Implementation of evidence-based dentistry into practice: analysis of awareness, perceptions and attitudes of dentists in the World Dental Federation–European Regional Organization zone

Abstract

Based on evidence-based dentistry (EBD) being a relatively new concept in dentistry, the attitudes, perceptions and level of awareness of dentists regarding EBD, and perceived barriers to its implementation into daily practice, were comparatively analysed in six countries of the FDI (World Dental Federation-Federation Dentaire Internationale)-European Regional Organization (ERO) zone (France, Georgia, Poland, Portugal, Slovakia and Turkey). For this purpose, a questionnaire, ‘The Relationship Between Dental Practitioners and Universities’, was developed by the FDI-ERO Working Group and applied by National Dental Associations (NDAs). A total of 850 valid responses were received, and cumulative data, comparisons between countries and potential impact of demographic variables were analysed. Regarding EBD, similar percentages of respondents reported that they ‘know what it is’ (32.8%) and ‘they practice’ (32.1%). Most respondents believed that ‘EBD is beneficial’ (89.1%); however, they had different thoughts regarding ‘who actually benefited from EBD’. Of the participants, 60% believed that ‘dentists experience difficulties in implementing EBD’. Although lack of time, lack of education and limited availability of evidence-based clinical guidelines were among the major barriers, there were differences among countries (P < 0.05). Significant differences were also observed between countries regarding certain questions such as ‘where EBD needed to be taught’ (P < 0.05), as both undergraduate and continuing education were suggested to be suitable. Age, practice mode and years of practice significantly affected many of the responses (P < 0.05). There was a general, positive attitude toward EBD; however, there was also a clear demand for more information and support to enhance dentists’ knowledge and use of EBD in everyday practice and a specific role for the NDAs.

INTRODUCTION

In dental practice, clinical decision making based on good-quality evidence is widely accepted to lead to more effective and efficient treatments¹. Thus, evidence-based dentistry (EBD) is currently considered as the best approach to apply evidence from relevant research to the care of patients². The American Dental Association defines EBD as ‘an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences’³. Two main goals of EBD are to find best evidence and to transfer this to everyday practice². Thereby, resolving the discrepancies between clinical research and dental practice might be possible⁴.

Evidence-based dentistry provides significant advantages to dentists, patients, the dental team and dental practice1., 5.. Dentists who make evidence-based clinical decisions have been shown to be able to continuously improve their clinical skills and performance. They can improve the quality and outcomes of the treatment by making decisions based on the best evidence with regard to treatment outcomes and cost-effectiveness after considering patient preferences1., 4., 6., 7.. The patients, who know that they will be treated in an evidence-based practice, can feel more confidence and trust in their dentist1., 8.. With regard to the dental team, staff confidence, trust and personal satisfaction can be increased by implementation of evidence-based practice. Thus, clinicians can provide interventions that are scientific, safe, efficient and cost-effective.

Evidence-based practice is a widely accepted term in medical fields worldwide; in dentistry, however, it has evolved over the past two decades and is still an emerging concept4., 6., 9.. Although the concept appears fundamentally simple and reasonable, dentists have been slow to translate current science into dental practice10., 11.. A number of studies have been performed to investigate the extent and mode of practitioners’ adoption of EBD and the described barriers to its implementation in countries around the world4., 9., 12., 13..

In several studies conducted among general dental practitioners, a low level of familiarity with evidence-based practice was found. Most respondents currently seek advice from their peer colleagues when faced with clinical uncertainties. Furthermore, only a small number of dentists could correctly define EBD and the various terms used in the field of EBD. The major barrier reported, by general dentists, to the practising of EBD was lack of time; however, a desire to find out more information on EBD was also observed4., 12.. In a study conducted by Madhavi et al.¹⁴ to evaluate EBD in orthodontics, it was reported that orthodontists generally had positive attitudes towards evidence-based practice. However, understanding the concept was poor, and awareness and understanding were influenced by age and educational level. Other barriers identified to practising EBD were the publication of ambiguous literature, lack of clinical guidelines and practical demands of work.

Other studies were also conducted to evaluate the levels of awareness and implementation of EBD among dentists in different countries8., 9., 12.. As an example, EBD was not a well-known concept among Malaysian dental practitioners. However, a majority of the respondents had positive attitudes, interest and a desire to learn further information about EBD⁸. In another study conducted among dentists in Kuwait, it was revealed that the overall awareness of EBD was low, and clinical decisions appeared to be mostly based on the clinician’s own judgment rather than on evidence-based sources. A majority of respondents highlighted the need for education in EBD¹². Positive attitudes towards EBD were also observed among dental professionals in Sweden⁹. Although these studies attempted to assess awareness and implementation of EBD among different groups of clinicians, to the best of the authors’ knowledge, there is limited evidence regarding awareness and perceptions of dentists, from different countries within the FDI-ERO zone, towards EBD.

Therefore, the primary aim of this study was to perform a comparative evaluation of the awareness, attitudes and practice of EBD, and perceived barriers to its use, by dentists in France, Georgia, Poland, Portugal, Slovakia and Turkey. The potential factors affecting the perception, attitudes and practice of dentists were also analysed.

METHODS

A questionnaire, ‘The Relationship Between Dental Practitioners and Universities’, was developed by the World Dental Federation-European Regional Organization (FDI-ERO) Working Group to determine the perceptions, awareness and attitudes of dentists regarding EBD and the implementation of EBD in daily practice. The questionnaire had an introductory section describing the background of the questionnaire and its aims (Figure 1).

Figure 1.

Questionnaire: (a) page 1 and (b) page 2.

This introduction was followed by nine closed questions aiming to analyse implementation of EBD into daily dental practice. In general, the issues focused on whether the dentists are familiar with EBD; if EBD is implemented in daily practice; if it is taught and, if so, when [e.g. undergraduate dental education (UDE) or continuing dental education (CDE)]; if there are obstacles to its effective implementation in practice; and if there is a perceived role in the field of EBD for the National Dental Associations (NDAs), as expressed by the individual dentists (e.g. organising courses, developing clinical guidelines and others) (The questionnaire is shown in Figure 1). The study was conducted in six countries of the FDI-ERO zone (France, Georgia, Portugal, Slovakia, Turkey and Poland), volunteered by their NDAs. The survey was either placed on the websites of each of these NDAs or was emailed to the member dentists by the relevant NDAs. Participants of the survey were voluntary responders.

The data were entered on a spreadsheet and the frequency distribution of the responses was calculated. For data analyses, the chi-square test was used (P < 0.05) using the SPSS Statistics for Windows Version 19.0 (IBM Corp., Armonk, NY, USA).

