Consider the Evidence
Basing practice decisions on evidence is neither contestable nor new. There are some concerns, however, that must be addressed.
Basing practice decisions on evidence is neither contestable nor new. There are some concerns, however, that must be addressed.
Fred E. Aurbach, DDS, FACD
What is evidence-based dentistry and what does it mean to the practitioner of the dental arts and sciences? Evidence-based dentistry is the "new" concept being bandied about in academia and in dental literature. The basic tenet of evidence-based dentistry is valid: Dentistry should be able to justify, scientifically, the treatment rendered for a given condition. Evidence-based dentistry is a call for the profession to do just that. Currently, many healthcare decisions are based principally on values and resources-opinion-based decision-making; little attention has been given or is paid to evidence derived from research - the scientific factor. It is the goal (and a lofty goal indeed) of evidence-based dentistry that every decision one makes in practice is supported in scientific literature. Evidence-based dentistry is, according to A. Lawrence, "The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."
Evidence-based dentistry is not new. Evidence-based dentistry is not unlike the way we practice today. Each of us, in deciding what is the best treatment for a given situation, relies on the experience that we have received didactically and in clinical situations. The criticism of this method is "the quality of the evidence" on which those decisions are based. The techniques will vary, somewhat, because of the variety of methods and the biases found within the educational system. Individual faculty members at the same institution may have developed a personal technique for accomplishing a given procedure, and this technique may vary from the technique taught in the preclinical course. Much of the information pertaining to dental materials from which decisions are made is obtained from dental manufacturers who promote techniques that use their products. The reliability of such information is biased and, therefore, would not necessarily be the best "evidence" on which to make a treatment decision. The same would be true for the information that is distributed by the supply company representatives.
Strict adherence to evidence-based dentistry does not take into consideration the experience of the dentist delivering the treatment. In reality, every procedure that an individual dentist has performed, every patient that the dentist has encountered, every lecture that the dentist has attended, every conversation with a colleague about a technique or a diagnosis is a part of the individual dentist`s bank of evidence. Even the techniques or therapies that didn`t work are a part of the evidence bank from which the dentist can withdraw knowledge.
How practical is evidence-based dentistry?
Graduation from a dental school is only the beginning of the dental-education process. Dentists must be committed to the continual improvement of skills and knowledge through lifelong learning. Continuing-education courses abound. Currently, more than 2 million biomedical articles are published in approximately 20,000 journals. About 500 of those journals are related to dentistry. As D. Richards said, "To read all of the available dental journals would take 175 days if we spent 15 minutes (the shortest time British Dental Journal readers said they spent reading the journal) per journal and 60 minutes per day reading them. Fifteen minutes per journal is sufficient time to find [and] identify any important paper, but whether it is sufficient to understand them is quite another matter." The recommendation then is that abstracts of the articles be printed, accompanied by an expert commentary. This would allow the dentists to peruse multiple articles in a short period of time. One difficulty in reading some of the journals is that they are so research-oriented that the practical application of the research is lost in the language of research.
A major difficulty is getting dentists to read. However, if the dentist should take the time to search for the "evidence," that is only the beginning. Lawrence and Richards once penned, "A number of publications that are widely read in dentistry are no subject to peer review and, even where they are, there is the tendency for publication bias. This bias may not be explicit, but there is a tendency, both by the researchers and editors, to publish positive reviews. Negative trials can be equally valuable, and concerns have been raised that increasing sponsorships of medical trials by commercial concerns could result in nonpublication of negative or unhelpful findings."
Other than journals, evidence can be obtained from a textbook, a colleague, or in a bibliographical database such as MEDLINE or the Cochrane Database of Systematic Reviews. When a colleague is asked, or the literature has been searched, one will find that experts often disagree. The colleague may not be up-to-date in that particular area or may not agree with the latest evidence. Textbooks are only as current as the most recent reference contained therein; one can usually find another text written by another expert that has a different opinion. Databases must be updated regularly to ensure that the content is current.
