Reflections on a Decade of Evidence-Based Dentistry
The need to communicate current research findings of the highest level more effectively is becoming imperative in influencing clinical practice in the 21st century. In 1998 a research paper published in Lancet set off a firestorm of reactions whose damaging effects are still being felt today. The paper suggested a link between a greater risk of autism and the combined measles, mumps, and rubella vaccine routinely given to children. Finally, some parents had an answer to the mystery of why their children were afflicted by the disorder. However, we now know it wasn’t the right answer (Wakefield et al. 1998).
Lancet has now retracted the 1998 paper, saying the lead author had been dishonest, violated research rules, and had subjected the 12 children involved with his study to needless suffering and procedures such as lumbar punctures and colonoscopies (Murch 2004). Dr. Andrew Wakefield recommended that the combined vaccine be split into three separate shots. But he didn’t disclose that a year earlier he had patented a measles vaccine that could be used if the combined vaccine were discredited. Nor did he disclose that his research was partly funded by lawyers of parents seeking to sue vaccine makers.
Despite the retraction by Lancet, much damage has been done—and cannot be undone. Now, even though study after study has found no link between vaccination and autism, many parents are still more willing to believe the one, small, now-discredited study that supposedly did find an associated risk. Parents continue to give credence to the discredited Lancet study, and because of this, children’s lives are endangered. Early and more effective communication with the public at large was needed in this case in support of childhood immunization.
With the publication of this text, I find it satisfying to realize how rapidly change in this area has been occurring. Several years ago (2003), while working on an editorial, I typed “evidence-based dentistry” into the PubMed database and got back nothing, a big zero, “no items found” (Turpin 2003). In 2010 the same question was answered with “2287 items found.” Fortunately, a number of people in dentistry are true believers in evidence-based research, and for this I am thankful. With early encouragement from Michael G. Newman, editor of the Journal of Evidence-Based Dental Practice, Mosby, Inc. sponsored the First International Conference on Evidence-Based Dentistry in Atlanta in 2003. This conference allowed those with experience in this new methodology to describe how to implement an evidence-based decision-making approach in everyday practice. This conference has become a landmark meeting that deserves credit for bringing together a wide range of sponsors, partners, researchers, educators, attorneys, and clinicians. The goals of the conference were as follows:
- Provide a venue for an accomplished group of international speakers to discuss a broad range of topics associated with the methods and outcomes of evidence-based initiatives and programs.
- Provide a context for, and examples of, cutting-edge evidence-based methodologies, skills, and research.
- Critically examine barriers and resistance to the evidence-based paradigm.
- Begin the process of culture change in education and clinical practice.
- Enhance networking and formation of new alliances and partnerships among attendees.
Since that time, the American Dental Association has been a strong proponent of multidisciplinary efforts to improve product assessment methods and advocates for the proper evaluation and use of the best available evidence in clinical practice. Following its lead in 2005, the American Association of Orthodontics adopted an official definition of evidence-based dentistry for the clinical practice of orthodontics.
Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences.
(AAO House 2005 Resolutions)
This process integrates the best research evidence, clinical expertise, and the patient’s treatment needs—three critical components in evidence-based practice. You can determine the best treatment and have the ability to complete it, but without patient acceptance, it doesn’t matter. The situation is different when a patient agrees to have a procedure, but the evidence does not support it. If the procedure is new or the research is incomplete, use of the best evidence might not be an option. What if several systematic reviews state that the procedure is unacceptable for correcting the problem and better alternatives are available? According to the rules of evidence-based practice, you should tell the patient. Mindful of this potential dilemma, the AAO House of Delegates charged the AAO and its Council on Scientific Affairs (COSA) to identify systematic reviews and meta-analyses on various orthodontic topics. Summaries of the findings provide a wealth of information for the practicing orthodontist.
The next time you examine an adult patient who asks what can be done to “cure” snoring and problems related to obstructive sleep apnea, you may want to know more about this subject. Take a look at the Cochrane Collaboration review of the topic.
Sleep apnea is characterized by recurrent episodes of partial or complete upper airway obstruction during sleep, leading to a variety of symptoms including excessive daytime sleepiness. The current first choice therapy is continuous positive airway pressure that keeps the upper airway patent during sleep. However, this treatment can be difficult for patients to tolerate and comply with on a long-term basis. Oral appliances have been proposed as an alternative to continuous positive pressure therapy. They keep the upper airway open by advancing the lower jaw forward or keeping the mouth open during sleep. This review found insufficient evidence to recommend oral appliances as first choice therapy for sleep apnea. When an active oral appliance was compared with an inactive oral appliance, there were improvements in daytime sleepiness and apnea/hypopnea severity. However, oral appliances proved less successful than continuous positive pressure in decreasing/>