Stumbling into the Age of Evidence

This article presents personal observations on how the concept of evidence-based dentistry is faring in the profession. It considers how the dental profession’s concept of evidence has matured, how evidence-based dentistry was originally envisioned, how it is currently embodied, and what its prospects might be for the immediate future. Evidence-based dentistry began in the profession approximately 2 decades ago, initiated by the appearance of the first systematic reviews on dental topics in the late 1980s. The emergence of the concept of evidence-based dentistry—and its fundamental construct, the systematic review—marks what can be considered a fundamental shift in how the dental knowledge base has grown and developed over time.

This article presents personal observations on how the concept of evidence-based dentistry is faring in the profession. It considers how the dental profession’s concept of evidence has matured, how evidence-based dentistry was originally envisioned, how it is currently embodied, and what its prospects might be for the immediate future.

Evidence-based dentistry began in the profession approximately 2 decades ago, initiated by the appearance of the first systematic reviews on dental topics in the late 1980s. The emergence of the concept of evidence-based dentistry—and its fundamental construct, the systematic review—marks what can be considered a fundamental shift in how the dental knowledge base has grown and developed over time.

Evolution of the dental knowledge base

The dental knowledge base defines the profession of dentistry and influences how dentists practice. It is a store of special information about oral health and diseases, treatment methods, and their outcomes. It serves as the basis for professional decision making, and portions of it form the principal content of predoctoral and postdoctoral dental curricula. The knowledge base has evolved in how knowledge has been created, synthesized, and disseminated. Four eras, or ages, can be delineated in the evolution of the knowledge base ( Table 1 ), and a brief consideration of these ages may help put the profession’s current involvement in evidence-based dentistry into perspective.

Table 1
Evolution of the dental knowledge base
Principal Method for Knowledge Base Process
Era Knowledge Creation Knowledge Synthesis Knowledge Dissemination
Age of the Expert Experiential Experimental Apprenticeship
Age of Professionalization Experiential limited observational Shared experimental Texts, societies, journals, schools
Age of Science Experiential Traditional literature review Texts, journals, schools, formal CE
Age of Evidence Experiential Systematic review Texts, journals, schools, CE, guidelines, evidence summaries

The dental knowledge base first began to develop during the “Age of the Expert.” Dentistry emerged in the middle ages as a guild of “barber surgeons” and “itinerant dentists.” Knowledge creation was strictly experiential, and little systematized observation was available. Knowledge synthesis was little more than deepening experience, with virtually no texts and limited opportunities for sharing knowledge among practitioners who were mostly illiterate and restricted in travel radius. Similarly, knowledge dissemination was restricted, informal, and limited principally to the master–apprentice relationship, wherein experts passed on their synthesis of experience to one or more novices.

Around the middle of the 18th century, the dental knowledge base entered the second era, the “Age of Professionalization.” Fauchard had published his comprehensive textbook, representing his observations, those of his mentor, other dentists at the hospital where he practiced, and, later, other experts in Paris. This better access to knowledge created by others led to a greater degree of knowledge synthesis, exemplified by Fauchard’s text and others. However, what was synthesized was still simply the experience of others.

Available texts initially represented the most important improvement in dissemination of the knowledge base, with later improvements accruing through the establishment of dental schools and the first dental society journals in the 1840s. The age of professionalization also saw the some growth of controlled experimentation for the creation of new knowledge, again focused primarily on treatment of dental disease.

The dental knowledge base entered the third era, the “Age of Science,” at approximately the dawn of the 20th century, presaging the profession’s gradual shift from proprietary educational to university-based institutions. Knowledge creation accelerated as protocol-based experimentation became more common, and the scope of inquiry broadened to more fully include the causes and prevention of disease.

Knowledge synthesis evolved slowly, from simple statements of fact based on an expert’s experience, toward consideration of the available knowledge in scientific literature. The product of this evolution was the traditional review of literature, with the expert remaining the key element of the review, selecting the studies to be included and providing a subjective interpretation of this literature. Thus, the synthesis was open to bias, both intended and unintentional. This phase marked the most active period of knowledge dissemination, with early rapid growth of university-based pre- and postdoctoral dental curricula and both early and more recent proliferations of journals, and organized continuing dental education in journals.

It can be argued that the dental knowledge base is now entering a fourth era: the “Age of Evidence.” Knowledge creation in this era can be characterized by the dominance of randomized clinical trials, although observational study designs continue to be used, with valuable information contributed through improved multivariate statistical methods.

A change in the principal method of knowledge synthesis represents the hallmark of the Age of Evidence, with the traditional literature review superseded by the systematic review. Systematic reviews represent a substantial change in the paradigm of synthesis through ensuring inclusion of all relevant evidence, deemphasizing the role of the expert, and minimizing bias through strict protocols demanding objectivity and transparency in the review process.

Systematic reviews have been published with ever-increasing frequency in the past decade, and probably now number more than 700. The methods of knowledge dissemination dominant in the previous era (eg, dental curricula, texts, scientific journals, continuing dental education) continue to be prominent, but initial signs of change also are apparent. Two distillations of the results of systematic reviews are growing more evident within the profession. Evidence-based clinical guidelines promulgated by various agencies and societies are increasingly common, and evidence summaries—essentially abstracts of systematic reviews accompanied by critical commentaries—form most of the content of two dental journals, and appear occasionally in others.