There are some sources of information that the practicing dentist can readily use. Dental Abstracts and The Yearbook of Dentistry are sources that print abstracts of articles related to dentistry. Should the dentist then want more information, the entire article can be obtained. Two widely known sources are the Newsletter, from Clinical Research Associates, and Reality. Both of these publications give practical, useful information about dental materials and some techniques. The presentations are relatively short and without prejudice for or against manufacturers. The information is presented in an easy-to-read format that does not overwhelm the practitioner with the language of research. These publications are different, but both present the research, findings, practical application, and a commentary on the article. A. Jokstad once quipped, "The experts on clinical dentistry are, and have always been, the clinical practitioners. Basic problem formulations and identification of gray areas should come from the front-line health workers and not from bureaucrats, physicists, or statisticians. This implies further that the ideal environment for producing evidence-based research is the general dental practice, not in the dental schools, not in the laboratories, and not in institutions ... Evidence-based dentistry is much more than randomized, controlled trials, and it must always be regarded as an adjunct to, and not as a substitute for, sound clinical judgment and patient preferences." This methodology follows closely the recommended protocol for evidence-based dentistry.
Dental specialty groups and groups with special areas of interest have one or more journals that focus on specific areas of dentistry. Another source of information is a thorough search of the literature contained within the American Dental Association Library. The ADA Library provides literature searches at a very reasonable cost for members of the ADA. Members can also access the ADA Internet site (www.ada.org) to conduct their own searches.
Even though the information base in dentistry is not adequate to support a strict application of evidence-based dentistry, there is an abundance of information available. The information is accessible, but it is up to the individual dentist to determine whether or not the evidence is current and valid. The dentist needs to apply the information collected during the search for evidence. What were the results of the studies? Were the studies valid? Are the likely treatment benefits worth the potential harm and costs? While this may sound like a challenging route to deciding on treatment, it is what clinicians do each time they administer therapy. After the literature has been reviewed, the information has been processed, and the expected outcomes have been weighed, it must all be considered in the context of the patient`s values and concerns.
The move toward evidence-based practice, if it follows the medical model, will further complicate the already-crowded academic schedule found in dental schools. Strategies being used in medicine include a weekly, formal academic half-day for residents that is devoted to learning the necessary skills. There is already an outcry from the dental schools that they can`t teach everything they need in the four-year curriculum. That`s strange. I remember that I was taught, in both undergraduate school and in dental school, how to use the resource material available in the texts and in the libraries. I was taught to consult with a colleague when I had an unusual situation. When did the schools stop teaching this? There may be more sources for evidence today, but most of today`s students have enough knowledge of computers so that the addition of the electronic base of information should not be a difficult barrier for obtaining "evidence."
Potential abuses of evidence-based dentistry
It is difficult to document the need for evidence-based dentistry. In reality, we implicitly use the concept of evidence-based dentistry in every procedure we do. The concept is good and noble. As professionals, we have an obligation to remain current and informed. As one of my mentors has said, "Who can be against evidence-based care? What alternative do we have? Whimsically based care?" The problem lies in the potential abuse of the concept by third parties. The model from which evidence-based dentistry is derived is found in medicine. And, surprise of surprises, the impetus is coming from the National Health Service of England, the bastion of socialized medicine.
It disturbs me greatly that we are not learning from the mistakes made by our colleagues in medicine. I`m beginning to believe that dentists either do not have physician friends or talk with those they know. I believe that medicine is a profession in crisis, as it has sold its soul to the socialized programs and third parties. Certainly, we should be aware of the failure of socialized medicine throughout the world. Every country that has it is trying to get away from it, yet we in the United States seem to be heading in that very direction! A select group of tax-exempt foundations - such as Carnegie, Ford, Rockefeller, and, as of late, Pew - have acted in concert to produce the crisis of which only some form of socialized health care will remedy.
