Evidence-based dentistry (EBD) is defined by the American Dental Association (ADA) as an approach to oral health care that requires the integration of systematic assessments of clinically relevant scientific evidence, relating the patient's medical history and oral condition, with the dentist's clinical expertise and the patient's treatment needs. As it is clearly seen, the ADA points out three main areas in EBD: (1) relevant scientific evidence, (2) patient needs and preferences, and (3) dentists' clinical expertise. ¹

EBD helps to minimize personal faults, reassures the best clinical decision making for the patient, and uses available sources more effectively. Dentists need to make daily decisions regarding patient care. These decisions should essentially be scientifically sound. EBD is meant to empower clinicians to provide the best contemporary treatment. ²

EBD is a means of lifelong learning in which clinicians base their decisions on evidence rather than opinions and are able to continuously monitor and develop their clinical skills and performance. EBD provides some advantages in which dentists can pursue more secure, effective, and cost-effective treatment. ³

General dental students can attend EBD courses to learn the required dentistry skills based on evidence. ⁴ Previous studies in Tehran Iran show that despite good attitudes about EBD, there was a deficiency in students' knowledge and awareness. ⁵ Dental faculty members were also investigated in this matter indicating a moderate level of actual knowledge about the basic principles of EBD. ⁶

EBD is a mutual responsibility for both researchers and therapists. As we expect a dentist to apply the most contemporary evidence in the clinic and to choose the best treatment method and applied materials accordingly, we should also expect a researcher to design and implement studies accurately without bias. On the other hand, scholars should evaluate and criticize these trials through systematic reviews to manage high-volume information. Researchers should rank data within clinical studies and academic papers to prevent any bias in the validity of academic researches and papers. In this case, designed studies like systematic reviews can be generalized clinically by removing the gap between research and clinical study. ⁷

Reforms and changes in dentistry courses are implemented to educate many dentists to provide oral health cares for patients whilst having academic capacity and skills for the management of clinical trials. Some changes also have other advantages, including a deeper understanding of the association between medical sciences and dentistry, society needs-based courses, academic-critical thinking skills, creating continuous education, and evidence-based trials for dental students. ⁸

Dentistry faculties also should pave the way for the education of thoughtful graduates who can solve problems and use research findings to be lifelong learners. ⁹

Since 2010 EBD practice has been included in the new dentistry curriculum of the Iranian Dental Schools. In line with other countries, different content and methods have been applied for training this course in all dental schools. Several researchers conducted studies on EBD in Iran by different perspectives including knowledge, attitude, and application. Since this is a new approach in the curriculum; it should be evaluated and discussed based on scientific principles. The purpose of this study was to collect and compare the available evidence regarding the attitude of Iranian dental students about EBD and the effects of EBD dental courses on their attitude. This systematic review can help designers of dental curriculums in Iran and other regions to find the gap in EBD courses.

Search strategy

The core search strategy was developed based on the Medical Subject Heading and the keywords of the article. A single reviewer performed the search in June 2021 on Medline (PubMed based) and Google scholar as international databases and Magiran, Scientific Information Database (SID) and Islamic World Science Citation (ISC) as local resources. English and Persian articles with publication years after 2010 by three main concepts “evidence-based dentistry,” “attitude,” “dental students,” and equivalent Persian phrases were applied for searching. The search strategy is explained in detail in Table 1.{Table 1}

Eligibility criteria

Inclusion criteria included English and Persian studies between 2010 and June 15, 2021, at any dental university or institute in Iran. The participants were dental students at any age or semester either undergraduate or postgraduate. The qualitative, cross-sectional, and interventional methods of research were considered. The articles which included dentists or faculty members were excluded.

Study selection and data extraction

At first, duplicates were removed by hand-searching. Two reviewers independently screened titles and abstracts for eligibility. If the articles were about the knowledge, awareness, and skills of the students and there was not any outcome about their attitude or perception they were deleted from the list. Specific studies such as epidemiology, Internet or computer usage, and searching which were assessed as a field of EBD were excluded because the content did not cover our concept. Then, full texts of relevant articles were identified and read and the main parts were extracted as evidence presented in two different tables. The items for preparing and evaluating the formats of descriptive studies included the first author's name, year of publication, number of participants, place of the study, the items or statements related to the attitude, main outcome, or findings regarding the status of the attitude Table 2. For the interventional studies, the formats for assessment included first author's name, year of publication, number of participants, and place of the study, the items used for assessing the attitude, main outcome, or finding about the change of the attitude Table 3.{Table 2}{Table 3}

Quality appraisal

The Joanna Briggs Institute (JBI) critical appraisal checklist for analytical cross-sectional studies with 8 items ²⁰ and the critical appraisal checklist for articles on educational studies with 13 items ²¹ were used for assessing the risk of bias by each of the 2 reviewers independently. They reported the results as articles included, excluded, or articles that seek further information. At the case of disagreement, they tried to reach a consensus or sought the opinion of a third reviewer. As this review intended to provide an overview of the evidence about EBD in dental education in Iran, we did not consider strict quality exclusions due to the limited amount of related studies. Therefore, all related articles regardless of quality level were included.