For analysis of cumulative data from the six countries, the percentage of responses to each questionnaire item was calculated. To compare awareness, perceptions, practice and perceived barriers of dentists from different countries towards EBD, pairwise comparisons of countries were performed using the chi-square test (P < 0.05).

The potential factors, including age, gender, years of practice and type of practice, affecting the perception, attitudes and practice of dentists were also analysed using the chi-square test (P < 0.05). From the questionnaire, ‘age’ of the respondents was obtained and categorised as ‘20–30’, ‘31–40’, ‘41–50’ and ‘≥51’ for comparison of age groups. Similarly, ‘years of practice’ was categorised as ‘0–10’, ‘11–20’, ‘21–30’ and ‘≥31’.

In the questionnaire, ‘kind of practice’ was evaluated under three categories, as follows: (i) General practice, or Specialist in dentistry; (ii) Private or public or Public and private; and (iii) Solo practice, or Solo practice in a medical clinic, or Group practice (in a dental clinic with other dentists), or Group practice (in a medical clinic with other dentists), or University faculty member (private university), or University faculty member (public university). In the third category, to obtain an adequate sample size for statistical analysis, the subcategories were combined into Solo practice, Group practice or University faculty member, which enabled us to evaluate further the potential impact of mode of various practice models on the perceptions and attitudes towards EBD.

RESULTS

A total of 850 responses were received from France, Georgia, Portugal, Slovakia, Turkey and Poland. Demographic characteristics of participants, expressed as number and frequency (percentage), are given in Table 1. Of the 850 valid responses obtained, most were from Portugal (n = 352; 41.4%), followed by Turkey (n = 209; 24.6%) and Poland (n = 145; 17.1%). Response rates to age, gender, years of practice and type of practice were different, and therefore the distribution of respondents according to these demographic variables was calculated on the basis of response rates. Regarding age, responders were evenly distributed between 20 and 50 years of age; in addition, 21.2% (n = 178) of dentists were ≥51 years of age. Gender was also evenly balanced, although female dentists were slightly more represented (n = 441; 52.9%). Most dentists who responded to the questionnaire were general practitioners (n = 675; 81.6%), working solo (n = 400; 48%) and in private practice (n = 644; 77.5%).

Table 1.

Demographic data (n = 850)

Characteristics	Number	Frequency (%)
Country
France	52	6.1
Georgia	28	3.3
Portugal	352	41.4
Slovakia	64	7.5
Turkey	209	24.6
Poland	145	17.1
Age (years)
20–30 years	203	22.2
31–40 years	235	28.1
41–50 years	222	26.5
≥51 years	178	21.2
Gender
Male	393	47.1
Female	441	52.9
Years of practice
0–10 years	323	39.3
11–20 years	235	28.7
21–30 years	185	22.3
≥31 years	87	10.5
Kind of practice
General practitioner	675	81.6
Specialist	152	18.4
Kind of practice
Private	644	77.5
Public	39	4.7
Private and public	148	17.8
Kind of practice
Solo	400	48
Group practice	365	44
University	62	7.6
Others	3	0.4

Overall data from six countries

Table 2 presents the response to each question given by the total study group without stratification according to demographic variables. Regarding EBD, similar percentages of respondents reported that they ‘know what it is’ (32.8%) and ‘I practice’ (32.1%) (Figure 2). The reported level of learning of EBD was 41.9% and 29.3% for ‘undergraduate dental education’ and ‘continuing dental education’, respectively. However, the majority of respondents (71%) thought that ‘EBD should be taught in UDE’. A large proportion of the respondents (89.1%) believed that ‘EBD was beneficial’ (Figure 2). However, 60% of the respondents believed that ‘dentists experience difficulties in implementing EBD’, and they reported different ‘barriers to implementation of EBD into practice’. The most common reason for limited implementation was ‘lack of necessary education’, followed by ‘lack of time’. For the respondents, NDAs were expected to improve the implementation of EBD in practice by ‘creating awareness’ (22.7%) and ‘organising continuing education courses on EBD’ (21.3%). Desire for ‘developing evidence-based clinical guidelines’ was reported by 18.2% of the respondents, of whom 85% believed that ‘dental faculties and NDAs can collaborate for effective implementation of EBD into practice’.

Table 2.

Cumulative data for all participants

Q1- About evidence-based dentistry (EBD)?			Q7- If yes, what are the barriers to implementation of EBD into practice?*
Total	797		Total	2023
I know what it is	261	32.8	Lack of time	215	10.6
I practice	256	32.1	Lack of financial incentives	156	7.7
Dentists should practice it	169	21.2	Lack of necessary education on EBD	301	14.9
No idea	111	13.9	Lack of necessary publications on EBD	170	8.4
Q2- Has EBD been taught to you in			Lack of necessary websites on EBD	112	5.5
Total	625		Lack of EB clinical guidelines for dental care	199	9.8
UDE	262	41.9	Lack of EB clinical decision support systems	114	5.6
CDE	183	29.3	Limited evidence available in the dental field	126	6.2
NI for UDE	19	3	Lack of awareness on EBD	173	8.5
NI for CDE	22	3.5	Lack of continuing education courses on EBD	132	6.5
NI for both	138	22.1	EBD being perceived as time consuming	102	5
Q3- Do you believe that EBD should be taught in			Lack of practical ways to reach to best evidence	110	5.4
Total	683		Limited knowledge regarding the quality of evidence (appraisal of evidence)	107	5.3
UDE	485	71	Others	6	0.3
CDE	134	19.6	Q8- What is the role of National Dental Associations in improvement of the implementation of EBD in practice?*
NI for UDE	13	1.9	Total	2001
NI for CDE	4	0.6	Creating awareness	455	22.7
NI for both	47	6.9	Developing EB clinical guidelines	365	18.2
Q4- Do you believe that generally EBD is beneficial			Developing EB clinical decision support systems	308	15.4
Total	734		Organising continuing education courses on EBD	427	21.3
Yes	654	89.1	Negotiating with the authorities for financial incentives to foster implementation of EBD into practice	200	10
No	19	2.6	Attempts to overcome the barriers to implementation of EBD into practice	221	11
No idea	61	8.3	Others	11	0.5
Q5- If yes, who benefits from EBD and its implementation to dental practice			None	14	0.7
Total	828		Q9- Do you believe that dental faculties and National Dental Associations can collaborate for implementation of EBD into practice
Dentists	350	42.3	Total	760
Patients	192	23.2	Yes	646	85
Public	104	12.6	No	41	5.4
Dental Profession	133	16.1	No idea	73	9.6
No idea	32	3.9
Other	17	2.1
Q6- Do you believe that dentists experience difficulties in implementing EBD
Total	779
Yes	469	60.2
No	137	17.6
No idea	173	22.2

^*Multiple choice questions.

