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PRACTICAL
GUIDE
SERIES
How to Use Evidence-Based Dental

Practices to Improve Your
Clinical Decision-Making
Alonso Carrasco-Labra, D.D.S.

Romina Brignardello-Petersen,
D.D.S.
Michael Glick, D.M.D.
Amir Azarpazhooh, D.D.S.
Gordon Guyatt, M.D.
Copyright © 2020 by the American Dental Association. All rights reserved. Except
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Book ISBN: 978-1-68447-061-7

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Acknowledgments
This book would not have been possible without the support of the
following American Dental Association staff members:
• From the ADA Center for Evidence-Based Dentistry (EBD):

Jeff Huber, M.B.A., Scientific Content Specialist, for production
management and editing; Erica Colangelo, M.P.H., Senior
Manager; and Tyharrie Woods, M.A., Coordinator, for logistics
support.
• From ADA Publishing: Kathy Pulkrabek, Manager/Editor,
Professional Products, Department of Product Development
and Sales, and Pamela Woolf, Senior Manager, Department of
Product Development and Sales, for production management
and editing.
• From ADA Scientific Information: Anita M. Mark, Senior
Scientific Content Specialist, for proofreading and copyediting.
• From the ADA Science Institute: Aaron Pinkston, Coordinator,
for meetings coordination.
Thank you to Kimberly Ruona, D.D.S., Associate Dean for Patient

Care, University of Texas School of Dentistry at Houston, for her
input into the development of the cover for this book.
And a big thank you to the broad community of enthusiastic and

forward-thinking EBD leaders who conceived the idea of, and wrote,
this book. Their knowledge and hard work were essential in
producing this compendium of the skills necessary to practice and
teach EBD.
Table of Contents
Preface
Derek Richards, M.Sc., D.D.P.H.
How to Use This Book

Alonso Carrasco-Labra, D.D.S., M.Sc., Ph.D., and Jeff Huber, M.B.A.
Chapter 1. Understanding and Applying the

Principles of Evidence-Based Dentistry (EBD)
Romina Brignardello-Petersen, D.D.S., M.Sc., Ph.D.; Alonso Carrasco-Labra, D.D.S.,
M.Sc., Ph.D.; Michael Glick, D.M.D.; Gordon H. Guyatt, M.D., M.Sc.; and Amir
Azarpazhooh, D.D.S., M.Sc., Ph.D.
Introduction
Definition and Principles of EBD
The Process of EBD
Chapter 2. Searching for the Best Oral Health

Evidence: Strategies, Tips, and Resources
Elizabeth Stellrecht, M.L.S., and H. Austin Booth, M.L.I.S., M.A.
Introduction
General Tips for Searching Electronic Resources
Searching Workflow
Resources
Comprehensive Resources
Epistemonikos
Trip
Summaries and Guidelines: Point-of-Care Resources
UpToDate
ClinicalKey
Lexicomp
ECRI Guidelines Trust
ADA Center for Evidence-Based Dentistry
Preappraised Resources
Cochrane Library
Journals
Evidence-Based Dentistry (EBD)
Journal of Evidence-Based Dental Practice (JEBDP)
The Journal of the American Dental Association (JADA)
Nonpreappraised Resources
PubMed
MEDLINE
Embase
Web of Science/Scopus
Google and Google Scholar
Citation Managers
Gray Literature
Patient Information Resources
Conclusion
Chapter 3. How to Appraise and Use an Article

about Therapy
Introduction
Clinical Questions of Therapy
What Study Design Best Addresses Questions of Therapy?
Critically Appraising an RCT to Inform Clinical Decisions
How Serious Is the Risk of Bias?
Did the intervention and control groups start with the same prognosis?
Was prognostic balance maintained as the study progressed?
Were the groups prognostically balanced at the completion of the study?
What Are the Results?
How large was the treatment effect?
How precise was the estimate of the treatment effect?
How Can I Apply the Results to Patient Care?
Were the study patients similar to my patients?
Were all patient-important outcomes considered?
Are the likely treatment benefits worth the potential harms and costs?
Conclusion
Chapter 4. How to Use an Article about Harm

Introduction
Clinical Questions of Harm
What Study Design Best Addresses Questions of Harm?
Critically Appraising Observational Studies to Inform Clinical Decisions
Are exposed and unexposed study participants sufficiently similar?
Is information collected in the same way in exposed and unexposed study
participants?
How strong is the association between exposure and outcome?
How precise was the estimate of the risk?
Were the study patients similar to the patients in my practice?
Was the follow-up sufficiently long?
Is the exposure similar to what might occur in my patient?
Are there any benefits that offset the risks associated with the exposure?
Conclusion
about Diagnosis
Introduction
Clinical Questions of Diagnosis
What Study Design Best Addresses Questions About Diagnosis?
Critically Appraising a Study Assessing the Properties of a Diagnostic
Test to Inform Clinical Decisions
Did participating patients present a diagnostic dilemma?
Did investigators compare the test with an appropriate, independent
reference standard?
Were the investigators who interpreted the test and reference standard
blinded to the other results?
Did investigators apply the same reference standard to all patients
regardless of the results of the test under investigation?
Will the reproducibility of the test results and its interpretation be
satisfactory in my clinical setting?
Are the study results applicable to the patients in my practice?
Will the test results change my management strategy?
Will patients be better off as a result of the test?
Conclusion
Chapter 6. How to Use a Systematic Review

and Meta-Analysis
Alonso Carrasco-Labra, D.D.S., M.Sc., Ph.D.; Romina Brignardello-Petersen, D.D.S.,
Introduction
Knowledge Synthesis and Translation
What Is the Difference Between Narrative and Systematic Reviews?
Why Are Systematic Reviews Considered to Be a Study Design?
Critically Appraising Systematic Reviews to Inform Clinical Decisions
Did the review present explicit and appropriate eligibility criteria?
Was the search for relevant studies exhaustive?
Did the primary studies have a low risk of bias?
Were the selection and assessment of primary studies reproducible?
Were the results similar from study to study?
What are the overall results of the review?
Anatomy of a Meta-Analysis
How precise were the results?
What is the overall quality of the evidence (also known as confidence in
the estimate of effect)?
Were all patient-important outcomes considered?
Are the likely treatment benefits worth the potential harms and costs?
Conclusion
Chapter 7. How to Use Patient Management

Recommendations from Clinical Practice
Guidelines
M.Sc., Ph.D.; Michael Glick, D.M.D.; Gordon H. Guyatt, M.D., M.Sc.; Ignacio
Neumann, M.D., M.Sc., Ph.D.; and Amir Azarpazhooh, D.D.S., M.Sc., Ph.D.
Introduction
Evidence-Based Clinical Practice Guidelines
Structured Process of Developing Management Recommendations
Where to Find Clinical Practice Guidelines
Critically Appraising Patient Management Recommendations
Are the Recommendations Clear and Comprehensive?
Is the recommended intervention clear and actionable?
Is the alternative clear?
Were all the relevant outcomes important to patients explicitly considered?
Was the Recommendation Made on the Basis of the Best Current Evidence?
Are Values and Preferences Associated with the Outcomes Appropriately
Specified?
Do the Authors Indicate the Strength of Their Recommendations?
Is the Evidence Supporting the Recommendation Easily Understood?
For strong recommendations, is the strength appropriate?
For weak recommendations, does the information provided facilitate
shared decision-making?
Was the Influence of Conflicts of Interest Minimized?
Conclusion
Chapter 8. How to Appraise an Article Based

on a Qualitative Study
Joanna E.M. Sale, Ph.D.; Maryam Amin, D.M.D., M.Sc., Ph.D.; Alonso Carrasco-
Labra, D.D.S., M.Sc., Ph.D.; Romina Brignardello-Petersen, D.D.S., M.Sc., Ph.D.;
Michael Glick, D.M.D.; Gordon H. Guyatt, M.D., M.Sc.; and Amir Azarpazhooh,
D.D.S., M.Sc., Ph.D.
Introduction
When Is Qualitative Research Relevant?
Where to Find Qualitative Studies
Critically Appraising Qualitative Research to Inform Clinical Decisions
Are the Results Credible?
Was the Choice of Participants or Observations Explicit and Comprehensive?
Was Research Ethics Approval Obtained?
Was Data Collection Sufficiently Comprehensive and Detailed?
Were the Data Analyzed Appropriately, and Were the Findings Corroborated
Adequately?
What Are the Results ?
Does the Study Offer Helpful Theory?
Does the Study Help Me Understand the Context of My Practice?
Does the Study Help Me Understand Social Interactions in Clinical Care?
Conclusion
about Economic Analysis
Lusine Abrahamyan, M.D., M.P.H., Ph.D.; Petros Pechlivanoglou, Ph.D.; Murray
Krahn, M.D., M.Sc.; Alonso Carrasco-Labra, D.D.S., M.Sc., Ph.D.; Romina
Brignardello-Petersen, D.D.S., M.Sc., Ph.D.; Michael Glick, D.M.D.; Gordon H.
Guyatt, M.D., M.Sc.; and Amir Azarpazhooh, D.D.S., M.Sc., Ph.D.
Introduction
Why Economic Analysis in Dentistry?
Cost-Effectiveness Analysis
Cost-Utility Analysis
Cost-Benefit Analysis
Trial-Based versus Decision Model-Based Economic Analyses
Critically Appraising an Economic Analysis to Inform Clinical Decisions
Are results reported separately for relevant patient subgroups?
Were consequences and costs measured accurately?
Did investigators consider the timing of costs and consequences?
What were the incremental costs and effects of each strategy?
Do incremental costs and effects differ between subgroups?
How much does allowing for uncertainty change the results?
How Can I Apply the Results to My Patient Care?
Are the viewpoints and setting used in the study relevant to my context?
Are the treatment benefits worth the risks and costs?
Can I expect similar costs in my setting?
Conclusion
Chapter 10. How to Avoid Being Misled by

Clinical Studies’ Results in Dentistry
M.Sc., Ph.D.; Amir Azarpazhooh, D.D.S., M.Sc., Ph.D.; Michael Glick, D.M.D.; and
Gordon H. Guyatt, M.D., M.Sc.
Introduction
Guidance on How to Avoid Being Misled by the Results of Clinical Studies
1. Read only the methods and results sections; disregard the inferences
2. Read synoptic abstracts published in secondary publications (preappraised
resources) for evidence-based dentistry
3. Beware of large treatment effects presented in trials with few events
4. Beware of statements of statistical significance that claim clinical
significance
5. Beware of differences that are not statistically significant being interpreted
as equivalence
6. Beware of uneven emphasis on benefits and harms
7. Beware of misleading subgroup analyses
Conclusion
Chapter 11. What Is the Difference between