Perhaps the most significant change in the dissemination of the dental knowledge base in these early years of the Age of Evidence is easy access to the substantial majority of the knowledge base through the Internet. For the first time, the general public can, with little special effort, access the information that theoretically drives dentists’ diagnostic and treatment decisions. The ramifications of this open access to the core of the profession have yet to fully manifest. Patient consultations that include a debate of the merits of the exclusion criteria of a newly released systematic review may not yet be possible, but expecting at least some patients to be aware of their diagnoses, reasonably well informed, and prepared to discuss their treatment options may be realistic.

Evidence-based dentistry as initially envisioned

When the concept of evidence-based health care first began to gain momentum in the health sciences in the late 1980s and early 1990s, the general assumption was that individual clinicians would become experts in interpreting the original scientific literature and applying the fruits of that appraisal to their practices. The Journal of the American Medical Association ( JAMA) ran a lengthy series of Users’ Guides to the Medical Literature developed by the Evidence-Based Working Group. In the words of the Working Group:

Clinicians need to be able to distinguish high from low quality in primary studies, systematic reviews, practice guidelines, and other integrative research focused management recommendations. An evidence-based practitioner must also understand the patient’s circumstances or predicament; identify knowledge gaps and frame questions to fill those gaps; critically appraise the research evidence and apply that evidence to patient care.

To assist in these endeavors, attention was paid to making the literature accessible to clinicians at the bedside.

The expectations in dentistry were similar. British dentists practicing evidence-based dentistry were envisioned as identifying the evidence online, critically appraising it, and acting on it. However, an early note of caution was expressed regarding dentists’ abilities to marshal the thought processes necessary for these tasks, although the problem was seen as being overcome to some extent by the development of computer programs teaching probabilistic thinking. The principal outcome associated with adopting evidence-based dentistry was to have better information, which was assumed to translate to a more knowledgeable practitioner. At the same time, evidence-based dentistry was seen as informing dental researchers and educators, thereby improving their insight and methods. Downstream benefits were expected to include more effective treatment and cost savings.

Early in the development of the evidence-based care movement in all health disciplines, the actual knowledge translation process was given little attention. The belief seemed to be widely held that the availability of more accurate information would lead to its uptake by most practitioners, leading to behavioral change. Furthermore, evidence-based practice guidelines were envisioned to be a substantial mechanism for change, with widespread adherence seemingly taken for granted. The overriding issue that evidence-based care could address was a lack of focused information addressing clinical problems, and thus the unwarranted reliance on experts or authorities. The availability and quality of evidence that addressed the problems of clinical practice were not often mentioned as a concern, and when availability was addressed it was seen as a limited problem.

Thus, it is not overreaching to conclude that, in the early flush of excitement over the development and implementation of evidence-based care concepts, a somewhat optimistic and uncritical attitude prevailed in the health care professions regarding the promise that these concepts held for patients and the health professions. In retrospect, it is somewhat surprising that this attitude could have flourished, because it was already well established that attempts to translate research findings into practice through conventional means were neither efficient nor effective.

Evidence-based dentistry as initially envisioned

When the concept of evidence-based health care first began to gain momentum in the health sciences in the late 1980s and early 1990s, the general assumption was that individual clinicians would become experts in interpreting the original scientific literature and applying the fruits of that appraisal to their practices. The Journal of the American Medical Association ( JAMA) ran a lengthy series of Users’ Guides to the Medical Literature developed by the Evidence-Based Working Group. In the words of the Working Group:

Clinicians need to be able to distinguish high from low quality in primary studies, systematic reviews, practice guidelines, and other integrative research focused management recommendations. An evidence-based practitioner must also understand the patient’s circumstances or predicament; identify knowledge gaps and frame questions to fill those gaps; critically appraise the research evidence and apply that evidence to patient care.

To assist in these endeavors, attention was paid to making the literature accessible to clinicians at the bedside.

The expectations in dentistry were similar. British dentists practicing evidence-based dentistry were envisioned as identifying the evidence online, critically appraising it, and acting on it. However, an early note of caution was expressed regarding dentists’ abilities to marshal the thought processes necessary for these tasks, although the problem was seen as being overcome to some extent by the development of computer programs teaching probabilistic thinking. The principal outcome associated with adopting evidence-based dentistry was to have better information, which was assumed to translate to a more knowledgeable practitioner. At the same time, evidence-based dentistry was seen as informing dental researchers and educators, thereby improving their insight and methods. Downstream benefits were expected to include more effective treatment and cost savings.

Early in the development of the evidence-based care movement in all health disciplines, the actual knowledge translation process was given little attention. The belief seemed to be widely held that the availability of more accurate information would lead to its uptake by most practitioners, leading to behavioral change. Furthermore, evidence-based practice guidelines were envisioned to be a substantial mechanism for change, with widespread adherence seemingly taken for granted. The overriding issue that evidence-based care could address was a lack of focused information addressing clinical problems, and thus the unwarranted reliance on experts or authorities. The availability and quality of evidence that addressed the problems of clinical practice were not often mentioned as a concern, and when availability was addressed it was seen as a limited problem.

Thus, it is not overreaching to conclude that, in the early flush of excitement over the development and implementation of evidence-based care concepts, a somewhat optimistic and uncritical attitude prevailed in the health care professions regarding the promise that these concepts held for patients and the health professions. In retrospect, it is somewhat surprising that this attitude could have flourished, because it was already well established that attempts to translate research findings into practice through conventional means were neither efficient nor effective.

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Oct 29, 2016 | Posted by in General Dentistry | Comments Off on Stumbling into the Age of Evidence
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