CDE, continuous dental education; EB, evidence-based; NI, no idea; UDE, undergraduate dental education.

Figure 2.

Frequency distribution of the total study population responses to (a) ‘Do you believe that generally EBD is beneficial?’ and (b) ‘About evidence based dentistry’.

Data based on individual countries

Varying numbers of dentists from the six participating countries responded to the question ‘About evidence based dentistry’ (Table 3a,b). Over 42% of Portuguese dentists ‘practice’ EBD and there was no dentist in that country who had ‘no idea’ about EBD (Table 3a). The percentage of dentists from Turkey who gave the response ‘I practice’ was significantly lower (P < 0.05) than those in France, Portugal and Poland (Table 4; Figure 3). All Portuguese dentists learned about EBD during their UDE, whereas more than half of Georgian and French dentists were trained in EBD during CDE. Statistical comparison of countries regarding the question ‘Has EBD been taught to you in’ generally revealed significant differences between counties (Table 4). In all countries, at least half of the respondents ‘believed that EBD should be taught in UDE’ (Table 3a). All dentists from Portugal and Georgia who were questioned thought that ‘EBD is beneficial’, and 76–90% of dentists from other countries agreed. Only one-third of French, Georgian and Slovakian dentists had been taught that ‘dentists’ get most benefits from implementing EBD, whereas this was the opinion of nearly 99% of Portuguese colleagues (Table 3a). Except for dentists from Portugal, about 25–29% of the respondents from five countries had been taught that ‘patients benefit from EBD’ and its implementation in dental practice. The benefits of EBD to the ‘public’ and ‘dental profession’ were most frequently reported by Turkish dentists (26.3% and 26.9%, respectively). About 70% of French and Polish dentists felt ‘difficulties in implementing EBD’, which was in contrast to Georgian dentists (30%) (Table 3a). Statistically significant differences (P < 0.05) were found between Georgia and Portugal, Portugal and Poland, and Turkey and Poland (Table 4). Regarding the question ‘what are the barriers to implementation of EBD into practice?’, dentists from Slovakia reported ‘lack of time’ as the most frequent barrier in implementation of EBD. For Portuguese dentists, ‘lack of time’ was not so important as in other countries (P < 0.001). In other countries, ‘lack of necessary education on EBD’ was the most frequent response, although ‘lack of awareness’ was also emphasised (Table 3a). The most frequently reported ‘role of NDAs in improvement of the implementation of EBD’ by French, Georgian, Slovakian and Polish dentists was ‘creating awareness’. The most popular response of dentists from Portugal and Turkey was ‘organising continuing education courses on EBD’. About 90% of dentists from France, Georgia, Portugal and Poland believed that ‘dental faculties and NDAs can collaborate for implementation of EBD into practice’, and 70% of dentists from Slovakia and Turkey agreed with this response (Table 3a).

Table 3.

(a) Percentages of respondents according to each variable and (b) Data based on age, gender, years of practice and kind of practice

Table 4.