Clinical and Statistical Significance?
M.Sc., Ph.D.; Prakeshkumar Shah, M.Sc., M.B.B.S., M.D., D.C.H., M.R.C.P.; and
Amir Azarpazhooh, D.D.S., M.Sc., Ph.D.
Introduction
Statistical Significance
Type I Error
Type II Error
Study Power
Issues Pertaining to Statistical Significance
Clinical Significance
Minimal Important Difference (MID)
Patient-Reported Outcome Measures (PROMs)
Surrogate Outcomes
Interpreting Research Findings
Confidence Intervals (CIs)
CIs and MID
Discussion
Conclusion
Chapter 12. A Primer to Biostatistics for Busy
Clinicians
Michael Glick, D.M.D., and Barbara L. Greenberg, Ph.D., M.Sc.
Introduction
Research Design and Clinical Interpretation
Experimental Trial
Observational Studies
Measures of Association
Mean Difference
Standard Mean Difference
Absolute Risk
Relative Risk
Odds Ratio
Absolute Risk Reduction and Relative Risk Reduction
Hazard Ratio
Hypothesis and Significance Testing
Confidence Intervals (CIs)
How to Interpret a CI
Probability and the Normal Curve
Standard Deviation and Standard Error
Sample Size Considerations
Why Is Sample Size Important?
Chapter 13. Issues of Bias and Confounding in

Clinical Studies
Elliot Abt, D.D.S., M.S., M.Sc.; Jaana Gold, D.D.S., M.P.H., Ph.D., C.P.H.; and Julie
Frantsve-Hawley, Ph.D., C.A.E.
Introduction
Confounding
Control of Confounding
Bias
Bias in Therapy Studies
Bias and Prognostic Studies
Bias in Diagnostic Test Studies
Conclusion
Chapter 14. What Is Certainty of the Evidence,

and Why Is It Important to Dental
Practitioners?
Alonso Carrasco-Labra, D.D.S., M.Sc., Ph.D.; Olivia Urquhart, M.P.H.; Malavika P.
Tampi, M.P.H.; Lauren Pilcher, M.S.P.H.; Jeff Huber, M.B.A.; Anita Aminoshariae,
D.D.S., M.S.; Douglas Young, D.D.S., Ed.D., M.S., M.B.A.; Satish S. Kumar, D.M.D.,
M.D.Sc., M.S.; Carlos Flores-Mir, D.D.S., M.Sc., D.Sc.; and Gordon H. Guyatt, M.D.,
M.Sc.
Introduction
Certainty of the Evidence
Criteria to Rate Down the Certainty of the Evidence
Risk of Bias
Inconsistency
Imprecision
Indirectness
• Population
• Intervention or diagnostic test strategy
• Outcome
Publication Bias
Criteria to Upgrade the Certainty of the Evidence
Conclusion
Chapter 15. Strategies for Teaching Evidence-

Based Dentistry
Cheryl L. Straub-Morarend, D.D.S.; Jaana Gold, D.D.S., M.P.H., Ph.D., C.P.H.; Kelly
C. Lemke, D.D.S., M.S.; Parthasarathy Madurantakam, D.D.S., M.D.S., Ph.D.; David
M. Leader, D.M.D., M.P.H.; Richard Niederman, D.M.D., M.A.; and Teresa A.
Marshall, Ph.D., R.D.N./L.D.N., F.A.N.D.
Introduction
Curricular Outcomes
Curricular Content
Knowledge
Scientific Evidence
Behavior
Application
Professionalism
Communication
Instructional Methods
Didactic Learning
Application
Clinical Activity
Real-World Examples
Virginia Commonwealth University School of Dentistry
University of Texas Health Science Center San Antonio School of Dentistry
Foundations
Critically Appraised Topics (CATs)
Evidence-Based Case Presentations
Graduate-Level EBD Training Strategy
FAST CATs Program: Academic Detailing
Impact of the UTHSCSA School of Dentistry EBD/CATs Program
Challenges
University of Iowa College of Dentistry
Overview
Assessment
Year 1 (D1)
Year 2 (D2)
Year 3 (D3)
Year 4 (D4)
Summary
Competency Assessment
Obstacles and Strategies
Program Evaluation
Accreditation Standards
Adaptations for Nonacademic Settings
Depth of Instruction
Audiences beyond the Formal Educational Setting
Conclusion
Chapter 16. Implementing Evidence into

Practice
Satish S. Kumar, D.M.D., M.D.Sc., M.S.; Ben Balevi, D.D.S., M.Sc.; Rebecca
Schaffer, D.D.S.; Romesh Nalliah, D.D.S., M.H.C.M.; Martha Ann Keels, D.D.S.,
Ph.D.; Norman Tinanoff, D.D.S., M.S.; and Robert J. Weyant, D.M.D., Dr.P.H., M.S.
Defining the Scope of Implementation Science
Translation of Scientific Evidence to Clinical Practice
Four Phases of Implementation
1. Exploration
Assessing the Need and Readiness for Change
Understanding Issues and Theories of Behavior Change
2. Adoption Decision/Preparation
Defining the Challenges and Barriers of Translating Best Evidence to
Practice in Different Practice Settings
• Financial
• Clinical awareness
• Evidence-based dentistry skill
• Staff training
• Information technology issues
• Diagnostic codes
• Peer influence
• Policy issues
• Organizational barriers and facilitators
3. Active Implementation
How to Implement a Clinical Practice Guideline in Various Dental Settings
• Step 1: Set an aim
• Step 2: Establish metrics
• Step 3: Identify the change
• Step 4: Test the change.
• Step 5: Implement the change.
4. Sustainment
Establishing an Ongoing Process for Finding the Latest Evidence
Issues in Program Sustainability
Conclusion
Chapter 17. Health Policymaking Informed by

Evidence
Jane Gillette, D.D.S., M.P.H.; Romesh Nalliah, D.D.S., M.H.C.M.; and Robert J.
Weyant, D.M.D., Dr.P.H., M.S.
Introduction
What Is Policy?
Responsible Policy Development
Types of Evidence Used in Health Policy
Barriers to and Facilitators of Evidence-Informed Policymaking (EIPM)
Strategies for Science Advocates in Promoting EIPM
Strategies for Organizations in Engaging in EIPM
Putting It All Together
Conclusion
Index
Preface
Evidence-based medicine was first articulated in the early 1990s1,
and by 19952, articles on evidence-based dentistry (EBD) were
starting to appear in the dental literature. While the uptake of EBD
approaches and improvements in the quality of dental research
have been slower than early adopters of the concepts would have
hoped for, this has not been for lack of support from the American
Dental Association.
The establishment of the ADA Center for EBD and its development
of a definition for EBD (that is, a patient-centered approach to
treatment decisions, which provides personalized dental care
based on the most current scientific knowledge3) have been
important milestones along the road to a more evidence-based
dental profession. The ADA has actively promoted EBD in its
journal, The Journal of the American Dental Association, and
organized EBD courses and workshops for a number of years. The
ADA EBD website also provides a broad range of helpful EBD
resources, including a number of evidence-based clinical practice
guidelines, chairside guides, and videos.
Since 1995, Cochrane Oral Health has produced around 150

systematic reviews that have clarified not only what we know but
also what is still uncertain in many areas of dentistry. In addition
to Cochrane reviews, there has been a significant increase in
dentistry’s overall number of systematic reviews, which more often
than not identify gaps in knowledge and limitations in the quality
of our primary research.
All of this means that it is important to continue teaching the key

skills of the evidence-based approach, including how to search for
and critically appraise evidence as well as how to translate this
evidence into the practice of dentists and the wider dental team.
While courses and conferences can stimulate and excite interest in
a subject, having a tangible resource that pulls short, informative,
how-to articles together in a practical format is a great help for
teachers and students alike. That is why I believe this book will
prove invaluable to the dental community.
Derek Richards, M.Sc., D.D.P.H.

Centre for Evidence-Based Dentistry
School of Dentistry
University of Dundee
Dundee, Scotland, U.K.
References
1. Guyatt GH. “Evidence-based medicine.” ACP J Club 1991;114(ACP J Club,
suppl 2):A-16.
2. Richards D, Lawrence A. “Evidence based dentistry.” Br Dent J
1995;179(7):270-273.
3. “About EBD.” ADA Center for Evidence-Based Dentistry.
https://ebd.ADA.org/en/about. Accessed March 5, 2019.
How to Use This Book
Evidence-based dentistry (EBD) relies on personalization. Dentists
work with each of their patients to make a unique treatment decision
that integrates the dentist’s expertise, the patient’s needs and
preferences, and the most current, clinically relevant evidence.
Melding all three of these elements ensures that the identified
treatment decision appropriately addresses the clinical scenario in
question. There is no one-size-fits-all approach to patient care.
As with EBD, there is no one way to use this book. Some may start
at the very beginning and read to the very end, since each chapter
builds on the one before it. Most will probably open the book when
they’re in need of a handy reference, turning to the section that is
most relevant to them at that time. Others will test their ability to
critically appraise evidence by reading the real-world examples that
are highlighted in some chapters’ call-out boxes and then go back to
review sections that cover self-identified gaps in knowledge. Any
strategy works. There is no one-size-fits-all approach to reading this
book.
Regardless of what tack you take, we hope that you find this book
covers a wide breadth of EBD topics. Perusing the pages ahead
should assist anyone who wants to learn about practicing EBD,
teaching EBD, defining an EBD curriculum, conducting a
journal/study club, or engaging in other activities that incorporate
evidence into patient care. The overall goal is to provide you with
the foundational knowledge you need to improve patient care
through the application of EBD.
Although this wealth of information is often addressed toward

clinicians throughout the book, readers from all walks of the dental
community can use this book to better harness the latest scientific
evidence in their clinical decision-making. That’s what EBD is all
about—empowering everyone to identify the best treatment for a
particular clinical scenario.
Alonso Carrasco-Labra, D.D.S., M.Sc., Ph.D., and Jeff Huber, M.B.A.

Center for Evidence-Based Dentistry
Science Institute
Chicago, Illinois, U.S.A.
Chapter 1. Understanding and
Applying the Principles of
Evidence-Based Dentistry
(EBD)
Romina Brignardello-Petersen, D.D.S., M.Sc., Ph.D.; Alonso Carrasco-Labra,
D.D.S., M.Sc., Ph.D.; Michael Glick, D.M.D.; Gordon H. Guyatt, M.D., M.Sc.; and
Amir Azarpazhooh, D.D.S., M.Sc., Ph.D.
In This Chapter:
The Process of EBD
Introduction
Scientific evidence is a crucial underpinning of clinical practice.
Nevertheless, the first series of articles aimed at providing clinicians
with guidelines for critically appraising the evidence that informs
clinical practices did not appear until 1981.1 Ten years later, the term
“evidence-based medicine”2 first appeared in the medical literature.
Subsequently, between 1993 and 2000, a group of evidence-based
medicine enthusiasts3 published a series of 25 articles aimed at
assisting clinicians in understanding and applying the medical
literature to their clinical decision-making in a clinical setting.4
The concept of evidence-based medicine soon expanded to other

clinical areas. The first article to use the term “evidence-based
dentistry” (EBD) was published in 1995 by Richards and Lawrence,5
and since then other articles have been published on the topic.6–11
There is, however, still no guide easily accessible for current and
future dental practitioners that addresses the critical appraisal and
use of evidence specifically aimed at clinicians and educators in oral
health care fields.
This book aims to provide an overview of the basic concepts of EBD

to assist oral health care professionals in making use of evidence to
inform their clinical decisions. This book addresses the main topics in
EBD, including how to formulate questions that are easy to answer
using the scientific literature, effectively search for relevant
evidence, identify the strengths and limitations of different study
designs and interpret their findings, and apply findings to clinical
decisions. Although this book mostly focuses on the application of
research to clinical practice, it also provides a perspective at the
health policy level.

