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How Dental Treatment Keeps Pace with Current Research

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How Dental Treatment Keeps Pace with Current Research In other words, evidence-based den- Evidence-Based Dentistryby Stanley Ayers, DDS tistry is an approach to dental treat- ment that combines research with the dentist’s skills and the patient’s needs and desires and centers on a question of whether a particular treatment is the best option for a specifi c patient. How Dental One thing to keep in mind is that the practice of evidence-based dentistry often leaves room for interpretation. Treatment Keeps Part of the challenge for the dentist is to make sure the quality of the research they are taking into account is sound. It’s important to see how Pace with a study was funded and reviewed to help judge whether a recommenda- tion is well founded and what biases could be contained in the outcome. Current Research Where to Start? The fi rst thing a dentist needs is a our clients’ dental plan can have an impor- question such as, “Should I encourage tant, positive infl uence on how its participat- my patients to chew gum sweetened ing dentists make treatment decisions. By with xylitol?” From there, a dentist naturally needs evidence to support or offering front-line information and sources refute the question he or she is trying of new research, the dental plan can help its to answer. Good sources for research Ydentists balance the most up-to-date research with pa- conclusions include peer-reviewed tient considerations when recommending treatment. journals, large scale research studies, and some scientifi c journals focused For dental plans, evidence-based degrees Fahrenheit before they could be dentistry offers an opportunity to create poured on the exposed nerve. Pain man- more value for its members by empha- agement is a relatively recent develop- sizing proven treatments, rather than ment as well, so you can imagine what following popular trends. For example, boiling metal on an exposed nerve one trend is for plans to cover third with no medication might feel like. and fourth cleanings. However, best Evidence-based dentistry helps evidence shows that the bacteria in your dentists recognize developments in mouth returns to the same level within the fi eld to bring the latest in den- a matter of a couple days, so these extra tal treatment from the research labs cleanings are unnecessary, barring any to the dental chair. It is a recent periodontal symptoms. The dental plan practice that helps dentists take a can offer tools to help identify increased broad-based view when planning and susceptibility to cavities through a recommending patient treatment. It simple screening such as the one of- was fi rst introduced in the 1990s by fered by CariFree. Far more effective Gordon Guyatt through the Evidence- in preventing cavities is controlling the Based Medicine Working Group. pH and bacteria level in the mouth. The American Dental Associa- tion (ADA) defi nes evidence-based Working up to Evidence- dentistry as “an approach to oral Based Dentistry health care that requires the judi- Dental treatment is advancing at a cious integration of systematic rapid pace. Not long ago, there were no assessments of clinically relevant x-rays, no method for preventive care or scientifi c evidence, relating to the oral hygiene, and no knowledge of mi- patient’s oral and medical condi- crobiology to know anything about the tion and history, with the dentist’s causes of cavities or tooth pain. The fi rst clinical expertise and the patient’s metal amalgam fi llings had to be 200 treatment needs and preferences.” 24 CALIFORNIA BROKER visit us at www.calbrokermag.com NOVEMBER 2011 specifically on evidence-based dentistry. interesting topic, but in the arena Evidence-based guidelines help define Evidence-Based Dentistry from Nature of evidence-based dentistry, it pro- evidence-based medicine on a macro lev- Publishing Group and the quarterly vides only corollary evidence, where el. Included in this approach are guide- publication, Journal of Evidence-Based the dentist should be looking for lines, protocol, standards and parameters Dental Practice are great examples. causative evidence. A final example of care. This lays framework for ensuring The most “widely” used free database of bad evidence is animal testing. the soundness of evidence analysis. is called Medline and is an excellent Ethical convictions aside, animal resource to access and research best testing has no bearing on what will Applying Evidence- current evidence for a question. One of happen in circumstances involving a Based Dentistry the most respected sources for current human and should not be leaned on Dentistry technology and research information is the Oral Health Group for clinical or treatment decisions. is moving at an accelerating pace. with the Cochrane Collaboration. It is Evidence-based dentistry is a proven an international network of