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Evidence-based Practice in Dentistry: Benefit or HindranceSchool of Dentistry, UCLA CHS 63-090, Los Angeles, CA 90095-1668; Correspondence: *corresponding author, Chiappelli{at}dent.ucla.edu
Key Words: evidence-based dentistry • CONSORT • PICO • PIPO • SESTA • NNT It has been said that "...the art (of dentistry) is in using the science and matching it with the patient’s characteristics and needs..." (Ismail, 2002). In reality, however, it may not always be the case that good practice rests on evidence from the literature as well as on the art and intuition of the practitioner. The awareness that the practice of dentistry needs to be based on research evidence actually appears to be quite recent. Evidence-based dentistry, which is distinct from dentistry based on evidence, has permeated dental research and dental practice only in the last few decades, as an offspring, as it were, of evidence-based health care in general and evidence-based medicine in particular. The first coherent set of scientific position papers on evidence-based medicine dates back only three decades, published from McMaster University in the early 1970s (Chiappelli and Prolo, 2001). The actual theoretical concept of basing medical intervention upon evidence gathered by observations is indeed less than 200 years old and can be traced to Dr. Pierre Louis (médecine d’observation) in Paris and Dr. Maurizio Buffalini (medicina basata sulle evidenze) in Florence in the mid-19th Century (Chiappelli and Prolo, 2001). Good and sound dental practice relies not upon bits and pieces of conveniently selected evidence (dentistry based on evidence), but rather upon the collection of the best available research evidence (evidence-based dentistry). The key phrase, "best available research evidence", implies a most important and fundamental nature of this approach to dentistry: It seeks to identify what is the "best" research evidence presently at the disposal of the dentist for any given patient, and it recognizes that dental research evidence is continuously evolving. Evidence-based methodology reflects the vitality that is inherent in the research process itself—questioning, testing, discovering, and questioning anew—and in so doing seeks to generate novel and improved treatments. It is important to note that the term "research evidence" implies data generated by a variety of research modalities (i.e., observational research, experimental research, clinical research, basic research, translational research). The question, then, is not whether we who practice clinical dentistry or perform dental research ought to be concerned with evidence-based dentistry. Of course we must. The future of dentistry depends on our consistent and concerted marriage, as it were, of the "best available" research evidence with the diagnostic modalities and the treatment interventions our patients need. The concerns over variability of practice is not a question of style or individuality. It is a question of quality and standards. Patients expect and deserve the best care available for them based on the evidence, personal preferences, and the skills and knowledge of the provider. The pressure on the dental care industry to have evidence for even its most basic of treatments and products is well-founded. Take for example the recent NIH Consensus Conference (http://www.nidcr.nih.gov/news/consensus.asp), which discusses dental caries. Among many other conclusions, the panelists agreed that more rigorous studies are needed not only to support current methods but also to improve them. The American Dental Association Commission on Accreditation requires that dental students acquire a wide variety of skills in managing scientific information with critical thinking. However, most dentists were not taught the skills and tools of evidence-based dentistry in dental school. Therefore, they have little confidence in or respect for the scientific method, and place little or no demands for higher standards of research evidence. Certain dental manufacturers may be content to publish their research in the form of abstracts, and to support their products with statements such as "University studies show...". It is time that dentists take control of the products they utilize: The liability is theirs. Therefore, dentists must take it upon themselves to evaluate the validity of the research evidence for or against any given products they use. It is also time for the socio-political environment that surrounds dentistry (e.g., the insurance companies for the coverage of dental treatment, Congress for the funding of dental research) to have access to the "best available" evidence to make the better-informed and cost-effective decision. The well-being of our patients depends upon the successful integration of the "best available" evidence into novel and improved treatment modalities. The question is not "why" but "how". How can we actualize this union? How can we identify the "best available" research evidence? How can we most effectively integrate it into the common day-to-day exercise of dental practice? These are fundamental and timely questions for dentistry in the 21st Century. There are many approaches to evidence-based dentistry, but it may suffice to paint a very broad picture at the onset and recognize two principal modalities. Either the average dentist may seek to rely upon integrative reports of some sort or another, or he/she may choose to address the issue of the quality of the evidence at hand. In the first instance, the dentist may consult documents (e.g., Cochrane Reports) designed and