The American Dental Association defines EBD as “an approach to
oral healthcare 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.”12 The definition of EBD has three main components:
• the best current research evidence;

• the clinician’s expertise;
• the patient’s values and preferences.13
Figure 1.1. The Components of Evidence-Based Dentistry
One definition of evidence is “any empirical observation whether

systematically collected or not.”14 Evidence can be obtained from a
range of sources, including clinical observation of the course of a
single patient or a multicenter and multinational clinical study.
Evidence to inform any clinical decision is abundant. However, as
some evidence is more trustworthy than other evidence, it is both
necessary and desirable to prioritize certain types of evidence.
Because unsystematic clinical observations of a small number of

patients are more likely to introduce more bias than are
appropriately designed and conducted clinical studies, for example,
astute clinicians always should prefer the latter evidence to the
former.14 For each type of clinical question, there is a hierarchy of
evidence that is based on degree of trustworthiness. For instance, to
answer questions regarding the effectiveness of a particular
intervention, the strongest evidence would come from randomized
clinical trials with a low risk of bias and large sample sizes, as such
evidence provides more precise estimates and more consistent
results and is directly applicable to the patients at hand. If findings
from such studies are not available for the specific question of
interest, clinicians must rely on less trustworthy evidence, including
well-designed and conducted observational studies, such as cohort
and case-control studies. If no randomized trials, cohort and case-
control studies, or case series/case reports are available, individual
observations by a clinical expert may become a valuable source of
evidence. In subsequent chapters, we discuss the hierarchy of
evidence for each type of clinical question (that is, therapy and
prevention, harm, prognosis, and diagnosis) and how to appraise the
relevant literature critically.
As stated above, evidence alone is not enough to support clinical

decision-making from an EBD perspective; decision-making should
rely on the integration of evidence with clinical expertise and
patients’ needs and preferences. The success of an intervention that
has proven to be effective in a clinical study depends on the ability
of a clinician to use the intervention in an appropriate clinical setting.
In other words, clinical expertise is key to determining whether and
how the evidence can be applied to a specific patient’s case.14
Finally, because clinical procedures are associated with potential
adverse effects, including the burden of the procedure and its costs,
it is important to consider patients’ values and preferences when
making a decision regarding treatment.
The Process of EBD

The decisions clinicians must make in daily clinical practice are the
most important source of questions for which we seek evidence-
based solutions. Such questions constitute the starting point of the
EBD process, which encompasses the following main steps:
• translating the clinical question into a well-formulated

searchable question format;
• searching for the best available evidence to answer this
question;
• critically appraising the evidence and applying it to the
particular clinical scenario that motivated the question.
To translate a clinical question into a well-formulated searchable

question, it is necessary to identify four main components of the
question: the Patient or Population of interest, the Intervention (or
exposure or new diagnostic test strategy, depending on the type of
the clinical question), the Comparison (or reference standard,
depending on the type of clinical question), and the Outcomes of
interest according to a patient-centered approach—hence, PICO.15
Examples of the PICO approach for the variety of types of clinical
question are discussed in detail in subsequent chapters in this book.
The PICO components of the question at hand are used as the basis
of searching for evidence in the literature by using electronic
databases and other sources. There are a number of sources that
provide clinicians with useful information. Depending on the degree
of detail sought, information from primary studies, summaries and
critical appraisals, and clinical practice guidelines may all provide
evidence.16 How to choose the most relevant source to search in
any particular case is addressed in subsequent chapters in this book.
Once a clinician obtains the evidence to answer the clinical question

at hand, it is necessary for him or her to conduct a critical appraisal
of the evidence discovered. As described in detail in subsequent
chapters, the critical appraisal of individual primary studies has three
main domains: risk of bias assessment, results, and applicability.17
The first domain explores whether the study was designed and
conducted in a manner in which potential biases were minimized.18
The second domain is an interpretation of the results of the study in
terms of direction, magnitude, and precision. The third domain
contextualizes the available evidence to determine implications for
clinical practice.19 Subsequent chapters in this book cover how to
appraise and apply evidence in a critical fashion to different types of
clinical questions.
Scientific evidence constitutes one of the fundamental tenets of

dental practice. Evidence-based dental practice integrates the use of
the best available evidence, clinicians’ expertise, and patients’ needs
and preferences to inform decision-making in clinical practice. This
book provides oral health care professionals with the fundamental
concepts of EBD and guidance on how to use evidence in their
clinical practices.
References
1. “How to read clinical journals, part I: why to read them and how to start
reading them critically.” Can Med Assoc J 1981;124(5):555-558.
2. Guyatt GH. “Evidence-based medicine.” ACP J Club 1991;114(ACP J Club,
suppl 2):A-16.
3. Evidence-Based Medicine Working Group. “Evidence-based medicine: a new
approach to teaching the practice of medicine.” JAMA 1992;268(17):2420-
2425.
4. Guyatt GH, Rennie D. “Users’ guides to the medical literature.” JAMA
1993;270(17):2096-2097.
5. Richards D, Lawrence A. “Evidence based dentistry.” Br Dent J
1995;179(7):270-273.
6. Azarpazhooh A, Mayhall JT, Leake JL. “Introducing dental students to
evidence-based decisions in dental care.” J Dent Educ 2008;72(1):87-109.
7. Cruz MA. “Evidence-based versus experience-based decision making in clinical
dentistry.” J Am Coll Dent 2000;67(1):11-14.
8. Faggion CM Jr, Tu YK. “Evidence-based dentistry: a model for clinical practice.”
J Dent Educ 2007;71(6):825-831.
9. Forrest JL, Miller SA. “Evidence-based decision making in dental hygiene
education, practice, and research.” J Dent Hyg 2001;75(1):50-63.
10. Laskin DM. “Finding the evidence for evidence-based dentistry.” J Am Coll
Dent 2000;67(1):7-10.
11. Scarbecz M. “Evidence-based dentistry resources for dental practitioners.” J
Tenn Dent Assoc 2008;88(2):9-13.
12. American Dental Association Center for Evidence-Based Dentistry. About EBD.
http://ebd.ADA.org/en/about. Accessed Oct. 5, 2014.
13. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. “Evidence
based medicine: what it is and what it isn’t.” BMJ 1996;312(7023):71-72.
14. Guyatt GH, Haynes B, Jaeschke R, et al. “The philosophy of evidence-based
medicine.” In: Guyatt GH, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides
to the Medical Literature: A Manual for Evidence-Based Clinical Practice. 2nd
ed. Columbus, Ohio: McGraw-Hill Education; 2008:9-16.
15. Guyatt GH, Meade MO, Richardson S, Jaeschke R. “What is the question.” In:
Guyatt GH, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides to the Medical
Literature: A Manual for Evidence-Based Clinical Practice. 2nd ed. Columbus,
Ohio: McGraw-Hill Education; 2008:17-28.
16. McKibbon A, Wyer P, Jaeschke R, Hunt D. “Finding the evidence.” In: Guyatt
GH, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides to the Medical
17. Guyatt GH, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides to the Medical
Ohio: McGraw-Hill Education; 2008.
18. Guyatt GH, Jaeschke R, Meade MO. “Why study results mislead: bias and
random error.” In: Guyatt GH, Rennie D, Meade MO, Cook DJ, eds. Users’
Guides to the Medical Literature: A Manual for Evidence-Based Clinical
Practice. 2nd ed. Columbus, Ohio: McGraw-Hill Education; 2008:59-64.
19. Dans A, Dans L, Guyatt GH. “Applying results to individual patients.” In:
Guyatt GH, Rennie D, Meade MO, Cook DJ, eds. Users’ Guides to the Medical
A version of this chapter originally appeared in the November 2014 edition of

JADA (Volume 145, Issue 11, Pages 1105–1107). It has been reviewed and
updated for accuracy and clarity by the editors of How to Use Evidence-Based
Dental Practices to Improve Your Clinical Decision-Making.
Chapter 2. Searching for the
Best Oral Health Evidence:
Strategies, Tips, and Resources
Elizabeth Stellrecht, M.L.S., and H. Austin Booth, M.L.I.S., M.A.
In This Chapter:
General Tips for Searching Electronic Resources
Searching Workflow
Resources
• Comprehensive Resources
• Summaries and Guidelines: Point-of-Care Resources
• Preappraised Resources
• Journals
• Nonpreappraised Resources
• Citation Managers
• Gray Literature
• Patient Information Resources
Conclusion
Introduction
To find answers to clinical inquiries, it is necessary to conduct an
evidence-based literature search. This chapter describes the most
commonly used evidence-based resources, recommends search
strategies that will help enable the oral health practitioner to retrieve
the most useful clinical information, and suggests a workflow for
navigating evidence-based information.
The practice of evidence-based dentistry includes articulating a

clinical question, conducting a search for relevant literature,
evaluating the retrieved evidence, applying that evidence to answer
the clinical question at hand, and putting that answer into effect in a
clinical setting.
The amount of health-related information available via the internet is

staggering. Even just the published results of clinical trials and
systematic reviews are impossible to keep up with. It is estimated,
for example, that an average of 11 systematic reviews and 75 results
of clinical trials are published in the medical literature daily.1 In
addition, health information found within the peer-reviewed
literature can be contradictory. The exponential growth of complex
health information is why it is essential to learn not only how to
search for the best evidence-based literature, but also how to
evaluate that literature.
Effective searching of medical databases is a very valuable skill these

days. Below, we outline effective and efficient ways for busy
clinicians to search the most important medical resources. For more
complex searches and the development of expert searching skills,
such as conducting systematic reviews, we recommend working with
a librarian who has been trained in extensive searching of the
scientific literature.
General Tips for Searching Electronic
Resources
A general search tip is to keep things simple when first starting a
search. Begin with a broad search and use only a few terms without
applying any search filters; take a look at the results to determine if
the search is too broad or too narrow and whether it’s displaying
relevant results. Try using nouns as search terms rather than
adjectives, as adjectives are difficult to quantify and can muddy the
results. Beginning a search with too many terms or multiple filters
applied may result in the inadvertent exclusion of relevant literature
(Table 2.1).
Table 2.1. General Searching Tips for Electronic Resources
Searching Tips to Remember

• Begin with a broad, simple search.
• Use nouns as search terms; avoid adjectives.
• Add additional terms using Boolean searching to narrow results.