Statistical data regarding comparative analysis of the six countries

	France/Georgia	France/Portugal	France/Slovakia	France/Turkey	France/Poland	Georgia/Portugal	Georgia/Slovakia	Georgia/Turkey	Georgia/Poland	Portugal/Slovakia	Portugal/Turkey	Portugal/Poland	Slovakia/Turkey	Slovakia/Poland	Turkey/Poland
Q1
I know what it is	0.691	0.0001*	0.287	0.002*	0.004*	0.022*	0.882	0.115	0.151	0.006*	0.199	0.195	0.086	0.132	0.891
I practice	0.628	0.415	0.233	0.002*	0.554	1	0.888	0.178	0.983	0.483	0.0001*	0.837	0.124	0.366	0.001*
Dentists should practice it	0.519	0.913	1	1	0.107	0.523	0.576	0.488	0.761	1	0.845	0.021*	1	0.123	0.021*
No idea	0.483	0.0001*	0.028*	0.189	0.219	0.005*	0.019*	0.093	0.104	0.0001*	0.0001*	0.113	0.155	0.174	0.963
Q2
UDE	0.151	0.0001*	0.658	0.738	0.0001*	0.0001*	0.056	0.217	0.0001*	0.002*	0.0001*	0.395	0.171	0.001*	0.0001*
CDE	0.754	0.0001*	0.014*	0.0001*	0.005*	0.0001*	0.216	0.001*	0.124	0.0001*	0.0001*	0.0001*	0.018*	0.858	0.003*
No idea for UDE	0.548	0.002*	1	0.711	0.189	n.a.	0.311	0.604	1	0.001*	0.0001*	0.024*	0.511	0.204	0.373
No idea for CDE	1	0.129	0.222	0.208	0.264	n.a.	0.318	0.229	n.a.	0.0001*	0.0001*	n.a.	1	0.002*	0.0001*
No idea for both	0.058	0.0001*	0.183	0.005*	0.434	0.0001*	0.508	1	0.001*	0.0001*	0.0001*	0.0001*	0.216	0.003*	0.0001*
Q3
UDE	0.021*	0.0001*	0.076	0.021*	0.414	0.338	0.474	0.469	0.055	0.001*	0.0001*	0.0001*	0.958	0.207	0.028*
CDE	0.252	0.0001*	0.007*	0.0001*	0.0001*	0.0001*	0.435	0.0001*	0.008*	0.0001*	0.0001*	0.0001*	0.0001*	0.032*	0.0001*
No idea for UDE	n.a.	n.a.	n.a.	0.078	n.a.	n.a.	n.a.	0.374	n.a.	n.a.	0.0001*	n.a.	0.087	n.a.	0.006*
No idea for CDE	n.a.	n.a.	n.a.	0.587	n.a.	n.a.	n.a.	1	n.a.	n.a.	0.019*	n.a.	0.576	n.a.	0.148
No idea for both	0.337	0.016*	0.019*	0.078	0.117	0.0001*	0.374	0.777	0.001*	0.0001*	0.0001*	n.a.	0.293	0.0001*	0.0001*
Q4
Yes	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.
No
No idea
Q5
Dentists	0.675	0.002*	0.026*	0.0001*	0.0001*	0.117	0.277	0.0001*	0.0001*	0.707	0.0001*	0.0001*	0.0001*	0.001*	0.017*
Patients	0.653	0.0001*	0.115	0.0001*	0.0001*	0.0001*	0.336	0.0001*	0.0001*	0.0001*	0.0001*	0.0001*	0.0001*	0.0001*	0.077
Public	0.638	0.0001*	0.031*	0.081	0.0001*	0.0001*	0.336	0.718	0.035*	0.0001*	0.0001*	0.0001*	0.376	0.396	0.005*
Dental profession	0.011*	0.0001*	0.0001*	0.0001*	0.0001*	0.0001*	0.669	0.762	0.447	0.0001*	0.0001*	0.0001*	0.865	0.902	0.383
No idea	1	0.016*	0.586	0.261	0.031*	0.074	0.518	0.397	0.082	0.154	0.051	0.0001*	1	0.003*	0.0001*
Other	0.548	0.002*	0.031*	0.008*	0.018*	n.a.	0.005*	n.a.	n.a.	0.0001*	n.a.	n.a.	0.0001*	n.a.	0.0001*
Q6
Yes	n.a.	0.331	n.a.	0.913	n.a.	0.0001*	n.a.	n.a.	n.a.	0.056	0.084	0.0001*	0.081	n.a.	0.0001*
No	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.
No idea	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.
Q7
Lack of time	0.883	0.0001*	0.669	0.196	0.994	0.032*	0.499	0.671	0.927	0.0001*	0.001*	0.0001*	0.023*	0.417	0.074
Lack of financial incentives	0.422	0.001*	0.031*	0.013*	0.673	0.268	0.376	0.591	0.607	1	0.449	0.0001*	0.821	0.041*	0.007*
Lack of necessary education on EBD	0.037*	0.017*	0.192	0.038*	0.501	0.0001*	0.001*	0.0001*	0.002*	0.627	0.771	0.018*	0.791	0.339	0.058
Lack of necessary publications on EBD	1	0.727	0.077	0.187	0.364	0.686	0.058	0.165	0.681	0.068	0.098	0.007*	0.413	0.001*	0.0001*
Lack of necessary websites on EBD	0.453	0.544	0.322	0.738	0.839	0.065	0.041*	0.083	0.543	0.534	0.805	0.069	0.426	0.092	0.201
Lack of EB clinical guidelines for dental care	1	0.038*	0.005*	0.007*	0.073	0.242	0.037*	0.089	0.297	0.117	0.243	0.948	0.412	0.144	0.308
Lack of EB clinical decision support systems	1	0.0001*	0.002*	0.017*	0.604	0.004*	0.003*	0.039*	0.615	0.391	0.218	0.0001*	0.126	0.004*	0.024*
Limited evidence in the dental field	1	0.361	0.202	0.0001*	0.888	0.601	0.166	0.0001*	0.776	0.006*	0.0001*	0.027*	0.001*	0.216	0.0001*
Lack of awareness on EBD	0.146	0.0001*	0.003*	0.011*	0.0001*	0.062	0.549	1	0.031*	0.349	0.0001*	0.338	0.273	0.116	0.0001*
Lack of continuing education courses on EBD	0.981	0.0001*	0.031*	0.094	0.0001*	0.002*	0.037*	0.118	0.0001*	0.736	0.004*	0.344	0.328	0.302	0.003*
EBD being perceived as time consuming	0.706	0.977	0.941	0.527	0.229	0.555	1	0.271	0.693	0.577	0.251	0.047*	0.245	0.399	0.007*
Lack of practical ways to reach to best evidence	0.125	0.488	0.072	0.276	0.001*	0.281	1	0.549	0.617	0.123	0.461	0.0001*	0.285	0.318	0.005*
Limited knowledge regarding the quality of evidence (appraisal of evidence)	1	0.0001*	0.0001*	0.223	0.639	0.0001*	0.0001*	0.293	0.915	0.154	0.0001*	0.0001*	0.002*	0.0001*	0.003*
Others	0.539	0.016*	1	0.102	0.171	n.a.	1	1	1	0.023*	0.373	0.292	0.138	0.223	1
Q8
Creating awareness	0.218	0.001*	0.004*	0.003*	0.036*	0.0001*	0.0001*	0.0001*	0.003*	0.771	0.671	0.089	0.591	0.166	0.226
Developing EB clinical guidelines	0.962	0.209	0.036*	0.686	0.002*	0.229	0.051	0.662	0.006*	0.147	0.096	0.002*	0.012*	0.619	0.0001*
Developing EB clinical decision support systems	1	0.012*	0.0001*	0.047*	0.0001*	0.117	0.0001*	0.228	0.0001*	0.0001*	0.484	0.0001*	0.0001*	1	0.0001*
Organising continuing education courses on EBD	1	0.747	0.076	0.851	0.201	1	0.228	1	0.478	0.031*	0.848	0.099	0.029*	0.371	0.097
Negotiating with the authorities for financial incentives to foster implementation of EBD into practice	1	0.001*	0.0001*	0.0001*	0.0001*	0.018*	0.003*	0.001*	0.0001*	0.134	0.051	0.0001*	0.802	0.138	0.011*
Attempts to overcome the barriers to implementation of EBD into practice	0.416	0.003*	0.011*	0.027*	0.015*	0.431	0.338	0.752	0.567	0.682	0.328	0.767	0.341	0.594	0.607
None	0.539	0.275	0.199	0.178	0.171	1	n.a.	1	1	0.597	0.716	0.679	1	1	1
Other	n.a.	n.a.	0.002*	1	0.567	n.a.	0.029*	1	1	0.0001*	0.373	0.024*	0.0001*	0.001*	0.309
Q9
Yes	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.	n.a.
No
No idea

CDE, continuing dental education; EB, evidence-based; EBD, evidence-based dentistry; UDE, undergraduate dental education. n.a, statistical comparison was not applicable because of the low response rate.

^*Difference is statistically significant (P < 0.05).

Figure 3.

(a) Frequency distribution of a total of 654 dentists who gave the response ‘yes’ to the question ‘Do you believe that generally EBD is beneficial?’, according to country. (b) Frequency distribution of a total of 256 dentists who gave the response ‘I practice’ to the question ‘About evidence based dentistry’, according to country.

