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Evidence-based Decision Making: Introduction and Formulating Good Clinical Questions

Course Number: 311

EBDM in Action

The PICO Process (Skill/Step 1)

The formality of using PICO to frame the question forces the questioner to focus on what the patient believes is the most important problem and the desired outcome. Doing this facilitates selecting language or key terms for conducting the computerized search, the second step in the process. Next, it allows you to determine the type of evidence and information required to solve the problem and the outcome measures that will be used to determine the effectiveness of the intervention.

One of the greatest difficulties in developing each aspect of the PICO question is providing an adequate amount of information without being too detailed. Each component of the PICO question should be stated as a concise short phrase as illustrated in the following case example.

Case Example

Your new patient, Mr. Nathan Baker, is a 20-year old student-athlete who has been swimming competitively since he was 12 years-old. His chief complaint is about the smooth, yellow areas near his gum line that he recently noticed. He wants to know what might be causing this and if there is anything he can do to fix and/or prevent it from getting worse. When reviewing his health history and behaviors, you learn that Nathan is a vegetarian, frequently snacking throughout the day on healthy fruits and vegetables. He also consumes sports drinks and an occasional energy drink with his hectic student/athlete schedule.

Nathan currently uses a manual toothbrush right after every meal, flosses nightly, and uses whatever fluoride toothpaste is on sale when he goes to buy one. He was apologetic for not getting in for his hygiene visits at all last year. Since you suspect his chief complaint is due to erosion, you perform the Basic Erosive Wear Examination (BEWE),20 an easy to use scoring system to measure erosive wear, recording the most severely affected tooth in each sextant. [See TABLES 1 and 2 for the criteria for grading erosive tooth wear and risk levels as a guide to clinical management.]20 Nathan's cumulative BEWE score of 10 alerts you that he is at medium risk for erosive wear, confirming your initial thought.

As summarized by White et al, “Erosive tooth wear (ETW) is an umbrella term that includes dental erosion, abfraction, attrition and abrasion, alone or in combination.”21 From Nathan’s assessments, we know that he has a moderate amount of ETW due to multiple risk factors including his: diet and dietary habits, oral health regimen, and his competitive swimming. Unlike dental caries, which begins by demineralization and is a subsurface, reversible disease process in early stages, dental erosion is characterized by irreversible surface and near surface damage to the tooth structure.22 Due to the permanent loss of hard tissue by ETW, it is very important that dental professionals assess, recognize and intervene to protect enamel from further destruction when signs exist. However, management of ETW may be challenging due to the multifactorial nature of the disease process.22

After discussing each of Nathan’s risk factors, he realizes that some of his habits are contributing to his oral health problem. He had always thought being a vegetarian was healthy and that it was good to brush right after meals. He did not know that his diet was acidic and eating too frequently could contribute to erosion.23,24 Nor did he realize that he should wait 1-2 hours before brushing his teeth after an acid exposure,21 or that as a competitive swimmer, if he is training in water with a pH lower than the optimal (7.2-8.0) he may be subject to further erosion.25

You both agree on changes that he can make with his eating and oral care habits but realize there are some things that aren’t going to change – like the fact he is a competitive swimmer and plans to remain a vegetarian. He then asks you about the toothpaste he should be using. He asks you about Sensodyne Pronamel® (a sodium fluoride toothpaste with potassium nitrate), since he recently heard a TV commercial stating that it helps with erosion. You typically recommend a stannous fluoride toothpaste, like Crest Pro-Health, but are not sure which one will be more effective in preventing the initiation and further progression dental erosion.

To answer Mr. Baker’s question, you investigate the two options so each of you are fully informed about the pros and cons before selecting a treatment. With the increased incidence of tooth erosion and the vast number of toothpaste options, this information will be a valuable addition to your evidence-based "library" that you are creating in your office.

To find the answer, you must define Nathan’s question so it facilitates an efficient search of the literature. To guide this process, the PICO Worksheet and Search Strategy form can assist you (Table 4).


Table 4. PICO Worksheet for Mr. Baker’s Case.

©2016 SA Miller and JL Forrest, PICO Worksheet, National Center for Dental Hygiene Research & Practice.

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