• Still too many results? Consider using search filters to limit results according
to study design type, age, publication date, language, and so on.
• Not getting the expected results? Use synonyms and variations in spelling for
original search terms.
If the search is not yielding the expected results, consider using

synonyms for search terms, including variations of spelling, such as
U.S. versus U.K. spelling of terms. For instance, a synonym for
“pregnant women” is “pregnancy.” Searching different terms for the
same concept can yield different results. Databases will often have a
controlled vocabulary, which is preferred terminology that is found in
the database’s thesaurus and can be very helpful when searching for
relevant literature, as database thesauri typically include all
synonyms for a search term. A team of indexers is responsible for
reading all included materials in any given database and identifying
the main concepts represented in each individual work; once the
main topics are identified, the indexer assigns subject headings to
the work using the preferred terminology. Using the preferred
terminology therefore standardizes the search process, making it
easier and quicker to locate relevant literature. The searcher should
consider looking up search terms in the database’s thesaurus and
using the suggested term, which will yield results in which the term
is one of the main subjects of the retrieved literature. If a database
does not use a controlled vocabulary, consider searching by a
specific field such as title, abstract, or author to further limit results.
Keyword searches will look for the terms to appear anywhere in the
record, while searching in a specific field limits where the term will
appear. The majority of the resources described below allow
searching by phrase by placing the phrase within quotation marks.
Most also recognize common misspellings and abbreviations, and will
suggest alternative search terms when no results are found. In
addition, most of the resources below search plurals automatically.
Boolean searching refers to connecting search terms with one of the

following three terms: AND, OR, or NOT. When combining two terms
with AND, search results will contain both terms, resulting in fewer
results than searching using only one of the terms. Combining terms
with OR will return results that contain at least one of the terms,
resulting in a higher number of search results than if only one of the
terms was searched. Combining two terms with NOT will yield
results in which the first term appears but not the second term,
narrowing the number of results (Figure 2.1).
Figure 2.1. Examples of Boolean Searching

Searching Workflow
We suggest searching several databases; searching a combination of
databases helps to ensure that information is not missed that might
influence the answer to the clinical question at hand. While the exact
databases searched will depend on the question/topic/need, the
importance of finding results that contain high levels of evidence
calls for, at a minimum, Cochrane, Trip, and PubMed to be searched.
Information about many additional available databases are listed in
the Resources section of this chapter. To avoid missing important
results, use all three resources: there is less overlap among them
than one would imagine, they cover different types of materials, and
the content in each is updated on different cycles. Each resource has
a unique architecture, vocabulary, and results algorithm and,
therefore, will return unique results. Searching Cochrane, Trip, and
PubMed is free, but the full text of results is not always available
without a subscription to source material, which is typically provided
when operating in an academic setting. For those in clinical practice
outside academic settings, the American Dental Association (ADA)
Library and Archives offers members access to full-text articles
identified through these databases. All three resources are relatively
easy to search and provide up-to-date information. By using these
three databases, the oral health practitioner will have searched the
gold standard for evidence-based information (Cochrane), the best
“preappraised” resource (Trip), and the most comprehensive medical
literature search engine (PubMed).
We recommend framing the search strategy using the PICO

framework to articulate the clinical question. PICO assists clinicians
in creating a clear, focused clinical question by breaking down the
question into four components: population (Who is being treated?
What specific characteristics does this population have?),
intervention (What treatment or therapy is being considered?),
comparison (What is the gold standard? The comparison can also be
no comparison, or a placebo), and outcomes (What improvements or
changes are hoped for?). Of course, PICO will not fit every clinical
question as not all questions are ones of therapy; the framework can
be modified depending on the type of question. For instance, if it is a
question of harm, the clinician will frame the question by considering
what exposure, rather than what intervention, to search for. We
recommend that clinicians refer to the framework as a starting point
and modify as necessary for individual research needs. Using the
PICO framework is likely to result in the return of relevant results
because the framework encourages clarity and specificity and it
breaks down the clinical question into easily searchable components.
Using the PICO framework to articulate the question will save the
clinician time when conducting the search and better enable the
clinician to review the results of the search for relevance and
applicability to clinical practice (or to a particular patient) (Table
2.2).
Searching a combination of databases helps to ensure
that information is not missed that might influence
the answer to the clinical question at hand.
Use keywords, indexing terms, and synonyms related to the

components of the PICO question for the search. We suggest
beginning with two PICO components as search terms rather than all
four. Begin with search terms based on the population and
intervention components of the PICO question, as the results will
most likely include the comparison term or concept. Adding the
outcome terms will further narrow the results, and these terms
should be added if the initial search yields far too many results.
Using all four components as search terms initially will narrow a
search too early and will miss results that may be important. Use the
Boolean operator OR to account for synonyms of the same concept.
Conversely, use the Boolean operator AND to require different
components to be present in the results. See Figure 2.1 for
examples of Boolean searching.
Table 2.2. Main Components and Examples of Clinical

Questions, According to Their Natures
Source: Brignardello-Petersen R, Carrasco-Labra A, Booth HA, Glick M, Guyatt GH,
Azarpazhooh A, Agoritsas T. “A practical approach to evidence-based dentistry: II:
how to search for evidence to inform clinical decisions.” J Am Dent Assoc. 2014
Dec;145(12):1262-7. doi: 10.14219/jada.2014.113. PubMed PMID: 25429040.
Most databases have a thesaurus that lists the preferred terminology
or subject headings used to index articles as they are added to the
database. Searching by subject headings is a simple way to retrieve
a smaller pool of relevant results, as subject headings standardize
the search process and return results where the search term is
considered a main topic (that is, subject) of the manuscript. When
not using subject headings to search, limit the search to the title and
abstract. If the initial search retrieves too many results, limit the
results to secondary and preappraised literature such as clinical
practice guidelines, summaries, critical summaries, and systematic
reviews. If secondary literature does not exist, it will be necessary to
consult primary studies; we suggest initially limiting the search to
randomized controlled trials as they are typically less prone to bias
(Figure 2.2).
Figure 2.2. Hierarchy of Evidence for Primary Studies, Level

of Processing, and Link to EBD Resources
Initially, set aside results that are more than a decade old. If the
search still retrieves too many items, do a search using all four PICO
components, starting with adding the outcome terms to the search.
If the results of the search include materials from the highest levels
of evidence (for example, guidelines or systematic reviews), consider
stopping the search and declaring it “good enough.” To conduct a
more comprehensive search, consult the additional databases listed
below. Note that this workflow is intended to be used as a roadmap
for an evidence-based search for a clinical question in order to
decide action in a clinical setting—it is not a substitute for a search
that would be used to conduct a systematic review or literature
review.
There is always an element of creativity in developing a search
strategy around a particular question and in determining the
appropriate balance among relevance, breadth, and depth of results.
Developing a search strategy is an iterative process; that is, as the
oral health practitioner searches, he or she will modify, narrow, or
expand the search terms used as well as the combinations of terms
and the overall search strategy based on results. The effectiveness
and efficiency of the search strategy will improve as the search
progresses. If too few results are retrieved in a particular database,
it may be necessary to modify the search by removing some search
terms, search filters, or both. Please note that simply adding more
terms to the search may not increase the number of relevant results
as the terms may retrieve redundant results. Once a search is
begun, there is a certain amount of trial and error in terms of
refining the search terms to be used in the end. Adding and
removing search terms and synonyms will allow the oral health
practitioner to retrieve varying amounts, breadth, and quality of
levels of evidence.
There is always an element of creativity in developing

a search strategy around a particular question and in
determining the appropriate balance among relevance,
breadth, and depth of results.
We suggest beginning the search process with Cochrane, then

searching Trip if not enough relevant results are found, and then
PubMed to fill in any remaining gaps in information. Since Cochrane
is a database consisting solely of systematic reviews, the results
presented are considered to be of a higher quality according to the
evidence pyramid hierarchy. Due to the type of content, it is also a
smaller database, so it is possible that the evidence needed might
not be available in Cochrane. PubMed will almost always retrieve the
most results from the search because of the breadth and scope of
the resource. As noted below, even when using the Systematic
Review filter or Clinical Queries search, which limits search results to
clinical study categories, systematic reviews, and medical genetics,
PubMed retrieves narrative reviews as well as descriptive articles.
(For more information about Clinical Queries, please see the PubMed
section of this chapter. Note that while Cochrane systematic reviews
are indexed in PubMed, we recommend a separate search of the
Cochrane Library because the results of a search of the Cochrane
Library database and a search of Cochrane systematic reviews in
PubMed will not retrieve identical results.)
We suggest conducting a search using both (that is, a combination

of) keywords and subject headings. Note that Cochrane and PubMed
share index terms—both databases use MeSH (Medical Subject
Headings) as a controlled vocabulary or thesaurus for subject
headings (see the PubMed section of this chapter for a detailed
explanation of MeSH). Trip does not use a controlled vocabulary. Do
not rely solely on index terms: many new articles and updates
appear in databases before they are indexed, and these materials
may prove to be the most useful. As the initial search is conducted,
note related terms and at the end, go back and do a search using all
relevant search terms. Including related terms or synonyms is crucial
to conducting an effective search (Table 2.3).
Table 2.3. Workflow for Searching for Evidence
Type of Resources to Level of Evidence

Question/Situation Consult Available
Consider first: Does a 1. Epistemonikos Guidelines, guideline
guideline for the 2. Trip summaries
question/situation
exist? 3. ECRI Guidelines
Trust
4. Point-of-care
resources
Therapy/Prevention 1. Cochrane Critical summaries,
question (general) Database of meta-analyses,
Systematic systematic reviews,
Reviews
2. Trip randomized controlled
3. PubMed trials (RCTs)
Therapy/Prevention 1. Cochrane Critical summaries,
question (drug therapy) 2. Trip meta-analyses,
systematic reviews,
3. Embase RCTs
4. PubMed
Harm/Etiology question 1. Cochrane Critical summaries,
2. Trip meta-analyses,
systematic reviews,
3. PubMed observational studies
Diagnosis question 1. Cochrane Critical summaries**,
2. Trip meta-analyses**,
systematic reviews**,
3. PubMed cross-sectional studies,
case report/series
Prognosis question 1. Cochrane Critical summaries**,
2. Trip meta-analyses**,
systematic reviews**,
3. PubMed
observational studies,
case report/series
Situation: Can only find 1. Web of Science or Follow standard
one or two articles on Scopus (cited evidence pyramid
topic, need more reference
searching)
2. Gray literature
** Indicates that this type of evidence may not be available for this type of
question.
For this chapter, our search examples will refer to the following PICO
framework question: Are pregnant women with periodontal disease
at greater risk of preterm birth or low birth weight than pregnant
women without periodontal disease? In this instance, the population
identified is pregnant women. Because this is not a question of
therapy but of harm, the exposure is periodontal disease, with the
comparison as the absence of periodontal disease. Outcomes of
interest are preterm birth and low birth weight.
Resources
Comprehensive Resources
Epistemonikos
Website: www.epistemonikos.org
Cost: Free, with some limited full-text availability
Specialty of resource: Clinical practice guidelines, synopses,
systematic reviews, primary studies, other
Epistemonikos is a publicly available resource whose objective is to