So what does socialized health care have to do with evidence-based medicine and dentistry? The concept is being promoted not as a care issue, but as an issue to contain costs. A further indication that there will likely be abuses of evidence-based dentistry, according to Lawrence and Richards: "With the ever-increasing pressure for efficient and cost-effective care, there is a need to move the process of evidence-based dentistry into all aspects of dental care. This is particularly important with the increasing role that insurance companies are playing in the provision of dental care. They will feel much happier at buying dental procedures that are supported by evidence and likely to produce a good long-term outcome." If history is any indication, then insurance companies and government agencies that pay for any portion of a treatment will use "evidence" to determine which procedures they will not cover. Manage-ment groups may dictate to employee-dentists which techniques and treatments will be "acceptable" in their clinics or offices. Evidence-based dentistry then becomes a method of cost containment for the benefit of someone other than the patient. Evidence-based dentistry used in this manner is an abuse of the concept. It eliminates the professional judgment of the attending dentists and the desires of the patient.
With such a potential for abuse, the ownership and the validity of the "evidence" becomes very important. Who will be the anointed one or group that determines which evidence is valid? Who will set the research agenda and determine where the results will be maintained? Who will validate the research? Who will maintain the database to ensure that it is current? How will the results be used? Will third parties (the "payers") manipulate their constituent "providers" so that the patients receive only the care that corresponds with the "evidence" the third party chooses to use in order to be "cost-effective?"
The dental schools are under great pressure from their parent institutions to justify their existence, both academically and financially. This struggle for survival leaves the dental schools with poor self-esteem and vulnerable to the influences of the foundations that fund research and the parent institution. There are those who believe that a closer alliance with medicine will solve dentistry`s problems. It is ironic that those in academic circles are advocating this when, in Europe, dentistry was often a specialty of medicine, and all dentists had medical degrees. But the recent trend has been toward separate programs and degrees as found in the United States. In my opinion, seeking to integrate dentistry with medicine compounds our problems; it does not solve them. The dental schools may be looking to evidence-based dentistry and outcomes to seek the research funds in order to gain recognition from the parent institution. The "gold rush" for research funding will result in another path by which dental education can, and will, be controlled by outside influences. If this rush to receive grants for research takes the focus away from the true mission of the school, then the quality of dental education may suffer. The ADA policy states that research is important to the mission of the dental school. However, there is great truth in the old adage, "He who has the gold makes the rules." A "research alliance" between a dental school and a foundation to bring forth "evidence" may cause one to question the validity of the research outcome.
I feel the profession of dentistry has long embraced evidence-based dentistry. Perhaps we have not had a name for it, but it has always been a responsibility of the professional to be a lifelong student. This wave of "evidenced-based" dentistry is being promoted as a new concept, and it is being done in response to the third parties that have invaded the profession of dentistry. This is truly the right thing for the wrong reason. If the profession accepts this as a "new concept," it is imperative that the evidence be based on clinical considerations only and not areas of special interest dictated by a third party. In other words, there needs to be a practical application of the concept not driven by costs.
Finding a way to do it right
The ADA, over a period of four years, developed a set of Dental Practice Parameters. This document provides professional consensus on appropriate oral health care. These parameters describe the range of acceptable treatment modalities for a given oral condition. The Dental Practice Parameters document could well be referred to as "the Bill of Rights for the dentist and patients." The parameters are not subject to "standards" of payers or regulatory agencies that may address the narrow concerns of financial objectives or the contractual agreement of a benefit plan. The purpose of the ADA parameters is to explicitly present the profession`s statement on appropriate oral health care. This has never been more critical than it is in today`s health-care environment, where a multitude of changes in the delivery and financing of care have the potential either to expand the access to quality care for more people or jeopardize the quality of care for all. The key element throughout this document is the professional judgment of the attending dentist, for a specific patient at a specific time. Since almost every dental condition has a "range" of possible treatment modalities, it remains the professional responsibility of the attending dentist to carefully weigh the unique clinical circumstances and individual patient preferences in the final decision as to the best treatment for a specific patient at a specific time. The professional judgment of the attending dentist as to the type of treatment, the type of materials used, and the techniques to be used must not be violated or restricted by any third-party groups. The decision by the attending dentist of what to treat and how to treat is "evidence-based," either implicitly or explicitly. Balancing individual patient needs with scientific soundness is a necessary step in providing care.
Evidence-based dentistry must be used to enhance, not interfere with, the professional judgment of the attending dentist.
Editor`s Note: This article was reprinted with permission from the Spring 1999 Journal of the American College of Dentists.