Data regarding the potential impact of variables on perceptions and attitudes towards EBD

Data analyses with regard to the variables ‘age’ and ‘year of graduation from dental school’ revealed similar findings between countries regarding having knowledge about EBD (Table 5). The statistical results of these two variables indicate that EBD was taught to younger dentists in UDE, whereas EBD was taught to older dentists in CDE, and a higher proportion of young dentists ‘practised’ EBD compared with older dentists (Figure 4). Younger dentists more frequently ‘believed that generally EBD is beneficial’ compared with older dentists, and this finding was statistically significant (P < 0.05) (Table 5). ‘Lack of time’ was listed as a barrier more often among young dentists. ‘The lack of financial incentives’ seemed to be less important for dentists with more years in practice compared with those with fewer years in practice (Figure 5). Gender did not have significant effect on the respondents’ awareness perceptions and behaviour regarding EBD; however, the responses obtained from general practitioners were significantly different compared with those obtained from specialists in the aspects awareness (P = 0.002), practice (P = 0.004) and ‘find EBD beneficial’ (P < 0.001). Specialists also reported that they had received education on EBD during CDE (40.3%) rather than UDE (15.3%) (Table 5). Dentists working in public health-care services reported lack of time as the significantly (P < 0.001) most important barrier in implementation of EBD compared with private practice dentists. University members (36.6%) were more likely to practise EBD (P < 0.001) compared with solo (48%) and group (44%) practising dentists.

Table 5.

Data regarding the impact of age, gender, years of practice and kind of practice on the responses