“gather scientific information (i.e., evidence) that might be relevant
for health decision-making and to provide rapid access to the best
available evidence for real-life questions.” It was created primarily for
health professionals, researchers, and individuals who make
decisions in health care.2 Epistemonikos, which translated from
Greek means “what is worth knowing,” includes evidence-based
policy briefs, systematic reviews, primary studies, and synopses of
systematic reviews as well as primary studies; although all of these
different levels of evidence are available in this resource, there is a
heavy emphasis on primarily identifying systematic reviews.
Epistemonikos acts as an aggregator and pulls information from 10
different databases: PubMed, the Cochrane Database of Systematic
Reviews, Embase, CINAHL, PsycINFO, LILACS, the Database of
Abstracts of Reviews of Effects (DARE), the Campbell Collaboration
online library, the JBI Database of Systematic Reviews and
Implementation Reports, and the EPPI-Centre Evidence Library.
Individuals are able to search all of these resources simultaneously
with one search, saving time, which may make this resource one of
the best places to begin a search.
Individuals can perform a basic search from the main page or select
the “advanced search” option. We recommend going straight to the
advanced search option as the basic search is meant to search only
one term at a time and does not support Boolean searching. For
instance, entering our search terms “periodontal disease” and
“pregnant women” into the basic search function returns fewer than
20 results, but entering those same terms into the advanced search
returns more than 60 results. The advanced search builder allows for
individuals to enter in PICO elements and combine them as needed.
Filters are available on the main page of search results to further
narrow down the original search results if needed.
Results are identified by level of evidence and include a basic

citation, as well as an abstract, for each result. As previously
mentioned, Epistemonikos is an aggregate database, so the full text
of an identified article is available at the original resource (linked in
the database). Availability of the full text depends on the individual’s
institutional subscriptions; ADA members may also check with the
librarians at the ADA Library. A helpful feature of this database is the
“related evidence” tab, which is available on the main search results
page. When a primary study is selected, the related evidence tab
includes citations of systematic reviews that include the primary
study and links to these systematic reviews. When a systematic
review is selected, the related evidence tab includes citations of the
included primary studies of the review, as well as a statement that
identifies the total number of systematic reviews that include the
individual primary study. This feature provides a quick and easy way
to find more evidence on a topic.
Epistemonikos allows for the option to create a free personal

account. Oral health care practitioners can save searches as well as
individual article citations, marking them as favorites. Creating a
personal account also allows individuals to create and save matrices
of evidence. Matrixes of evidence pull the included articles from a
selected systematic review and then search for other systematic
reviews that include the original review’s primary studies; the end
result is a grid that demonstrates what systematic reviews on the
topic include which primary studies and where they overlap. The
option to create a matrix is available within the record of a
systematic review. The created matrix can then be saved to the
personal account (Figure 2.3).
Figure 2.3. Example of an Epistemonikos Matrix of Evidence
Source: Epistemonikos.org, accessed on March 18, 2019.
Trip
Website: www.tripdatabase.com
Cost: The Trip database, previously only available via a subscription,
is now freely accessible. A premium version of Trip is available to
individuals via a subscription.
Specialty of resource: Clinical practice guidelines, synopses,
systematic reviews, primary studies, other
Trip (which originally stood for Translating Research into Practice) is

a database/meta-search engine that covers a wide range of sources,
including MEDLINE, the Cochrane Library, guidelines, and more. Trip
is a useful resource to consult initially because it covers a wide range
of material and its search technology allows individuals to find high-
quality evidence quickly and easily. Trip results provide information
from multiple sources and are color-coded by level of evidence as
well as sorted by category. Results are displayed according to an
algorithm that provides relevant, recent, and higher quality
information first. “Higher quality” information in Trip means types of
information that are more highly ranked in the hierarchy of
evidence-based information represented in the evidence pyramid
(Figure 2.4). Results can be filtered using the “refine by” function on
the right-hand side of the screen to filter by level of evidence.
Results may be refined by systematic reviews, evidence-based
synopses, guidelines, primary research from a core set of more than
300 journals, controlled trials, electronic textbooks, and more. Each
of these categories contains information from multiple resources.
“Guidelines,” for example, includes guidelines issued within North
America, Europe, and other countries, while “evidence-based
synopses” includes material from Bandolier, BestBets, POEMs
(Patient-Oriented Evidence that Matters), Clinical Evidence, the
journal Evidence-Based Complementary and Alternative Medicine,
and more. The type of information being provided by any given
result is indicated by an accompanying image locating the type of
information on the evidence pyramid.
Trip is a useful resource to consult initially because it

covers a wide range of material and its search
technology allows individuals to find high-quality
evidence quickly and easily.
Another random document with
no related content on Scribd:
much poor and nasty milk in England, that rickets in one shape or
another is so prevalent?
When will mothers arouse from their slumbers, rub their eyes, and
see clearly the importance of the subject? When will they know that
all the symptoms of rickets I have just enumerated usually proceed
from the want of nourishment, more especially from the want of
genuine and of an abundance of milk? There are, of course, other
means of warding off rickets besides an abundance of nourishing
food, such as thorough ablution, plenty of air, exercise, play, and
sunshine; but of all these splendid remedies, nourishment stands at
the top of the list.
I do not mean to say that rickets always proceeds from poorness
of living—from poor milk. It sometimes arises from scrofula, and is
an inheritance of one or of both the parents.
Rickety children, if not both carefully watched and managed,
frequently, when they become youths, die of consumption. A mother,
who has for some time neglected the advice I have just given, will
often find, to her grievous cost, that the mischief has, past remedy,
been done, and that it is now “too late!—too late!”
271. How may a child be prevented from becoming Rickety? or, if
he be Rickety, how ought he to be treated?
If a child be predisposed to be rickety, or if he be actually rickety,
attend to the following rules:
Let him live well, on good nourishing diet, such as on tender
rump-steaks, cut very fine, and mixed with mashed potatoes, crumb
of bread, and with the gravy of the meat. Let him have, as I have
before advised, an abundance of good new milk—a quart or three
pints during every twenty-four hours. Let him have milk in every
form—as milk gruel, Du Barry’s Arabica revalenta made with milk,
batter and rice puddings, suet-pudding, bread and milk, etc.
To harden the bones, let lime-water be added to the milk (a
tablespoonful to each teacupful of milk).
Let him have a good supply of fresh, pure, dry air. He must almost
live in the open air—the country, if practicable, in preference to the
town, and the coast in summer and autumn. Sea bathing and sea
breezes are often, in these cases, of inestimable value.
He ought not, at an early age, to be allowed to bear his weight
upon his legs. He must sleep on a horse-hair mattress, and not on a
feather bed. He should use, every morning, cold baths in the
summer, and tepid baths in the winter, with bay salt (a handful)
dissolved in the water.
Friction with the hand must, for half an hour at a time, every night
and morning, be sedulously applied to the back and to the limbs. It is
wonderful how much good in these cases friction does.
Strict attention ought to be paid to the rules of health as laid down
in these Conversations. Whatever is conducive to the general health
is preventive and curative of rickets.
Books, if he be old enough to read them, should be thrown aside;
health, and health alone, must be the one grand object.
The best medicines in these cases are a combination of cod-liver
oil and the wine of iron, given in the following manner: Put a
teaspoonful of wine of iron into a wineglass, half fill the glass with
water, sweeten it with a lump or two of sugar, then let a teaspoonful
of cod-liver oil swim on the top; let the child drink it all down
together, twice or three times a day. An hour after a meal is the best
time to give the medicine, as both iron and cod-liver oil sit better on
a full than on an empty stomach. The child in a short time will
become fond of the above medicine, and will be sorry when it is
discontinued.
A case of rickets requires great patience and steady perseverance;
let, therefore, the above plan have a fair and long-continued trial,
and I can then promise that there will be every probability that great
benefit will be derived from it.
272. If a child be subject to a scabby eruption about the mouth,
what is the best local application?
Leave it to Nature. Do not, on any account, apply any local
application to heal it; if you do, you may produce injury; you may
either bring on an attack of inflammation, or you may throw him into
convulsions. No! This “breaking-out” is frequently a safety-valve, and
must not therefore be needlessly interfered with. Should the eruption
be severe, reduce the child’s diet; keep him from butter, from gravy,
and from fat meat, or, indeed, for a few days from meat altogether;
and give him mild aperient medicine; but, above all things, do not
quack him either with calomel or with gray powder.
273. Will you have the goodness to describe the eruption on the
face and on the head of a young child, called Milk-Crust or Running
Scall?
Milk-crust is a complaint of very young children—of those who are
cutting their teeth—and as it is a nasty-looking complaint, and
frequently gives a mother a great deal of trouble, of anxiety, and
annoyance, it will be well that you should know its symptoms, its
causes, and its probable duration.
Symptoms.—When a child is about nine months or a year old,
small pimples are apt to break out around the ears, on the forehead,
and on the head. These pimples at length become vesicles (that is to
say, they contain water), which run into one large one, break, and
form a nasty dirty-looking yellowish, and sometimes greenish scab,
which scab is moist, indeed, sometimes quite wet, and gives out a
disagreeable odor, and which is sometimes so large on the head as
actually to form a skull-cap, and so extensive on the face as to form a
mask! These, I am happy to say, are rare cases. The child’s beauty is,
of course, for a time completely destroyed, and not only his beauty,
but his good temper; for as the eruption causes great irritation and
itching, he is constantly clawing himself, and crying with annoyance
a great part of the day, and sometimes also of the night, the eruption
preventing him from sleeping. It is not contagious, and soon after he
has cut the whole of his first set of teeth, it will get well, provided it
has not been improperly interfered with.
Causes.—Irritation from teething; stuffing him with overmuch
meat, thus producing a humor, which Nature tries to get rid of by
throwing it out on the surface of the body, the safest place she could
fix on for the purpose, hence the folly and danger of giving medicines
and applying external applications to drive the eruption in.
“Diseased nature oftentimes breaks forth in strange eruptions,”[264]
and cures herself in this way, if she be not too much interfered with,
and if the eruption be not driven in by injudicious treatment. I have
known in such cases disastrous consequences to follow over-
officiousness and meddlesomeness. Nature is trying all she can to
drive the humor out, while some wiseacres are doing all they can to
drive the humor in.
Duration.—As milk-crust is a tedious affair, and will require a
variety of treatment, it will be necessary to consult an experienced
medical man; and although he will be able to afford great relief, the
child will not, in all probability, be quite free from the eruption until
he has cut the whole of his first set of teeth—until he be upwards of
two years and a half old—when, with judicious and careful treatment,
it will gradually disappear, and eventually leave not a trace behind.
It will be far better to leave the case alone—to get well of itself
rather than to try to cure the complaint either by outward
applications or by strong internal medicines; “the remedy is often
worse than the disease,” of this I am quite convinced.
274. Have you any advice to give me as to my conduct toward my
medical man?
Give him your entire confidence. Be truthful and be candid with
him. Tell him the truth, the whole truth, and nothing but the truth.
Have no reservations; give him, as near as you can, a plain,
unvarnished statement of the symptoms of the disease. Do not
magnify, and do not make too light of any of them. Be prepared to
state the exact time the child first showed symptoms of illness. If he
have had a shivering fit, however slight, do not fail to tell your
medical man of it. Note the state of the skin; if there be a “breaking-
out,” be it ever so trifling, let it be pointed out to him. Make yourself
acquainted with the quantity and with the appearance of the urine,
taking care to have a little of it saved, in case the doctor may wish to
see and examine it. Take notice of the state of the motions—their
number during the twenty-four hours, their color, their smell, and
their consistence, keeping one for his inspection. Never leave any of
these questions to be answered by a servant; a mother is the proper
person to give the necessary and truthful answers, which answers
frequently decide the fate of the patient. Bear in mind, then, a
mother’s untiring care and love, attention and truthfulness,
frequently decide whether, in a serious illness, the little fellow shall
live or die! Fearful responsibility!
A medical man has arduous duties to perform; smooth, therefore,
his path as much as you can, and you will be amply repaid by the
increased good he will be able to do your child. Strictly obey a
doctor’s orders—in diet, in medicine, in everything. Never throw
obstacles in his way. Never omit any of his suggestions; for depend
upon it, that if he be a sensible man, directions, however slight,
ought never to be neglected; bear in mind, with a judicious medical
man,—
“That nothing walks with aimless feet.”[265]
If the case be severe, requiring a second opinion, never of your

