agree that literature is conflicting or ambiguous Insufficient For guidelines: 44.0% agree

NE

Haron and colleagues,66 2012

Inaccessible or unavailable For evidence: 67.5% (n ¼ 120) For international journals: 91.7% (n ¼ 120)

NE

NE

Straub-Morarend and colleagues,67 2013

Inaccessible or unavailable Lack of access to scientific journals: 21.8% (n ¼ 39)dmore than 1 answer allowed 16.8% (87 of 518)d1 answer allowed

NE

NE

Al-Ansari and ElTantawi,38 2014

Inaccessible or unavailable For evidence: 60.3% (n ¼ 201)

NE

NE

Wilder and colleagues,60 2014

NE

NE

NE

Gupta and colleagues,68 2015

NE

NE

NE

NE

NE

NE

NE

NE

NE

Yamalik and colleagues,69 2015

Ahad and Sukumaran,37 2016 Guncu and colleagues,45 2018

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Insufficient For evidence: 6.2% For guidelines: 9.8% For publications on EBD: 8.4% For clinical decision support systems: 5.6% For Web sites on EBD: 5.5% NE Inaccessible or unavailable For clinical guidelines: 11.1% Unclear Certain aspects of the available guidelines are considered conflicting: 4.2% Insufficient Guidelines: 10.2%; 7.7% Outdated For guidelines, new evidence becomes available: 6.2% Unreliable Regarding guideline developing process: 3.5% Regarding competing interests on guideline development: 3.0% Regarding guideline development groups: 2.9%

Own experience or expertise Satisfied with current knowledge: 30.0% agree

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eTable 5. Summary of the results concerning context-related and patient-related barriers in the qualitative and quantitative studies. STUDY

CONTEXT-RELATED BARRIERS

Qualitative

Practical Issues 59

PATIENT-RELATED BARRIERS

Unfavorable Work Conditions

Attitudes or Conditions

Shortage of time No time to attend to courses or to conduct clinical audit Financial constraints EBD* techniques or materials perceived as costly

Related to public health system practice Restrictions placed on remuneration system Working within the constraints set by practice principals Related to the work environment Motivating environment associated with receptiveness to change Absence of teamwork and interaction between colleagues

High expectations with treatment results Media-generated expectations difficult to be fulfilled Threat of litigation Low compliance Limited concern with oral health and irregular attendance were considered discouraging behaviors for changing practices Influence over clinical decisions Previously informed patients request specific treatment approach

Hannes and colleagues,63 2008

Shortage of time Heavy workload No time to experiment with new evidence-based devices Financial constraints Limited monetary incentives

Related to public health system practice Strong focus on cost-efficiency Strong focus on cure rather than prevention Incomplete and outdated reimbursement system Little political influence of professional organizations Strong focus on economic rather than educational topics (professional organizations) Strong influence of managers over dental practices

High expectations with treatment results Media-generated expectations difficult to be fulfilled High expectations with dentists’ availability Limited free time for searching for information Low compliance With recommendations Limited concern with oral health Influence over clinical decisions Preference for treatments liable to be reimbursed Media-generated expectations difficult to confront Unique features Hard to standardize treatments

Wårdh and colleagues,58 2009

Shortage of time Heavy workload Financial constraints Economy seen as an increasing incitement for the choice of treatment

Related to the work environment Discouraging climate to create possibilities to gain knowledge

Limited access to dental care Association with decreasing the quality of the offered care

Stone and colleagues,56 2014

Shortage of time No time to attend to courses or to conduct clinical audit Financial constraints EBD techniques or materials perceived as costly

Related to public health system practice Management of resources controlled by practice principals Production requirements

Watt and colleagues, 2004

NM†

Quantitative NE‡

Selvi and Ozerkan,55 2002

Shortage of time Lack of free time after work: ranked first (percentage not reported)

Yusof and colleagues,64 2008

Shortage of time: 64.4% (n ¼ 135) Related to physical structure Financial constraints: 40.0% (n ¼ 135) Limited access to computers and internet: 17.0% (n ¼ 135)

Spallek and colleagues,65 2010

Shortage of time No time to implement new evidence-based approaches: median 3.0 (range, 0.0-5.0)

NE

Madhavji and colleagues,49 2011

In general Practical demands of work: 46.0% agree

NE

Haron and colleagues,66 2012

Shortage of time: 56.7%

Straub-Morarend and colleagues,67 2013

Shortage of time: 33.7% (n ¼ 39)dmore than 1 answer allowed 36.0%d1 answer allowed

Al-Ansari and El-Tantawi,38 2014

Shortage of time: 59.6% Financial constraints: 45.2% (91 of 201)

Related to physical structure Lack of computer: 88.3% (n ¼ 120) Lack of access to internet: 94.2% (n ¼ 120) NE

Related to physical structure Lack of access to internet: 33.5% (n ¼ 201)

NE

NE

Influence over clinical decisions Patient satisfaction as main criterion to justify treatments: median 3.0 (range, 0.0-5.0) NE

NE

Influence over clinical decisions Patients would object to additional fees for services: 90.3% NE

* EBD: Evidence-based dentistry. † NM: Not mentioned. ‡ NE: Not evaluated.