people who How Do You Identify Bias? technique for applying sound research prepare, disseminate and sort the ran- Bias can be as subtle as the word- in the dental office and from a plan domized controlled trials in oral health ing of a survey question, or as overt design standpoint for dental plans to help practitioners keep current. as a company with an obvious to deliver more efficiency. From Evidence-based dentistry has guide- incentive to make sure that find- teeth being grown in a laboratory lines for how to qualify research for ings point in a certain direction. and repairing cavities by restoring how much stock to put into a particular There are two types of bias relevant to tooth enamel, the available tools are study. “Best evidence” refers to infor- evidence-based dentistry. One is selection improving to the point where there mation gained from studies and trials bias, which is a problem with the sample will be several options available for and is given a strength depending on of the group being studied. This can someone with a cavity including re- the objectivity of the study and how be a non-representative sample of the versing early tooth decay. The den- conclusive the findings are. Some of population or a sample that isn’t large tist drill may be obsolete in the not the best kinds of evidence are random- enough from which to draw a meaning- too distant future. Just be glad your ized controlled clinical trials, non- ful conclusion. Selection bias happens dentist has proper training, can rec- randomized controlled clinical trials, when there is an outcome distortion ommend some preventive treatments cohort studies, case-control studies, because of the method of sampling. and if need be can administer an cohort studies and crossover studies. The other bias is measurement anesthetic if you need to have some These can all supply strong evidence bias. Measurement bias refers to a treatment done in the meantime. q to help provide a convincing answer to problem with measuring the data –––––––––– a dentist with a treatment question. incorrectly. This can be with an in- Stanley Ayers, DDS, is director of Den- These can be split generally into “inter- correct baseline or data measured tal Services and Compliance for Dental ventional” and “observational” evidence. with equipment that isn’t calibrated Health Services. Dr. Ayers is responsible Interventional is when a study was properly. As bias can skew research for ensuring quality, timely, and ap- conducted as an intentional experi- results, it must be considered as a propriate application of Dental Health ence; and observational takes data factor when evaluating evidence. Services plan benefits and overseeing the and draws conclusions from it. development of systems to proactively A randomized, systematic controlled How do you Find prevent issues from arising. He carries trial is a strong method for gaining Good Evidence? a wide-reaching background in compli- unbiased conclusions. This is a clinical In order to find good evidence, there ance. He was a private practice dentist trial in which participants are assigned are practices to help dentists qualify in Switzerland and San Francisco be- at random to either an experimental research. Before beginning research fore moving into regulatory and quality or control group. Outcomes are found though, it’s important to have a well- assurance with Pacific Dental Benefits. through follow-up, and this creates defined clinical question. One useful As a team survey with Managed Health a very neutral, objective study. tool for defining the question is called Care Unlimited, he assisted with dental Population, Intervention, Compari- plan surveys for the California De- What Isn’t Evidence? son and Outcome (PICO). Population partment of Managed Health Care. It’s important to be aware of what is the answer to the question, “Who As a dental benefits company founded cannot be considered good evidence as was surveyed?” It should include some by Godfrey Pernell, DDS, 36 years well as what can. A case report is an geographic and demographic informa- ago, Dental Health Services carries example of poor evidence, as it shows tion to help define the study. Interven- a long-standing and wide ranging the treatment plan for an individual tion is what treatment or exposure experience in delivering quality den- patient. Good evidence should be based was administered to the experimental tal benefits by managing plan design, on a study with a larger sample size. group; comparison is about what hap- holding to rigorous quality assurance Another example of bad evidence pened between the control group and the standards for dentists, and provid- is epidemiology, or the study of experimental group; and the outcome is ing incentives to encourage preven- health patterns in society. It is an the difference between those two groups. tive care and holistic coverage. 26 CALIFORNIA BROKER visit us at www.calbrokermag.com NOVEMBER 2011.
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