written with the intent of compiling and evaluating the research evidence in any given topic of oral biology and medicine, and clinical practice. There are several significant advantages to this approach, including the high quality, stringency, reliability, and validity of these reports. There are, however, disadvantages, the least of which being the fact that these reports are usually voluminous—hence, dentists may or may not have the time to read and to absorb them. These communications are generally quite sophisticated in their research methodology and biostatistical jargon. Dentists may or may not have the skills to read and to absorb them. Other sources of integrative reports are available (e.g., Bandolier), which focus generally on medical rather than dental research issues. At present, there are two journals (Journal of Evidence Dental Practice, Evidence Based Dentistry) and one international association (International Society of Evidence Based Dentistry) that together serve the needs of this emerging domain of research and practice in evidence-based dentistry. It is clear that evidence-based dentistry must strive to be a practical and beneficial aid to the average dentist, and that the generation of copious and erudite documents must therefore be avoided. What is needed is the development of a set of practical tools that can be simply and efficiently taught to, and acquired by, dental students in the regular curriculum, and by established dentists as part of continuing education. A few dental schools, including UCLA and Harvard, have integrated formal evidence-based training into the dental curriculum. Dental students and dentists in continuing education courses increasingly recognize the need for and importance of evidence-based dentistry in successful clinical practice. The fundamental lesson plan generally revolves around providing the elements for quick and reliable identification of issues and problems in research methods (i.e., sampling, measurement, study’s validity), design (i.e., diagnostic vs. prognostic, observational vs. experimental, randomized blinded trial), and data analysis (i.e., categorical vs. continuous, comparison vs. prediction, parametric vs. non-parametric, power and sample size). These are the fundamental principles that constitute evidence-based dentistry, when the case is made for evaluating the "best available" evidence from the perspective of CONSORT (i.e., consolidated standards for reporting clinical trials), PIC/PO (population/problem question, intervention, comparison/prediction, outcome), and SESTA (systematic evaluation of the statistical analysis) (Chiappelli and Prolo, 2002; Chiappelli et al., 2002). Depending upon the quality of the methods, the design, and the handling of the data, the results of any given paper will be translatable into an event rate observed in the control group and an experimental group event rate: The "event" under consideration could represent an improvement due to the treatment intervention or an undesirable side-effect. Based on the event rate, the average dentist can, in the comfort of his/her practice, quickly compute the number of patients to be treated (NNT) for the expected beneficial outcome to be attained, or the number of patients who need to be treated for adverse outcomes to be avoided. Take, for example, a study done by the Helsinki (Finland) City Health Department. The study was designed to investigate the prevalence of subjective dry mouth and burning mouth in hospitalized elderly patients and outpatients in relation to saliva, medication, and systemic diseases. Findings indicated that 63% of the hospitalized patients and 57% of the outpatients complained of dry mouth, and that the respective percentages of burning mouth were 13% in the hospitalized and 18% in the outpatients. The authors concluded that the prevalence of dry mouth and burning mouth was consistently lower in outpatients, compared with hospitalized patients (Pajukoski et al., 2001). From these data, the number needed to treat (NNT) is simply calculated as the inverse of the proportion of individuals who experienced side-effects in the control and the experimental groups—that is, NNT = 1/(0.63 - 0.57) = 17. In other words, 17 patients from the outpatient group needed to be treated for one more case of dry mouth side-effect to be prevented. A similar computation based upon the proportions of reported burning mouth (NNT = 1/[0.18 - 0.13] = 20) indicates that 20 additional patients from the outpatient group needed to be treated for one case of burning mouth undesired side-effect to be prevented. It should be evident from this discussion that NNT provides a critical piece of information to the clinician, and it is simple to derive from the data provided in a research paper. It should also be clear that NNT depends on the quality of the data generated by the research: Erroneous methods, designs, or data analysis will generate erroneous numbers, which will in turn produce erroneous NNT values. In conclusion, evidence-based dentistry is a way of thinking, a philosophy, a paradigm, if you will, of the practice of dentistry for the New Millennium. The ultimate goal of evidence-based dentistry is to aid clinical judgment, to minimize errors in diagnosis, and to ensure optimal decision-making about therapies and treatment. This is achieved by filtering the body of dental research to identify the "best available" evidence. Accepted for publication November 11, 2002. REFERENCES
Journal of Dental Research, Vol. 82, No. 1,
6-7 (2003) This article has been cited by other articles:
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