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eTable 5. Continued STUDY

CONTEXT-RELATED BARRIERS

Qualitative Wilder and colleagues, 2014

Practical Issues 60

Shortage of time: 77.1% consider it a barrier Financial constraints Lack of reimbursement from third-party payers: 84.9%

Gupta and colleagues,68 2015

Shortage of time: 79.5% agree Financial constraints: 31.9% agree

Yamalik and colleagues,69 2015

Shortage of time: 10.6% Financial constraints Lack of financial incentives: 7.7%

Ahad and Sukumaran,37 2016

Shortage of time: 40.0% Financial constraints: 16.4%

Guncu and colleagues,45 2018

Shortage of time: 13.9%

25.e15

PATIENT-RELATED BARRIERS

Unfavorable Work Conditions

Attitudes or Conditions

NE

NE

Related to physical structure Lack of access to internet: 28.4% agree

NE

NE

NE

Related to physical structure Lack of access to internet: 10.0%

NE

NE

NE

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eTable 6. Quality assessment of the qualitative and quantitative studies according to the Critical Appraisal Skills Programme* and the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies,† respectively. QUESTION

QUALITATIVE STUDY Watt and Colleagues,59 2004

Hannes and Colleagues,63 2008

Wårdh and Colleagues,58 2009

Stone and Colleagues,56 2014

1. Was There a Clear Statement of the Aims of the Research?

Yes

Yes

Yes

Yes

2. Is a Qualitative Methodology Appropriate?

Yes

Yes

Yes

Yes

3. Was the Research Design Appropriate to Address the Aims of the Research?

Yes

Yes

Yes

Yes

4. Was the Recruitment Strategy Appropriate to the Aims of the Research?

Yes

Yes

Yes

Yes

5. Were the Data Collected in a Way That Addressed the Research Issue?

Yes

Yes

Yes

Yes

‡

6. Has the Relationship Between Researcher and Participants Been Adequately Considered?

CT

Yes

CT

CT

7. Have Ethical Issues Been Taken Into Consideration?

CT

CT

CT

No

8. Was the Data Analysis Sufficiently Rigorous?

Yes

Yes

Yes

Yes

9. Is There a Clear Statement of Findings?

Yes

Yes

Yes

Yes

HVR

HVR

HVR

§

10. How Valuable Is the Research?

HVR

QUESTION

QUANTITATIVE STUDY StraubMadhavji Wilder Morarend Al-Ansari Selvi and Yusof and Spallek and and Haron and and Eland Gupta and Yamalik and Ahad and Guncu and and 55 64 65 49 66 67 38 Ozerkan, Colleagues, Colleagues, Colleagues, Colleagues, Colleagues, Tantawi, Colleagues,60 Colleagues,68 Colleagues,69 Sukumaran,37 Colleagues,45 2002 2008 2010 2011 2012 2013 2014 2014 2015 2015 2016 2018

1. Research Question

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

2. Study Population

Yes

Yes

Yes

Yes

Yes

Yes

No

Yes

Yes

No

No

Yes

3. Participant Rate of Eligible People

No

Yes

No

No

No

No

No

No

CD{

No

No

No

4. Eligibility Criteria

NR#

NR

NR

NR

Yes

NR

NR

NR

Yes

NR

NR

NR

5. Sample Size

NR

NR

NR

NR

Yes

NR

NR

NR

NR

NR

NR

NR

NA**

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

7. Time Frame

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

8. Exposure Levels

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

9. Exposure Measures

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

10. Repeated Exposure Assessment

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

11. Outcomes Measures

No

Yes

No

CD

CD

CD

CD

CD

CD

No

No

No

12. Assessors Blinding

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

13. Follow-Up Rate

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

14. Relationship Between Exposure and the Outcome

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

6. Exposure Assessment

* Treloar and colleagues.32,33 † National Heart, Lung, and Blood Institute.34 ‡ CT: Cannot tell. § HVR: High-value research. { CD: Cannot determine. # NR: Not reported. ** NA: Not applicable.

JADA 151(1)

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http://jada.ada.org

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January 2020

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