	Age, years (n/%)					Gender (n/%)			Years of practice (n/%)					Kind of practice (n/%)
	20–30	31–40	41–50	≥51	P	Male	Female	P	0–10	11–20	21–30	≥31–over	P	General practitioner	Specialist	P	Private	Public	Private and public	P	Solo	Group practice	University member	P
Q1
I know what it is	33.2	33.3	34.6	36.9	0.931	30.9	34.8	0.655	30.7	31.5	32.4	28.7	0.935	31.8	36	0.004*	32.8	34.1	32.5	0.421	35.9	35.4	31.5	0.271
I practice	32.6	37.1	28.8	37.5	0.436	33.8	30.4	0.088	32.8	29.8	27.6	28.7	0.626	31.3	36.6	0.002*	30.9	29.5	37	0.052	26	27.7	36.6	0.0001*
Dentists should practice it	23.8	17.4	21.5	25.5	0.175	21.1	21.2	0.624	20.7	18.3	20	24.1	0.701	23.6	14	0.116	23.3	18.2	14.3	0.197	18.4	23.1	23.1	0.385
No idea	10.4	12.2	15.1	18.5	0.058	14.2	13.6	0.516	9.9	12.3	15.1	23	0.011*	13.4	13.4	0.388	13	18.2	16.2	0.111	19.7	13.8	8.8	0.0001*
Q2
UDE	30.2	52.5	38.1	18	0.0001*	37.2	47.4	0.182	39	32.8	25.4	13.8	0.0001*	47.7	26.7	0.116	43.8	18.9	45	0.002*	33.4	55	48.7	0.639
CDE	19.1	23.8	35.8	31.5	0.0001*	28.8	29.2	0.481	12.1	23	31.4	33.3	0.0001*	23.2	48.7	0.0001*	25.2	45.9	37.1	0.0001*	30	27.9	28.3	0.015*
No idea for UDE	2.9	1.9	3.4	3.4	n.a.	3.6	2.6	0.472	1.5	3	1.6	4.6	n.a.	3.4	2	1	3.4	5.4	1.4	n.a.	3.4	2.3	1.6	0.631
No idea for CDE	0	1.9	2.3	7.9	0.0001*	3.6	3.5	0.954	0.6	1.3	3.8	11.5	n.a.	4.3	1.3	0.401	3.9	5.4	1.4	n.a.	5.9	2.3	1	0.006*
No idea for both	19.9	20	20.5	23	0.036*	26.9	17.3	0.001*	11.5	16.2	18.4	28.7	0.001*	21.3	21.3	0.068	23.8	24.3	15	0.407	27.2	14	20.4	0.001*
Q3
UDE	78.4	74.7	66.3	57.7	0.046*	68.9	73.2	0.411	52.9	56.6	62.2	70.1	0.018*	73.5	66.1	0.0001*	72.3	67.5	67.1	0.0001*	66.7	74	73.3	0.311
CDE	14.4	17.1	23.8	21.9	0.001*	17.5	21.8	0.487	9.3	17	21.6	24.1	0.0001*	15.6	30.5	0	61.7	17.5	28.4	0.0001*	20.9	22	19.5	0.044*
No idea for UDE	0	2.4	2.1	2.8	n.a.	3	0.9	0.059	0.3	2.1	2.7	2.3	n.a.	2.6	0	0.142	2.3	5	0		3.3	2	0	0.028*
No idea for CDE	0	0	0.5	1.7	n.a.	0.9	0.3	0.348	0	0	1.1	2.3	n.a.	0.8	0	1	0.8	0	0		1.3	0	0
No idea for both	7.2	5.9	7.3	6.7	0.651	9.8	3.8	0.001*	4.6	4.7	6.5	9.2		7.5	3.4	0.571	7.5	10	4.5	0.409	7.8	2	7.2	0.765
Q4
Yes	91.8	92.9	85.9	87.5	0.005*	88.7	89.6	0.004*	83.3	73.6	72.4	82.8	0.0001*	89	92	0.0001*	90.4	86.8	84.1	n.a.	84.8	87.1	92.4	0.041*
No	0	1	5.8	3.4		1.1	4		0.0	4.7	4.3	0		2.3	4		1.3	0	8.7		2.8	9.7	1.2
No idea	8.2	6.1	8.4	9.6		10.2	6.4		6.2	5.5	8.1	12.6		8.7	4		8.3	13.2	7.2		12.4	3.2	6.4
Q5
Dentists	51.7	49	42.3	36.5	0.467	39	45.8	0.891	46.4	41.7	37.8	34.5	0.114	48.1	30	0.068	46.3	30.8	34.9	0.681	33.8	52.5	48.6	0.023*
Patients	20.9	19.4	22.5	37.1	0.0001*	23.7	22.3	0.101	17.3	20.4	27.6	40.2	0.0001*	18.2	33.6	0.0001*	22	19.2	27.6	0.0001*	25.4	14.8	22.9	0068
Public	11.6	9.7	14	18.5	0.011*	14.6	10.6	0.012*	9	12.3	14.1	21.8	0.011*	11.8	15	0.0001*	12.2	25	10.4	0.0001*	13.6	13.1	10.6	0.025*
Dental profession	7.6	17	14.9	28.7	0.0001*	17.5	14.6	0.041*	8.4	14.5	21.1	34.5	0.0001*	16.1	16.6	0.0001*	15.7	17.3	15.1	0.094	20.5	11.5	13.4	0.012*
No idea	5.8	3.9	4.5	1.7	0.341	2.9	5	0.352	4	4.7	3.2	1.1	0.493	3.9	4	0.092	2.3	1.9	9.4	0.0001*	4	6.6	3.2	0.647
Other	2.3	1	1.8	3.9	n.a.	2.4	1.7	0.465	1.5	1.3	1.1	8	n.a.	1.9	0.8	1	1.6	5.8	2.6	n.a.	2.6	1.6	1.4	0.123
Q6
Yes	63	54.9	62.9	50.6	0.718	59.3	60.9	0.743	56.3	57.9	54.1	51.7	0.891	61	59.7	0.0001*	58.2	62.2	68.1	0.017*	60.4	56.9	59.6	0.028*
No	15.3	19.4	14.1	20.8		17.3	17.7		17	13.6	16.8	21.8		15.6	26.2		17.4	27	15.3		14.6	12.3	19.5
No idea	21.7	21.2	22.9	21.3		23.3	21.4		19.8	21.3	22.7	18.4		23.4	14.1		24.4	10.8	16.7		25	30.8	21
Q7
Lack of time	13	10.3	10.4	11.2	0.325	10.8	10.3	0.461	28.8	27.2	18.9	24.1	0.091	10.1	11.8	0.001*	9.6	17.3	12.6	0.0001*	10.9	11	10.6	0.608
Lack of financial incentives	9.2	7.3	8.9	5.7	0.193	8.9	6.7	0.026*	20.1	18.3	16.8	16.1	0.734	7.8	7.5	0.134	7.4	7.3	9.6	0.053	7.7	9	7.7	1
Lack of necessary education on EBD	15.7	13.6	13.7	20.3	0.042*	14.8	14.9	0.761	35.6	31.5	38.9	41.4	0.276	14.8	15.2	0.002*	14.9	13.6	14.9	0.464	15.2	15.5	14	0.122
Lack of necessary publications on EBD	9	8.6	7.3	10.4	0.637	8.1	8.7	0.778	20.4	20.9	18.9	18.4	0.936	8.8	7.1	0.636	8.5	5.5	9.1	0.337	9.3	7.7	8	0.779
Lack of necessary websites on EBD	6.1	5	5.6	6.5	0.817	5.5	5.6	0.964	13	14.9	10.8	16.1	0.551	5.7	4.7	0.735	6	2.7	4.5	0.475	6.4	3.9	5.3	0.785
Lack of EB clinical guidelines for dental care	9.2	11.6	8.9	11.6	0.488	10.1	9.6	0.444	23.5	24.3	22.2	27.6	0.802	9.9	9.2	0.131	10.1	12.7	7.8	0.146	8.5	8.4	10.8	0.011*
Lack of EB clinical decision support systems	2.9	6.5	7.7	5.9	0.005*	5.1	6.1	0.389	9.6	14.5	21.6	10.3	0.002*	5.7	5.4	0.269	5.4	2.7	7.3	0.041*	6.5	6.5	5.2	0.376
Limited evidence in the dental field	10	5.6	3.6	7.5	0.0001*	5.2	7.2	0.084	20.7	11.5	10.3	12.6	0.003	7	3.6	0.183	6.4	3.6	6.5	0.479	4.2	9	7.3	0.035*
Lack of awareness on EBD	6.5	9	9.2	11.4	0.128	9.2	7.9	0.173	16.7	21.7	24.3	25.3	0.119	8.4	9	0.019*	9.4	9.1	5.3	0.083	9.2	7.1	8.5	0.183
Lack of continuing education courses on EBD	6.3	6.9	6.6	7.6	0.981	6.3	6.8	0.819	14.9	16.2	15.7	19.5	0.767	6.1	8.2	0.001*	6.6	5.5	6.5	0.781	5.5	6.5	6.8	0.023*
EBD being perceived as time consuming	4.6	4.3	5.3	7.3	0.289	5	5.1	0.931	11.1	10.6	13	19.5	0.151	5.2	4.7	0.452	5.5	7.3	2.8	0.054	4.4	5.8	5	0.018*
Lack of practical ways to reach to best evidence	5.4	6	4.9	6.4	0.901	6	5	0.206	13.9	12.3	14.1	11.5	0.888	5.9	4.3	1	6.2	3.6	3	0.102	4.6	6.5	6.4	0.149
Limited knowledge regarding the quality of evidence	2.1	5.4	7.7	6.8	0.0001*	4.9	5.7	0.478	6.5	16.6	18.9	12.6	0.0001*	4.2	9.2	0.0001*	3.7	8.2	10.1	0.0001*	7.2	3.2	4.1	0.052
Others	0	0	0.2	1.3	n.a.	0.3	0.3	1	0	0.4	1.6	2.3	n.a.	0.3	0	0.591	0.3	0.9	0	n.a.	0.4	0	0.4	n.a
Q8
Creating awareness	22.2	21.1	24.7	28.7	0.128	22.9	22.5	0.486	53.6	57.4	49.7	55.2	0.465	22.6	23.5	0.032*	21.7	27.9	26	0.101	23.2	21.6	23.9	0.001*
Developing EB clinical guidelines	17.8	19.8	17	23.1	0.288	19.4	17.4	0.069	49.5	40.4	37.3	44.8	0.035	18.2	19	0.073	18.7	17.4	16.5	0.294	16	22.3	19.3	0.0001*
Developing EB clinical decision support systems	15.9	15.7	14.8	18.8	0.251	15.3	15.3	0.743	41.2	34.9	31.9	36.8	0.176	15.3	16	0.103	15.9	14	13.3	0.194	13.9	17.6	16	0.0001*
Organising continuing education courses on EBD	20	22.2	21.1	27.4	0.745	20.6	22.1	0.559	52.3	48.5	50.3	54	0.761	21.6	20.2	0.469	21.7	19.8	19.9	0.303	23.9	16.9	19.8	0.011*
Negotiating with the authorities for financial incentives to foster implementation of EBD into practice	11.5	10.2	8.9	11.4	0.057	10.1	10	0.775	27.6	21.3	18.9	27.6	0.092	9.9	10.1	0.332		7	9.5	0.383	8.7	10.1	10.9	0.0001*
Attempts to overcome the barriers to implementation of EBD into practice	11.3	10	11.9	13.9	0.397	10.5	11.5	0.614	296.9	23.4	28.1	29.9	0.584	11.1	10.9	0.446	10.7	10.5	12.7	0.555	12.5	10.8	9.3	0.077
None	0	0.6	0.6	1.2	n.a.	0.5	0.6	1	0.3	2.1	2.2	1.1	n.a.	0.7	0	0.231	0.6	0	0.3	n.a.	0.9	0	0.5	n.a
Other	1.3	0.2	1	0.2	n.a.	0.7	0.7	1	2.217	0.5	2.3		n.a.	0.6		0.699	0.3	3.5	1.7	n.a.	1	0.7	0.3	0.073
Q9
Yes	89.9	87	82.2	75	0.114	82	87.6	0.115	56.3	57.9	54.1	51.7	0.891	84.9	87.9	0.003*	85.1	83.3	84.4	n.a.	78.6	91.7	88.8	0.061
No	4.3	5.3	7.1	6.3		6.4	4.6		17.	13.6	16.8	21.8		5.3	6		5	2.8	7.8		7.4	5	3.7
No idea	5.9	7.7	10.7	18.7		11.6	7.8		19.8	21.3	22.7	18.4		9.8	6		9.9	13.9	7.8		14	3.3	7.5