own accord call in a physician without first consulting and advising
with your own medical man. It would be an act of great discourtesy
to do so. Inattention to the foregoing advice has frequently caused
injury to the patient, and heart-burnings and ill will among doctors.
Speak, in the presence of your child, with respect and kindness of
your medical man, so that the former may look upon the latter as a
friend—as one who will strive, with God’s blessing, to relieve his pain
and suffering. Remember the increased power of doing good the
doctor will have if the child be induced to like, instead of dislike, him.
Not only be careful that you yourself speak before your child
respectfully and kindly of the medical man, but see that your
domestics do so likewise; and take care that they are never allowed to
frighten your child, as many silly servants do, by saying that they will
send for the doctor, who will either give him nasty medicine, or will
perform some cruel operation upon him. A nurse-maid should, then,
never for one moment be permitted to make a doctor an object of
terror or of dislike to a child.
Send, whenever it be practicable, for your doctor early in the
morning, as he will then make his arrangements accordingly, and
can by daylight better ascertain the nature of the complaint, more
especially if it be a skin disease. It is utterly impossible for him to
form a correct opinion of the nature of a “breaking-out” either by gas
or by candle-light. If the illness come on at night, particularly if it be
ushered in either with a severe shivering, or with any other urgent
symptom, no time should be lost, be it night or day, in sending for
him.
WARM BATHS.
275. Have the goodness to mention the complaints of a child for

which warm baths are useful?
1. Convulsions; 2. Pains in the bowels, known by the child drawing
up his legs, screaming violently, etc.; 3. Restlessness from teething;
4. Flatulence. The warm bath acts as a fomentation to the stomach
and the bowels, and gives ease where the usual remedies do not
rapidly relieve.
276. Will you mention the precautions and the rules to be
observed in putting a child into a warm bath?
Carefully ascertain before he be immersed in the bath that the
water be neither too hot nor too cold. Carelessness, or over-anxiety
to put him in the water as quickly as possible, has frequently, from
his being immersed in the bath when the water was too hot, caused
him great pain and suffering. From 96 to 98 degrees of Fahrenheit is
the proper temperature of a warm bath. If it be necessary to add
fresh warm water, let him be either removed the while, or let it not
be put in when very hot; for if boiling water be added to increase the
heat of the bath, it naturally ascends, and may scald him. Again, let
the fresh water be put in at as great a distance from him as possible.
The usual time for him to remain in a bath is a quarter of an hour or
twenty minutes. Let the chest and the bowels be rubbed with the
hand while he is in the bath. Let him be immersed in the bath as high
up as the neck, taking care that he be the while supported under the
armpits, and that his head be also rested. As soon as he comes out of
the bath he ought to be carefully but quickly rubbed dry; and, if it be
necessary to keep up the action on the skin, he should be put to bed,
between the blankets; or, if the desired relief has been obtained,
between the sheets, which ought to have been previously warmed,
where, most likely, he will fall into a sweet refreshing sleep.
WARM EXTERNAL APPLICATIONS.
277. In case of a child suffering pain either in his stomach or in

his bowels, or in case he has a feverish cold, can you tell me of the
best way of applying heat to them?
In pain, either of the stomach or of the bowels, there is nothing
usually affords greater or speedier relief than the external
application of heat. The following are four different methods of
applying heat: 1. A bag of hot salt—that is to say, powdered table salt
—put either into the oven or into a frying-pan, and thus made hot,
and placed in a flannel bag, and then applied, as the case may be,
either to the stomach or to the bowels. Hot salt is an excellent
remedy for these pains. 2. An india-rubber hot water bottle,[266] half
filled with hot water—it need not be boiling—applied to the stomach
or to the bowels will afford great comfort. 3. Another, and an
excellent remedy for these cases, is a hot bran poultice. The way to
make it is as follows: Stir bran into a vessel containing either a pint
or a quart (according to size of poultice required) of boiling water,
until it be of the consistence of a nice soft poultice, then put it into a
flannel bag and apply it to the part affected. When cool, dip it from
time to time in hot water. 4. In case a child has a feverish cold,
especially if it be attended, as it sometimes is, with pains in the
bowels, the following is a good external application: Take a yard of
flannel, fold it three widths, then dip it in very hot water, wring it out
tolerably dry, and apply it evenly and neatly round and round the
bowels; over this, and to keep it in its place and to keep in the
moisture, put on a dry flannel bandage, four yards long and four
inches wide. If it be put on at bedtime, it ought to remain on all
night. Where there are children, it is desirable to have the yard of
flannel and the flannel bandage in readiness, and then a mother will
be prepared for emergencies. Either the one or the other, then, of the
above applications will usually, in pains of the stomach and bowels,
afford great relief. There is one great advantage of the external
application of heat—it can never do harm; if there be inflammation,
it will do good; if there be either cramps or spasms of the stomach, it
will be serviceable; if there be colic, it will be one of the best remedies
that can be used; if it be a feverish cold, by throwing the child into a
perspiration, it will be useful.
It is well for a mother to know how to make a white-bread
poultice; and as the celebrated Abernethy was noted for his poultices,
I will give you his directions, and in his very words: “Scald out a
basin, for you can never make a good poultice unless you have
perfectly boiling water, then, having put in some hot water, throw in
coarsely crumbled bread, and cover it with a plate. When the bread
has soaked up as much water as it will imbibe, drain off the
remaining water, and there will be left a light pulp. Spread it a third
of an inch thick on folded linen, and apply it when of the
temperature of a warm bath. It may be said that this poultice will be
very inconvenient if there be no lard in it, for it will soon get dry; but
this is the very thing you want, and it can easily be moistened by
dropping warm water on it, while a greasy poultice will be moist, but
not wet.”[267]
ACCIDENTS.
278. Supposing a child to cut his finger, what is the best