One hundred and eighty-three records were identified in the international and local databases. The flow diagram of the process is explained as recommended by Preferred Reporting Items for Systematic review and Meta-Analysis Figure 1. The abstracts were screened using the eligibility criteria. Finally, 10 English and Persian language articles were included in the review. A complete review of the articles was conducted and the results were summarized as two separate tables for descriptive and interventional studies as stated previously Table 2. Figure 1

PRISMA flow chart of reports. PRISMA: Preferred Reporting Items for Systematic review and Meta-Analysis.

In the recent years, dentists are expected to keep up with the advancements in dental therapies, materials, and research. There is an overflow of research-based and even unreliable evidence supporting various aspects of dentistry on the internet. The gap between research and clinical dental practice needs to be filled and the information available to clinicians needs to be optimized. This can somewhat be met by formulating evidence-based clinical guidelines for best practices that the dentists can refer to with simple chairside and even patient-friendly versions. ¹

Despite the good attitude toward the application of EBP in dental work, the real work setting would be more challenging for new general dentists. As Neuppmann Feres et al. classified the barriers involved in the application of EBD into four categories: self-related, evidence-related, context-related, and patient-related barriers. Shortage of time and financial constraints were the barriers most frequently studied. ²² A study was conducted on self-assessment of students about their awareness, knowledge, and attitude at Tehran University in 2011, and results indicated that despite good attitudes about EBD there was a deficiency in students' knowledge and awareness. Accordingly, students were interested in the EBD course, while they had poor knowledge and awareness. ⁵ This is also true for the dental faculty, who are well-trained dentists and researchers; Sabounchi et al. ⁶ carried out a study on the knowledge and attitude of dental faculty members toward EBD. In this study, a total of 377 dental instructors indicated a moderate level of actual knowledge of the basic principles of EBD. Reference books, reviews, and core papers were used more, while the Cochrane library was used less.

The inconsistency between the self-reported status and real performance is presented in Ciancio et al.'s ²³ study. 69% of dental practitioners transitioning to dental educators rated themselves better than satisfactory in their knowledge, skills, and attitudes regarding EBD skills application. However, only 33%–42% of them indicated that they frequently used the evidence pyramid and systematically, objectively, and critically appraised the evidence.

This shows the importance of research in regard to the attitude and practice next to the knowledge about EBD in dental students. ²⁴

As Chiappelli concluded the most urgent and important of these is undoubtedly to craft and validate novel didactic and practical methodologies to teach EBD-both research and practice-to the next generation of dental researchers and clinical dentists and to optimize the integration of EBD in the dental curriculum. ²⁵ A change in attitudes from negative to positive were found in Najafi's and Asgari's ¹⁹ study after intervention. Spallek et al., ⁷ introduced the lack of students' desire to use EBD in clinical practice as the reason for such negative attitudes. They also believe that EBD should be incorporated into clinical practice to achieve a positive attitude in this context.

This systematic review showed that in all descriptive studies reported in Iran, dental students were involved only in a self-administered questionnaire survey for assessing the attitude toward EBD. Moreover, nearly all studies explained the status of Iranian dental students as satisfactory or acceptable. However, the quality assessment especially for the descriptive studies was mostly medium and poor.

As the review showed, most of the studies had applied the questionnaire tool which was developed by Khami et al., ⁵ Since, in this questionnaire the researcher had drafted the questions and received the comments from a number of students, there was not any quantitative score of the validity or reliability for the finalized tool. From a critical view, it seems that some questions are more due to the awareness and knowledge of the persons about evidence-based process (statements 5, 6, 7, 8, 9) rather than their perspective of the evidence-based practice in dentistry. Regarding the importance of a precise tool and method to measuring the attitude, it would be suggested to use more qualified assessment tools for future studies. Furthermore, the need for a robust designing in descriptive studies exists. Moreover, other forms of educational program or intervention which is reflective of the real setting work should be examined in future studies.

Furthermore, the assessment of the students in the studies reflected in this review doubted to be problematic for several reasons. First, a close-ended sole questionnaire tool could not reflect the real belief and ideas of dental students of the importance, necessity, and practice of the evidence-based principles and process. Although it is common to apply a predesigned questionnaire to assess the knowledge, attitude, and practice (KAP) as KAP studies do, we should be more sensitive about the measurement of the attitude by a valid tool or method. Second, we have not seen a well-designed questionnaire tool in most studies. The items had not been gathered from a qualitative study among the target group or expert panel opinion. Furthermore, the details of the validation process were not explained properly. Thirdly, despite the good sample size and distri bution in the country, a significant percentage of the subjects did not involve students who were involved with real patients and clinical settings. Hence, they had no insight into the best use of evidence for decision-making of treatments Table 2and Table 3.

In conclusion, this review showed that the attitude of dental students regarding EBD in Iran is fairly good. However, the validity of the studies is questionable. Therefore, well-designed future studies, using reliable tools of assessment, with greater sample size and more accurate selection of subjects are still needed to assess EBD in Iranian dental students and future dentists.

Financial support and sponsorship

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Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or nonfinancial in this article.