CDE, continuing dental education; EB, evidence-based; EBD, evidence-based dentistry; UDE, undergraduate dental education. n.a, statistical comparison was not applicable because of the low response rate.

^*Difference is statistically significant (P < 0.05).

Figure 4.

(a) Frequency distribution of dentists who received evidence-based denstistry (EBD) education in ‘undergraduate dental education’, according to years of practice. (b) Frequency distribution of dentists who responded ‘I practice’ to the question ‘About evidence based dentistry’, according to years of practice.

Figure 5.

Frequency of reported barriers to the implementation of evidence-based dentistry (EBD) into practice.

DISCUSSION

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research²⁰. Compared with medicine, evidence-based practice in dentistry is a relatively new concept that has evolved during the past 15–20 years and continues to evolve13., 21.. A number of previous studies have evaluated the level of awareness, and attitudes and practice of dentists of EBD, and described barriers to its implementation4., 8., 22., 23., 24.. These international reports provide evidence that the concept of EBD has different levels of awareness and adaptation amongst various groups of clinicians. However, to the best of the authors’ knowledge, there are currently very little data on a target population consisting of several FDI-ERO zone countries, together with the determination of the potential impact of a number of sociodemographic factors on evidence-based practice. Thus, the findings of the present study might be useful for designing effective national/regional/global strategies for implementing EBD into practice.

It was encouraging to note that when dentists were asked about EBD, most respondents reported familiarity and positive attitudes. Furthermore, 89.1% believed that ‘EBD is beneficial’. This finding, which is inconsistent with previous studies4., 8., 9. is important because it might reflect the high demands of modern-day dentists for best practice and clinical decision making. However, the percentage of dentists practising EBD (32.1%) was rather low among all respondents, in the absence of stratification according to country and other demographic variables (Figure 2), which also seems to be an important finding that needs to be taken into consideration.

The reasons for not adopting EBD in their daily practice might include the following: EBD is still an emerging concept and therefore the benefits of EBD in providing best practice are not known; poor understanding of evidence-based concepts by clinicians; and difficulties experienced by dentists in implementing EBD10., 11.. The last potential reason was confirmed by 60% of respondents in this study. As identifying barriers is an important step towards increasing evidence-based practice in dentistry, several studies were conducted to identify these barriers4., 8., 9., 11., 14.. In line with previous studies, the most frequently noted barriers were lack of education on EBD, lack of time and lack of clinical guidelines for dental care4., 8., 9.. Other frequent barriers reported in the reports were the ambiguous and conflicting nature of the literature, the demands of work, financial constraints and poor availability of evidence4., 8., 9.. Spallek et al.¹¹ identified barriers previously not emphasised in the literature, such as fear of criticism by colleagues or lack of confidence in the research results. They performed a comprehensive survey on barriers to implementing EBD of early adopters. The survey included analysing barriers under the subtitles of associated with patient, with health-care provider and with health-care organisation, rating the barriers and their opinions for overcoming barriers. In the present study, basic barriers were identified by a large number of dentists. By revealing barriers, the practice of EBD, which aimed to provide continuous improvements in patient care based on new research developments, might be enhanced²⁵. Taken together, all of these studies reveal that, despite the positive attitude of dentists towards EBD, there are an array of barriers in place when it comes to implementation of EBD in practice.

The role of NDAs in improvement of the implementation of EBD has also been evaluated in this survey, which previously had not been emphasised in the literature. The most frequent expectations of clinicians from NDAs included creating awareness, organising continuing education courses and developing evidence-based clinical guidelines. However, it should be emphasised that whilst well-developed evidence-based guidelines and continuing education courses improve dentists’ knowledge and overcome some barriers, they do not improve dentists’ clinical decision-making skills, which themselves may inadvertently create other barriers11., 13., 26., 27.. Therefore, drawing attention to finding best evidence and transferring this into everyday practice seems more important. Furthermore, producing guidelines is a precise procedure, and organisations should develop dissemination strategies for timely delivery of information, reduce the complexity of recommendations for clinicians and produce useable chairside tools with easy-to-understand evidence-based recommendations. The results of this survey also revealed that dentists have positive attitudes towards the collaboration of dental facilities and NDAs for implementation of EBD into practice, which has not been mentioned in the literature. In one study, conducted by Marshall et al.¹³ dental faculty members confirmed the importance of teaching students EBD. The EBD content of the facilities’ curriculum is unknown. It is likely that the collaboration of NDAs and dental faculties may have the potential to overcome some of the reported barriers and improve evidence-based practice.

Knowledge on EBD might be associated with cultural shifts or curricular variations⁹. Therefore, one objective of this study was to perform a comparative evaluation of the perceptions of dentists from six FDI-ERO zone countries: France, Georgia, Portugal, Slovakia, Turkey and Poland. As such a diverse response from FDI-ERO zone countries regarding EBD perceptions and attitudes of dentists has not previously been obtained, the findings of the present study might provide valuable information on the dentists in these countries. The literature reveals that EBD is presumed to be well accepted and practised in European countries⁸; however, this survey presents conflicting results. For example, the percentage of respondents who gave the response ‘I practice’ ranged from 20% to 42%. Although most of the dentists (77–100%) reported that they ‘believe EBD is beneficial’, EBD practice was still limited. This might be attributed to the lack of EBD training during UDE in all countries, except Portugal. Nowadays, academic dental institutions seek to provide curricular content and learning opportunities for students to develop an essential skill set for evidence-based practice. However, emphasis on EBD is relatively new, and thus educating undergraduate and graduate dentists on EBD may take time. Marshall et al.¹³ investigated the perceptions of members of a dental faculty regarding EBD and reported their positive attitudes and efforts in designing and expanding the EBD content in their curriculum. CDE is also an important resource for learning EBD¹¹. In France and Georgia, most dentists learned EBD from CDE, rather than from their dental education.