application?
There is nothing better than tying it up with rag in its blood, as
nothing is more healing than blood. Do not wash the blood away, but
apply the rag at once, taking care that no foreign substance be left in
the wound. If there be either glass or dirt in it, it will, of course, be
necessary to bathe the cut in warm water, to get rid of it before the
rag be applied. Some mothers use either salt, or Fryar’s Balsam, or
turpentine to a fresh wound; these plans are cruel and unnecessary,
and frequently make the cut difficult to heal. If it bleed
immoderately, sponge the wound freely with cold water. If it be a
severe cut, surgical aid, of course, will be required.
279. If a child receive a blow, causing a bruise, what had better be
done?
Immediately smear a small lump of fresh butter on the part
affected, and renew it every few minutes for two or three hours; this
is an old-fashioned, but a very good remedy. Olive oil may—if fresh
butter be not at hand—be used, or soak a piece of brown paper in
one-third of French brandy, and two-thirds of water, and
immediately apply it to the part; when dry renew it. Either of these
simple plans—the butter plan is the best—will generally prevent both
swelling and disfiguration.
A “Black Eye.”—If a child, or indeed any one else, receive a blow
over the eye, which is likely to cause a “black eye,” there is no remedy
superior to, nor more likely to prevent one, than well buttering the
parts for two or three inches around the eye with fresh butter,
renewing it every few minutes for the space of an hour or two; if such
be well and perseveringly done, the disagreeable appearance of a
“black eye” will in all probability be prevented. A capital remedy for a
“black eye” is the arnica lotion:
Take of—Tincture of Arnica, one ounce;
Water, seven ounces:
To make a Lotion. The eye to be bathed, by means of a soft piece of linen rag,
with this lotion frequently; and, between times, let a piece of linen rag, wetted
in the lotion, be applied to the eye, and be fastened in its place by means of a
bandage.
The white lily leaf, soaked in brandy, is another excellent remedy
for the bruises of a child. Gather the white lily blossoms when in full
bloom, and pot them in a wide-mouthed bottle of brandy, cork the
bottle, and it will then always be ready for use. Apply a leaf to the
part affected, and bind it on either with a bandage or with a
handkerchief. The white lily root sliced is another valuable external
application for bruises.
280. If a child fall upon his head and be stunned, what ought to be
done?
If he fall upon his head and be stunned, he will look deadly pale,
very much as if he had fainted. He will in a few minutes, in all
probability, regain his consciousness. Sickness frequently
supervenes, which makes the case more serious, it being a proof that
injury, more or less severe, has been done to the brain; send,
therefore, instantly, for a medical man.
In the mean time, loosen both his collar and neckerchief, lay him
flat on his back, sprinkle cold water upon his face, open the windows
so as to admit plenty of fresh air, and do not let people crowd around
him, nor shout at him, as some do, to make him speak.
While he is in an unconscious state, do not on any account
whatever allow a drop of blood to be taken from him, either by
leeches or by bleeding; if you do, he will probably never rally, but will
most likely sleep “the sleep that knows no waking.”
281. A nurse sometimes drops an infant and injures his back;
what ought to be done?
Instantly send for a surgeon; omitting to have proper advice in
such a case has frequently made a child a cripple for life. A nurse
frequently, when she has dropped her little charge, is afraid to tell
her mistress; the consequences might then be deplorable. If ever a
child scream violently without any assignable cause, and the mother
is not able for some time to pacify him, the safer plan is that she send
for a doctor, in order that he might strip and carefully examine him;
much after-misery might often be averted if this plan were more
frequently followed.
282. Have you any remarks to make and directions to give on
accidental poisoning by lotions, by liniments, etc.?
It is a culpable practice of either a mother or nurse to leave
external applications within the reach of a child. It is also highly
improper to put a mixture and an external application (such as a
lotion or a liniment) on the same tray or on the same mantle-piece.
Many liniments contain large quantities of opium, a teaspoonful of
which would be likely to cause the death of a child. “Hartshorn and
oil,” too, has frequently been swallowed by children, and in several
instances has caused death. Many lotions contain sugar of lead,
which is also poisonous. There is not, fortunately, generally sufficient
lead in the lotion to cause death; but if there be not enough to cause
death, there may be more than enough to make the child very poorly.
All these accidents occur from disgraceful carelessness.
A mother or a nurse ought always, before administering a dose of
medicine to a child, to read the label on the bottle; by adopting this
simple plan many serious accidents and much after-misery might be
averted. Again, I say let every lotion, every liniment, and indeed
everything for external use, be either locked up or be put out of the
way, and far away from all medicine that is given by the mouth. This
advice admits of no exception.
If your child has swallowed a portion of a liniment containing
opium, instantly send for a medical man. In the mean time, force a
strong mustard emetic (composed of two teaspoonfuls of flour of
mustard, mixed in half a teacupful of warm water) down his throat.
Encourage the vomiting by afterward forcing him to swallow warm
water. Tickle the throat either with your finger or with a feather.
Souse him alternately in a hot and then in a cold bath. Dash cold
water on his head and face. Throw open the windows. Walk him
about in the open air. Rouse him by slapping him, by pinching him,
and by shouting to him; rouse him, indeed, by every means in your
power, for if you allow him to go to sleep, it will, in all probability, be
the sleep that knows no waking!
If a child has swallowed “hartshorn and oil,” force him to drink
vinegar and water, lemon-juice and water, barley-water, and thin
gruel.
If he have swallowed a lead lotion, give him a mustard emetic, and
then vinegar and water, sweetened either with honey or with sugar,
to drink.
283. Are not Lucifer Matches poisonous?
Certainly, they are very poisonous; it is therefore desirable that
they should be put out of the reach of children. A mother ought to be
very strict with servants on this head. Moreover, lucifer matches are
not only poisonous but dangerous, as a child might set himself on
fire with them. A case bearing on the subject has just come under my
own observation. A little boy, three years old, was left alone for two
or three minutes, during which time he obtained possession of a
lucifer match, and struck a light by striking the match against the
wall. Instantly there was a blaze. Fortunately for him, in his fright, he
threw the match on the floor. His mother, at this moment, entered
the room. If his clothes had taken fire, which they might have done,
had he not thrown the match away, or if his mother had not been so
near at hand, he would, in all probability, have either been severely
burned, or have been burned to death.
284. If a child’s clothes take fire, what ought to be done to
extinguish them?
Lay him on the floor, then roll him either in the rug or in the
carpet, or in the door-mat, or in any thick article of dress you may
either have on, or have at hand—if it be woolen, so much the better;
or throw him down, and roll him over and over on the floor, as by
excluding the atmospheric air, the flame will go out: hence, the
importance of a mother cultivating presence of mind. If parents were
better prepared for such emergencies, such horrid disfigurations and
frightful deaths would be less frequent.
You ought to have a proper fire-guard before the nursery grate,
and should be strict in not allowing your child to play with fire. If he
still persevere in playing with it when he has been repeatedly
cautioned not to do so, he should be punished for his temerity. If
anything would justify corporal chastisement, it would surely be such
an act of disobedience. There are only two acts of disobedience that I
would flog a child for—namely, the playing with fire and the telling of
a lie! If after various warnings and wholesome corrections he still
persists, it would be well to let him slightly taste the pain of his doing
so, either by holding his hand for a moment very near the fire, or by
allowing him to slightly touch either the hot bar of the grate or the
flame of the candle. Take my word for it, the above plan will
effectually cure him—he will never do it again! It would be well for
the children of the poor to have pinafores made either of woolen or
of stuff materials. The dreadful deaths from burning, which so often
occur in winter, too frequently arise from cotton pinafores first
taking fire.[268]
If all dresses, after being washed, and just before being dried,
were, for a short time, soaked in a solution of tungstate of soda, such
clothes, when dried, would be perfectly fire-proof.
Tungstate of soda may be used either with or without starch; but
full directions for the using of it will, at the time of purchase, be
given by the chemist.
285. Is a burn more dangerous than a scald?
A burn is generally more serious than a scald. Burns and scalds are
more dangerous on the body, especially on the chest, than either on
the face or on the extremities. The younger the child, of course, the
greater is the danger.
Scalds, both of the mouth and of the throat, from a child drinking
boiling water from the spout of a tea-kettle, are most dangerous. A
poor person’s child is, from the unavoidable absence of the mother,
sometimes shut up in the kitchen by himself, and being very thirsty,
and no other water being at hand, he is tempted in his ignorance to
drink from the tea-kettle: if the water be unfortunately boiling, it will
most likely prove to him to be a fatal draught!
286. What are the best immediate applications to a scald or to a
burn?
There is nothing more efficacious than flour. It ought to be thickly
applied, over the part affected, and should be kept in its place either
with a rag and a bandage, or with strips of old linen. If this be done,
almost instantaneous relief will be experienced, and the burn or the
scald, if superficial, will soon be well. The advantage of flour as a
remedy is this, that it is always at hand. I have seen some extensive
burns and scalds cured by the above simple plan. Another excellent
remedy is cotton wool. The burn or the scald ought to be enveloped
in it; layer after layer should be applied until it be several inches
thick. The cotton wool must not be removed for several days.[269]
These two remedies, flour and cotton wool, may be used in
conjunction; that is to say, the flour may be thickly applied to the
scald or to the burn, and the cotton wool over all.
Prepared lard—that is to say, lard without salt[270]—is an admirable
remedy for burns and for scalds. The advantages of lard are: (1) It is
almost always at hand; (2) It is very cooling, soothing, and
unirritating to the part, and it gives almost immediate freedom from
pain; (3) It effectually protects and sheathes the burn or the scald
from the air; (4) It is readily and easily applied: all that has to be
done is to spread the lard either on pieces of old linen rag, or on lint,
and then to apply them smoothly to the parts affected, keeping them
in their places by means of bandages—which bandages may be
readily made from either old linen or calico shirts. Dr. John Packard,
of Philadelphia, was the first to bring this remedy for burns and
scalds before the public—he having tried it in numerous instances,
and with the happiest results. I myself have, for many years, been in
the habit of prescribing lard as a dressing for blisters, and with the
best effects. I generally advise equal parts of prepared lard and of
spermaceti cerate to be blended together to make an ointment. The
spermaceti cerate gives a little more consistence to the lard, which, in
warm weather, especially, is a great advantage.
Another valuable remedy for burns is, “carron oil;” which is made
by mixing equal parts of linseed oil and lime-water together in a
bottle, and shaking it up before using it.
Cold applications, such as cold water, cold vinegar and water, and
cold lotions, are most injurious, and, in many cases, even dangerous.
Scraped potatoes, sliced cucumber, salt, and spirits of turpentine,
have all been recommended; but, in my practice, nothing has been so
efficacious as the remedies above enumerated.
Do not wash the wound, and do not dress it more frequently than
every other day. If there be much discharge, let it be gently sopped
up with soft old linen rag; but do not, on any account, let the burn be
rubbed or roughly handled. I am convinced that, in the majority of
cases, wounds are too frequently dressed, and that the washing of
wounds prevents the healing of them. “It is a great mistake,” said
Ambrose Paré, “to dress ulcers too often, and to wipe their surfaces
clean, for thereby we not only remove the useless excrement, which
is the mud or sanies of ulcers, but also the matter which forms the
flesh. Consequently, for these reasons, ulcers should not be dressed
too often.”
The burn or the scald may, after the first two days, if severe,
require different dressings; but, if it be severe, the child ought of
course to be immediately placed under the care of a surgeon.
If the scald be either on the leg or on the foot, a common practice
is to take the shoe and the stocking off; in this operation, the skin is
also at the same time very apt to be removed. Now, both the shoe and
the stocking ought to be slit up, and thus be taken off, so that neither
unnecessary pain nor mischief may be caused.
287. If a bit of quicklime should accidentally enter the eye of my
child, what ought to be done?
Instantly, but tenderly remove, either by means of a camel’s-hair
brush or by a small spill of paper, any bit of lime that may adhere to
the ball of the eye, or that may be within the eye or on the eyelashes;
then well bathe the eye (allowing a portion to enter it) with vinegar
and water—one part of vinegar to three parts of water, that is to say,
a quarter fill a clean half-pint medicine bottle with vinegar and then
fill it up with spring water, and it will be ready for use. Let the eye be
bathed for at least a quarter of an hour with it. The vinegar will
neutralize the lime, and will rob it of its burning properties.
Having bathed the eye with the vinegar and water for a quarter of
an hour, bathe it for another quarter of an hour simply with a little
warm water; after which, drop into the eye two or three drops of the
best sweet oil, put on an eye-shade made of three thicknesses of linen
rag, covered with green silk, and then do nothing more until the
doctor arrives.
If the above rules be not promptly and properly followed out, the
child may irreparably lose his eyesight; hence the necessity of a
popular work of this kind, to tell a mother, provided immediate
assistance cannot be obtained, what ought instantly to be done; for
moments, in such a case, are precious.
While doing all that I have just recommended, let a surgeon be
sent for, as a smart attack of inflammation of the eye is very apt to
follow the burn of lime; but which inflammation will, provided the
previous directions have been promptly and efficiently followed out,
with appropriate treatment, soon subside.
The above accident is apt to occur to a child who is standing near a
building when the slacking of quicklime is going on, and where
portions of lime, in the form of powder, are flying about the air. It
would be well not to allow a child to stand about such places, as
prevention is always better than cure. Quicklime is sometimes called
caustic lime: it well deserves its name, for it is a burning lime, and if
proper means be not promptly used, will soon burn away the sight.
288. “What is to be done in the case of Choking?”
Instantly put your finger into the throat and feel if the substance
be within reach; if it be food, force it down, and thus liberate the
breathing; should it be a hard substance, endeavor to hook it out; if
you cannot reach it, give a good smart blow or two with the flat of the
hand on the back; or, as recommended by a contributor to the
Lancet, on the chest, taking care to “seize the little patient, and place
him between your knees side ways, and in this or some other manner
to compress the abdomen [the belly], otherwise the power of the
blow will be lost by the yielding of the abdominal parietes [walls of
the belly], and the respiratory effort will not be produced.” If that
does not have the desired effect, tickle the throat with your finger, so
as to insure immediate vomiting, and the consequent ejection of the
offending substance.[271]
289. Should my child be bitten by a dog supposed to be mad, what
ought to be done?
Instantly well rub for the space of five of ten seconds—seconds, not
minutes—a stick of nitrate of silver (lunar caustic) into the wound.
The stick of lunar caustic should be pointed, like a cedar-pencil for
writing, in order the more thoroughly to enter the wound.[272] This, if
properly done directly after the bite, will effectually prevent
hydrophobia. The nitrate of silver acts not only as a caustic to the
part, but it appears effectually to neutralize the poison, and thus by
making the virus perfectly innocuous is a complete antidote. If it be
either the lip, or the parts near the eye, or the wrist, that have been
bitten, it is far preferable to apply the caustic than to cut the part out;
as the former is neither so formidable, nor so dangerous, nor so
disfiguring as the latter, and yet it is equally as efficacious. I am
indebted to the late Mr. Youatt, the celebrated veterinary surgeon,
for this valuable antidote or remedy for the prevention of the most
horrible, heart-rending, and incurable disease known. Mr. Youatt
had an immense practice among dogs as well as among horses. He
was a keen observer of disease, and a dear lover of his profession,
and he had paid great attention to rabies—dog madness. He and his
assistants had been repeatedly bitten by rabid dogs; but knowing
that he was in possession of an infallible preventive remedy, he never
dreaded the wounds inflicted either upon himself or upon his
assistants. Mr. Youatt never knew lunar caustic, if properly and
immediately applied, to fail. It is, of course, only a preventive. If
hydrophobia be once developed in the human system, no antidote
has ever yet, for this fell and intractable disease, been found.
While walking the London Hospitals, upwards of thirty-five years
ago, I received an invitation from Mr. Youatt to attend a lecture on
rabies—dog madness. He had, during the lecture, a dog present
laboring under incipient madness. In a day or two after the lecture,
he requested me and other students to call at his infirmary and see
the dog, as the disease was at that time fully developed. We did so,
and found the poor animal raving mad—frothing at the mouth, and
snapping at the iron bars of his prison. I was particularly struck with
a peculiar brilliancy and wildness of the dog’s eyes. He seemed as
though, with affright and consternation, he beheld objects unseen by
all around. It was pitiful to witness his frightened and anxious
countenance. Death soon closed the scene!
I have thought it my duty to bring the value of lunar caustic as a
preventive of hydrophobia prominently before your notice, and to
pay a tribute of respect to the memory of Mr. Youatt—a man of talent
and genius.
Never kill a dog supposed to be mad who has bitten either a child,
or any one else, until it has, past all doubt, been ascertained whether
he be really mad or not. He ought, of course, to be tied up, and be
carefully watched, and be prevented the while from biting any one
else. The dog, by all means, should be allowed to live at least for
some weeks, as the fact of his remaining will be the best guarantee
that there is no fear of the bitten child having caught hydrophobia.
There is a foolish prejudice abroad, that a dog, be he mad or not,
who has bitten a person ought to be immediately destroyed; that
although the dog be not at the time mad, but should at a future
period become so, the person who had been bitten when the dog was
not mad, would, when the dog became mad, have hydrophobia! It
seems almost absurd to bring the subject forward; but the opinion is
so very general and deep rooted, that I think it well to declare that
there is not the slightest foundation of truth in it, but that it is a
ridiculous fallacy!
A cat sometimes goes mad, and its bite may cause hydrophobia;
indeed, the bite of a mad cat is more dangerous than the bite of a
mad dog. A bite from a mad cat ought to be treated precisely in the
same manner—namely, with the lunar caustic—as for a mad dog.
A bite either from a dog or from a cat who is not mad, from a cat
especially, is often venomous and difficult to heal. The best
application is immediately to apply a large hot white-bread poultice
to the part, and to renew it every four hours; and, if there be much
pain in the wound, to well foment the part, every time before
applying the poultice, with a hot chamomile and poppy-head
fomentation.
Scratches of a cat are best treated by smearing, and that freely and
continuously for an hour, and then afterward at longer intervals,
fresh butter on the part affected. If fresh butter be not at hand, fresh
lard—that is to say, lard without salt—will answer the purpose. If the
pain of the scratch be very intense, foment the part affected with hot
water, and then apply a hot white-bread poultice, which should be
frequently renewed.
290. What is the best application in case of a sting either from a
bee or from a wasp?
Extract the sting, if it have been left behind, either by means of a
pair of dressing forceps, or by the pressure of the hollow of a small
key—a watch-key will answer the purpose; then, a little blue (which
is used in washing) moistened with water, should be immediately
applied to the part; or, apply a few drops of solution of potash,[273] or
“apply moist snuff or tobacco, rubbing it well in,”[274] and renew from
time to time either of them: if either of these be not at hand, either
honey, or treacle, or fresh butter, will answer the purpose. Should
there be much swelling or inflammation, apply a hot white-bread
poultice, and renew it frequently. In eating apricots, or peaches, or
other fruit, they ought to, beforehand, be carefully examined, in
order to ascertain that no wasp is lurking in them; otherwise, it may
sting the throat, and serious consequences will ensue.
291. If a child receive a fall, causing the skin to be grazed, can you
tell me of a good application?
You will find gummed paper an excellent remedy; the way of
preparing it is as follows: Apply evenly, by means of a small brush,
thick mucilage of gum arabic to cap paper; hang it up to dry, and
keep it ready for use. When wanted, cut a portion as large as may be
requisite, then moisten it with your tongue, in the same manner you
would a postage stamp, and apply it to the grazed part. It may be
removed when necessary by simply wetting it with water. The part in
two or three days will be well. There is usually a margin of gummed
paper sold with postage stamps; this will answer the purpose equally
well. If the gummed paper be not at hand, then frequently, for the
space of an hour or two, smear the part affected with fresh butter.
292. In case of a child swallowing by mistake either laudanum, or
paregoric, or Godfrey’s Cordial, or any other preparation of opium,
what ought to be done?
Give, as quickly as possible, a strong mustard emetic; that is to
say, mix two teaspoonfuls of flour of mustard in half a teacupful of
water, and force it down his throat. If free vomiting be not induced,
tickle the upper part of the swallow with a feather; drench the little
patient’s stomach with large quantities of warm water. As soon as it
can be obtained from a druggist, give him the following emetic
draught:
Take of—Sulphate of Zinc, one scruple;
Simple Syrup, one drachm;
Distilled Water, seven drachms:
To make a Draught.
Smack his buttocks and his back; walk him, or lead him, or carry
him about in the fresh air; shake him by the shoulders; pull his hair;
tickle his nostrils; shout and holla in his ears; plunge him into a
warm bath and then into a cold bath alternately; well sponge his
head and face with cold water; dash cold water on his head, face, and
neck; and do not, on any account, until the effects of the opiate are
gone off, allow him to go to sleep; if you do, he will never wake again!
While doing all these things, of course, you ought to lose no time in
sending for a medical man.
293. Have you any observations to make on parents allowing the
Deadly Nightshade—the Atropa Belladonna—to grow in their
gardens?
I wish to caution you not on any account to allow the Belladonna—
the Deadly Nightshade—to grow in your garden. The whole plant—
root, leaves, and berries—is poisonous; and the berries, being
attractive to the eye, are very alluring to children.
294. What is the treatment of poisoning by Belladonna?
Instantly send for a medical man; but, in the mean time, give an
emetic—a mustard emetic;—mix two teaspoonfuls of flour of
mustard in half a teacupful of warm water, and force it down the
child’s throat; then drench him with warm water, and tickle the
upper part of his swallow either with a feather or with the finger, to
make him sick; as the grand remedy is an emetic to bring up the
offending cause. If the emetic have not acted sufficiently, the medical
man when he arrives may deem it necessary to use the stomach-
pump; but remember not a moment must be lost, for moments are
precious in a case of belladonna poisoning, in giving a mustard
emetic, and repeating it again and again until the enemy be
dislodged. Dash cold water upon his head and face; the best way of
doing which is by means of a large sponge, holding his head and his
face over a wash-hand basin, half filled with cold water, and filling
the sponge from the basin, and squeezing it over his head and face,
allowing the water to continuously stream over them for an hour or
two, or until the effects of the poison have passed away. This
sponging of the head and face is very useful in poisoning by opium,
as well as in poisoning by belladonna; indeed, the treatment of
poisoning by the one is very similar to the treatment of poisoning by
the other. I, therefore, for the further treatment of poisoning by
belladonna, beg to refer you to a previous Conversation on the
treatment of poisoning by opium.
295. Should a child put either a pea or a bead, or any other
foreign substance, up the nose, what ought to be done?
Do not attempt to extract it yourself, or you might push it farther
in, but send instantly for a surgeon, who will readily remove it, either
with a pair of forceps, or by means of a bent probe, or with a director.
If it be a pea, and it be allowed for any length of time to remain in, it
will swell, and will thus become difficult to extract, and may produce

