Evidence-based dentistry and its role with implants

April 1, 2007
It is very gratifying to be involved in implant dentistry as it increases its reliance on an evidence-based practice model.

by Shankar Iyer, DDS, MDS

It is very gratifying to be involved in implant dentistry as it increases its reliance on an evidence-based practice model. In essence, this model requires sound judgment and evaluation of the best available scientific evidence in making clinical decisions.

A leader in promoting evidence-based approach is the American Academy of Implant Dentistry (AAID). This year, I have the honor of serving as chairman of the scientific program committee for the AAID annual meeting in November. The theme of the meeting, coincidentally, is “Excellence Through Evidence-based Implant Dentistry.”

Implantology has evolved into mainstream dentistry, but most of the research ushering it into the dentist’s office has come from corporate-sponsored work focused on new products and technologies. We also should evaluate and refine time-tested techniques, and communicate knowledge from practitioners with more than five years of experience who use products and procedures that have withstood the test of time.

According to the Journal of Dental Research, most dentists still employ an eloquence-based approach. They provide care that is practical, prudent, and personal. In this model, dentists make clinical decisions based mainly on intuitive comparisons with other patients. They place a high value on their accumulated knowledge and reliance on standard practices. As a result, many clinicians are slow to adopt change.

“All improvement requires change, but not all change is improvement,” wrote Dr. Donald Berwick, founder of the Institute for Health Care Improvement. Following this wise observation, I believe the evidence-based approach is helping leaders in implant dentistry build a more scientific discipline that effectively separates improvement from mere change.

Annual scientific meetings sponsored by AAID and other dental societies offer the best opportunities to educate practitioners about evidence-based care. Busy dentists simply don’t have enough hours in a normal day to research journal articles, but they often read abstracts. When they take time away from their practices to attend the annual scientific meeting, for example, the program committee must take great care to schedule presentations that are as free from commercial bias as possible. AAID speakers are required to disclose their corporate relationships at the beginning of their talks. Slowly, it’s becoming clear that the evidence-based approach offers scientific objectivity through data collected in randomized clinical trials, retrospective studies, and case reports.

For example, one presentation at the AAID meeting is, “Are There Really Gold Standards in Implant Dentistry?” The speaker is an eminent oral implantology researcher, educator, and clinician - Dr. Gordon Christensen. The session will focus in part on how evidence-based methods have made significant contributions in the quality and integrity of implant dentistry.

In my view, the biggest mark made by evidence-based implant dentistry so far has been in the areas of implant surfaces and bone grafting. Thanks to clinical research conducted in dental schools, we now know that certain implant surfaces are better than others. Outcomes reported in retrospective trials have led practitioners to discontinue using implants with plain machined surfaces.

With regard to bone grafting, the results of several clinical studies have steered many implant dentists away from synthetic nonresorbing bone grafting materials. Trials have generated strong evidence that bone additives and growth factors achieve comparable if not better outcomes as synthetic bone, allografts, or harvesting from extraoral sources.

Bone augmentation studies have provided compelling evidence, offering clinicians greater confidence for successful outcomes in bone-fortification procedures that significantly impact the long-term success of dental implant treatment.

The evidence-based approach assures practitioners that their decisions are backed by solid research that will help standardize implant protocols. According to Richard Niederman and Rachel Badovinac of the Office of Evidence-based Dentistry at Harvard School of Dental Medicine, the strength of evidence-based health care, “lies in its ability to separate, quantify, evaluate, and then balance the individual elements of knowledge that a tradition-based clinician would consider to be ‘good judgment.’”

Distinguishing change from improvement in implant dentistry requires extensive evaluation by scientific evidence. That means discoveries, new methods, and technologies should not be implemented in clinical practice without rigorous investigation in controlled trials. Evidence-based dentistry, therefore, is far superior to eloquence-based approaches for differentiating improvement and change.

In 1997, D.L. Sacket and co-authors wrote “How to Practice Evidence-based Medicine,” which identified a five-step process to apply to clinical decision-making. The steps outlined in this classic work are:

  1. Address your clinical information needs in the form of answerable questions
  2. Use electronic databases to find the best available evidence from primary journals and secondary sources
  3. Evaluate the evidence you find for its validity and relevance
  4. Integrate your critical assessment of the evidence with your patients’ needs and apply them clinically
  5. Evaluate your performance and patient outcomes.

Today, our challenge as implant dentists is to continue applying the principles of evidence-based dentistry in our practices. As implant dentistry grows in popularity, greater numbers of general dentists will add the specialty to their clinical services. Success will depend on receiving high-quality training, such as the AAID credentialing program. Training focused on rigorous science from widely published researchers and clinicians enables new implant practitioners to adopt techniques and procedures that have been validated over time.

Evidence-based research also holds great promise for developing streamlined protocols that will make implants affordable for more patients. We must adopt stricter controls and performance standards - especially when evaluating new products and technologies - for generating robust data in clinical studies to help find ways to further standardize our protocols. Following this roadmap, we will reach our goal of implementing standardized, streamlined implant procedures.

As implant dentists, we are concerned about both oral health and cosmetic outcomes. Replacing missing teeth helps many of our patients stay fit and healthy by maintaining good nutritional habits and eating foods they previously were unable to chew. Also, let’s not forget the psychological benefits we bring to our patients. The ability to flash an attractive smile is a confidence-builder for all age groups.

As our profession moves more dramatically toward becoming an evidence-based discipline, our patients will reap the benefits of the expanding scientific knowledge we can apply in our practices every day.

Shankar Iyer, DDS, MDS, of Elizabeth, N.J., is a member of the Board of Trustees of the American Academy of Implant Dentistry. He is a Fellow of the AAID and earned the designation as a Diplomate of the American Board of Oral Implantology/Implant Dentistry in 2004. Dr. Iyer is the Director of the AAID India MaxiCourse®. For more information about the AAID, please visit www.aaid.com or call (877) 335-AAID (2243).

The evidence is clear

The theme of AAID’s annual scientific meeting (Nov. 7-11, 2007, in Las Vegas) is “Excellence through Evidence-based Implant Dentistry.” At the meeting, researchers and clinicians who have published extensively will share their findings and provide insights on their clinical techniques and results they have achieved.

Some of the evidence-based presentations include:

Are There Really Gold Standards in Implant Dentistry? Applying Vital Scientific Evidence in Clinical Practice
Gordon Christensen, DDS, MSC, PhD

Protocols for Long-term Block Graft Success
Michael Pikos, DDS

Grafts with Osteogenic Additive - Materials for Predictability
Dennis Smiler, DDS

Augmentation with Extra-oral Sourcing: Which Sites Provide Long-term Stability?
Peter Moy, DMD

Achieving Predictable and Stable Soft Tissue Esthetics - Long-term Options
Dennis Tarnow, DDS

Implant Design and Esthetic Predictions - Long-term Clinical Results
Peter Wohrle, DMD, MMS

Efficient Sequencing for Prosthetic Success - A Ten-year Perspective
Carl Misch, DDS, MDS

Achieving Predictable Perio-Prosthetic Excellence
Andre Saadoun, DDS

For more information, visit www.aaid.com

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