Evaluation of perceived barriers according to country revealed that ‘lack of education’ and ‘lack of awareness on EBD’ were the most frequent difficulties. However, dentists from Slovakia reported ‘lack of time’ as the most frequent barrier in implementation of EBD, in line with previous studies4., 8., 9.. In contrast to the literature, ‘lack of time’ was of low statistical significance for dentists from Portugal compared with dentists from other countries. In the present study, lack of necessary education on EBD was the main difficulty. Besides these common difficulties, financial constrains were reported by dentists from Malaysia and the UK4., 8., poor availability of evidence was emphasised by dentists from Sweden⁹ and lack of Internet connection in the workplace was reported in Kuwait¹². These results may lead to the conclusion that differences in sociocultural habits, the national economy, workplace conditions and health-care systems may influence dentists’ implementation of EBD.

A novel aspect of EBD, the role of NDAs in improvement of the implementation of evidence-based practice, was analysed in the present study. The results of the survey revealed that creating awareness was the most frequent expectation of dentists from the six countries included in this study; developing clinical guidelines and organising continuing education courses were also reported. This might be interpreted as the expectation, by dentists, of support and solutions from NDAs for the most frequently perceived barriers, such as ‘lack of education’ and ‘lack of awareness’. Whilst modern-day NDAs and institutions make efforts to emphasise the importance of EBD, efficient strategies to implement EBD should be applied, and the number of continuing educational courses may be increased. This might be a way to increase the collaboration between dental faculties and NDAs²⁸.

Trends in awareness, perceptions and behaviour regarding EBD, with respect to age of participant and year of graduation from dental school, were quite prominent in the present study. Age of participant and years of practice did not have a significant effect on dentists regarding their awareness and practice of EDB. However, an important finding was that EBD was taught to younger dentists in UDE and they believed that education in UDE is the correct approach, whereas older dentists were educated in EBD through CDE. These findings support those reported in previous studies9., 29. indicating that EBD has evolved over the past two decades and that its inclusion in the curricula of academic dental institutions is relatively recent. A recent study of Straub-Morarend et al.⁹ indicated that as the year of dental school graduation became more recent, the percentage of students understanding EBD increased. They found that recent graduates were more likely to report insufficient time as a primary barrier to practising EBD, which is in agreement with our results; however, the results were not statistically significant. Considering all age groups, lack of education on EBD was the primary barrier, which was significantly higher for older dentists.

The responses obtained for general practitioners showed notable differences compared with those obtained for specialists. Specialists were significantly more likely to report that they ‘know’, ‘practice’ and ‘find EBD beneficial’, as indicated in previous research⁹. Following the trend of the dentists with more years in practice, specialists also reported that they had received education on EBD during CDE rather than during UDE. This may be related to the advanced training they received in evidence-based practice. Furthermore, all scientific activities performed during the postgraduate education period may make dentists familiar with critical thinking and EBD practice9., 13.. Regarding the barriers, specialists had a significant emphasis on quality of science and reported that limited knowledge was available regarding the quality of evidence. However, the skewed distribution of the general practitioners and specialists, in which general practitioners comprised the majority (81.6%) of respondents, should be considered when interpreting these findings.

University members were more likely to practice EBD; however, their frequency in this study was quite low (7.6%) compared with solo practising (48%) and group practising (44%) dentists. Their high awareness of, and effort to teach, EBD has previously been reported¹³. This study also uncovered interesting and unaddressed considerations regarding the effect of the type of practice on EBD. Awareness of the concept of EBD and believing its benefits was significantly low among solo practising dentists. This may indicate the advantages of team work and a multidisciplinary approach. Dentists working in public health-care services reported lack of time as a significant and the most important barrier to the implementation of EBD compared with private practice dentists. This reveals that the high demand by patients of public health-care services may preclude dentists from performing EBD practice. However, this finding should not be overestimated as 77.5% of the respondents worked in private, 4.7% worked in public and 17.8% worked in both private and public practices.

This questionnaire survey was anonymous and therefore the respondents could be comfortable communicating their true thoughts. However, the study included a number of limitations. One was the difficulty in achieving good feedback from most of the Web questionnaires. The data were self-reported and this is not the most accurate method of gathering the perceptions of health-care professionals²⁹. However, it would have been difficult to gather information from such a large number of people from different countries using a method other than a self-reported survey. Another possible problem was that, even though the surveys were anonymous, in order to create a good impression, the respondents may not report their actual and true perceptions¹⁴. Setting a more detailed questionnaire, including items measuring the level of knowledge and practice, may partially overcome this problem. In previous studies, technical terms commonly used in evidence-based practice were considered and the source of information was asked for when faced with clinical uncertainties4., 8.. Further research is warranted, especially to identify knowledge levels and solutions to increase the use of the relevant literature in scientific practice.

Despite these limitations, the present study is likely to provide significant data based on the perceptions and attitudes of European dentists regarding EBD and implementation of EBD into daily practice. It is possible that these data may be a helpful tool for decision-makers, educators and members of organised dentistry who plan to further improvements the implementation of EBD into daily practice.

Evidence-based practice is a relatively new concept in dentistry. Awareness, attitudes and knowledge of dentists from different countries varied towards EBD, which might be attributed to socio-economic, cultural and curricular variations. Respondents expressed awareness and positive attitudes towards EBD; however, the frequency of practising EBD was low. Except for Portugal, there is a lack of EBD training during UDE in all countries, and young dentists, in particular, believed that they were receiving such education, during their undergraduate training, from the dental faculty. Dental specialists generally had a higher level of awareness regarding EBD compared with general practitioners. Lack of education on EBD, lack of time and lack of clinical guidelines for dental care were the major barriers identified in this study. Respondents desired to enhance their knowledge and use of EBD in everyday practice. They expect educational programmes to be organised by NDAs and supported by dental faculties.

Previous studies reveal the expressed need, for an improved collaboration between the NDAs and the dental faculties28., 30.. It is likely that EBD, and its effective implementation into practice, may be an appropriate area in which NDAs and dental faculties may consider for working together.

Acknowledgements

The authors would like to thank to the six National Dental Associations (French Dental Association, Georgian Dental Association, Polish Dental Chamber, Portuguese Dental Association, Slovakian Dental Chamber, Turkish Dental Association) for kindly participating this survey. The authors also would like to thank all the members of WG.

Conflict of interest

The authors declare no conflict of interest.