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How to Use Evidence Based Dental

Practices to Improve Clinical Decision

Managing the Dental Team Guidelines for Practice

Managing the Regulatory Environment Guidelines for

Managing Patients the Patient Experience Guidelines for

The ADA Practical Guide to Effective Infection

ADA Dental Drug Handbook A Quick Reference 2019th

How to Develop Your Career in Dental Nursing 1st

How to Heal and Prevent Dental Disasters Book 1 1st

Oral Pathology in Clinical Dental Practice Robert E

How to Use Evidence-Based Dental

Alonso Carrasco-Labra, D.D.S.

Book ISBN: 978-1-68447-061-7

American Dental Association

• From the ADA Center for Evidence-Based Dentistry (EBD):

Thank you to Kimberly Ruona, D.D.S., Associate Dean for Patient

And a big thank you to the broad community of enthusiastic and

How to Use This Book

Chapter 1. Understanding and Applying the

Chapter 2. Searching for the Best Oral Health

Chapter 3. How to Appraise and Use an Article

Chapter 4. How to Use an Article about Harm

Chapter 6. How to Use a Systematic Review

Chapter 7. How to Use Patient Management

Chapter 8. How to Appraise an Article Based

Chapter 10. How to Avoid Being Misled by

Chapter 11. What Is the Difference between

Chapter 13. Issues of Bias and Confounding in

Chapter 14. What Is Certainty of the Evidence,

Chapter 15. Strategies for Teaching Evidence-

Chapter 16. Implementing Evidence into

Chapter 17. Health Policymaking Informed by

Since 1995, Cochrane Oral Health has produced around 150

All of this means that it is important to continue teaching the key

Derek Richards, M.Sc., D.D.P.H.

Although this wealth of information is often addressed toward

Alonso Carrasco-Labra, D.D.S., M.Sc., Ph.D., and Jeff Huber, M.B.A.

The concept of evidence-based medicine soon expanded to other

This book aims to provide an overview of the basic concepts of EBD

Definition and Principles of EBD

• the best current research evidence;

Figure 1.1. The Components of Evidence-Based Dentistry

One definition of evidence is “any empirical observation whether

Because unsystematic clinical observations of a small number of

As stated above, evidence alone is not enough to support clinical

The Process of EBD

• translating the clinical question into a well-formulated

To translate a clinical question into a well-formulated searchable

Once a clinician obtains the evidence to answer the clinical question

Scientific evidence constitutes one of the fundamental tenets of

A version of this chapter originally appeared in the November 2014 edition of

The practice of evidence-based dentistry includes articulating a

The amount of health-related information available via the internet is

Effective searching of medical databases is a very valuable skill these

Table 2.1. General Searching Tips for Electronic Resources

Searching Tips to Remember

• Add additional terms using Boolean searching to narrow results.

If the search is not yielding the expected results, consider using

Boolean searching refers to connecting search terms with one of the