PRACTICE PARAMETERS IN DENTISTRY: WHERE DO WE STAND?

II.

PRACTICE PARAMETERS IN DENTISTRY:

WHERE DO WE STAND? DANIEL A. SHUGARS, D.D.S., PH.D., M.P.H.; JAMES D. BADER, D.D.S., M.P.H.

..l ... Practice parameters or guidelines have been touted as a means of enhancing clinical de-

cision making. The authors surveyed dental organizations and reviewed the literature to determine the availability of parameters for dental conditions. An In-

stitute of Medicine report has

suggested that for parameters to provide the desired benefits,

they must meet certain criteria and possess certain characteris-

tics. Using these criteria, the authors assess available parameters in dentistry.

uidelines and parameters for clinical practice are defined as

"systematically developed statements [designed] to assist [the] practitioner and patient [in making] decisions about appropriate health care for specific clinical circumstances."' There is an explosion of clinical guidelines in medicine, and all signs point to a similar occurrence in dentistry. The growing presence of clinical guidelines will substantially influence most health care decisions made by patients, dentists and payers. In dentistry, parameters could explicitly specify and define much of our professional knowledge, including what is known and what is not.2 As parameters become widespread, dentists must be aware of them and incorporate them appropriately into their practices. But before incorporating them, dentists must evaluate the validity and suitability of these decision aids for use in their practices. In other words, dentists must be informed consumers of parameters or guidelines. (The term "practice parameter," introduced by the American Medical Association,2 is used by several dental provider organizations to refer to descriptive-as opposed to prescriptiverecommendations. In this article, we use the terms "parameter" and "guideline" interchangeably.) To help dentists make appropriate decisions regarding their use, this article addresses three questions: - What should dentists expect of clinical guidelines? - What guidelines are available in dentistry? - To what extent do the available dental guidelines measure up to what is expected? WHAT SHOULD DENTISTS EXPECT OF CLINICAL GUIDELINES?

To serve as useful decision aids, guidelines must reflect what is known about a clinical condition in terms of its risk factors and natural course, diagnosis and the relative effectiveness of treatment alternatives and their outcomes. Thus, guidelines should be outcome-based,3'4 meaning that the effective health intervention should be linked explicitly to health outcomes that the guideline developers aim to improve or prevent.34 To meet this criterion, guidelines must-whenever possible-be based on scientific evidence, that is, the scientific literature. Guidelines can serve as decision aids in choosing screening, pre1134 JADA, Vol. 126, August 1995

CLINICAL PRACTICE ventive, diagnostic or treatment procedures. Although they are usually designed to be used by providers and sometimes by patients, guidelines may include information useful to others, such as payers, administrators, attorneys, accrediting agencies, malpractice underwriters, peer review groups and policy makers. The dramatic increase in the number and type of clinical guidelines being issued has prompted a need for standards to which guidelines should conform. The two most prominent efforts to evaluate and enhance clinical guidelines are sponsored by the American Medical Association and the Agency for Health Care Policy and Research (AHCPR). The American Medical Association, which "strongly supports the use of practice parameters as a method to improve the quality of medical care and assure the appropriate utilization of health care resources," regularly publishes a directory of practice parameters and endorses the use of a set of attributes to guide the development of practice parameters.5 In summary, these attributes stipulate that - physicians should participate in the development of parameters; - parameter development should integrate research findings and clinical expertise; - parameters should be disseminated widely and should be comprehensive and up to date. The AHCPR also has established standards to help organizations develop guidelines. In 1989, Congress created the AHCPR to enhance "the quality, appropriateness and effectiveness of health care services, and access to such services, through

TABLE I

~~~I

I1 1 1111 g 1

llI

,

,1I11|1:II,.g

APPROPRIATE DEVELOPMENT PROCESS

The developing organization should document the procedures used in developing the guidelines, the methods used to obtain expert opinion, the strength of the evidence used, the rationales and assumptions employed and the participants involved. This documentation should include evidence that representatives of key affected groups were involved in the process and that the available scientific literature was exhaustively reviewed and incorporated. CLINICAL APLICABILITY

Giwdelines shoWd dce patients and the clinical conditions t pvide information about lnical ch theyol, and non-clinical factors make the guidelinenot applicable in certain cases, descbe the treatment alternatives available for the condition and be presented logicall and n a manner that makes them easy to use. RELIABILITY

Guidelines should be sufficiently reliable so that practitioners can interpret and apply them consistently. The developing organization should maintain evidence of independent review by experts or outside panels, evaluation of the guidelines' use and pretesting by dentists in practice. VALIDITY

Guidelines should be based on outcomes and rooted in the scientific literature. The devloping organization should maintain substantial evidence that the guidelines will, when followed appropriately, lead to the projected health outcome as determined from the literatur and4 by systematically obtained expert opinion. Guidelines should be accompanied by estimatesof the outcomes expected from the intervention compared wt alternative practices. Asessment of outcomes shod include consideration ofpafient perceptons and preferencs. * Modified from Field and Lohr, 1992.1

the establishment of a broad base of scientific research and through the promotion of improvements in clinical practice."6 As one means of achieving these goals, the AHCPR conducts extensive research and demonstration projects, including the development of practice guidelines. One branch of the AHCPR is devoted to helping

develop, disseminate, evaluate and update practice guidelines.6 To ensure a more systematic approach to guideline development and evaluation, an Institute of Medicine committee, at the request of the AHCPR, developed criteria for evaluating clinical guideline development.' These criteria are presented as a series of "desirable attributes JADA, Vol. 126, August 1995 1135

C[INICAL PRACTICE of practice guidelines." These attributes stipulate that guidelines should be credible and allow flexibility. They must be based on scientific evidence or expert judgment in the absence of direct empirical evidence. The process of developing guidelines should include participation by representatives of key affected groups and disciplines. Such participation increases the likelihood that all relevant scientific evidence will be evaluated, that the practical problems associated with using the guidelines can be addressed and that the affected groups will see the guidelines as worth using. These attributes also are directly applicable to the practice of dentistry. A summary of these attributes modified for use with dental guidelines is shown in Table 1. This summary specifies the characteristics dentists should expect to find in acceptable guidelines, based on the IOM attributes. WHAT GUIDELINES ARE AVAILABLE IN DENTISTRY?

We have categorized the practice guidelines available in dentistry according to the type of agency sponsoring their development: professional dental organizations, government agencies, non-profit organizations and others, such as third-party payers and private practices. We used a mail survey with telephone follow-up to identify which professional dental organizations had developed guidelines. A review of the literature and informal contacts served to identify other guidelines. Professional dental organizations. In June 1993, we surveyed the nine members of the Specialty Liaison Panel to the 1136 JADA, Vol. 126, August 1995

Committee on the Future of Dental Education (representatives of all ADA-recognized specialty organizations and the Academy of General Dentistry) as well as a representative of the Office of Quality Assurance of the American Dental Association to collect information about their organizations' activities in development and dissemination of practice guidelines. We received responses from all 10 organizations. These responses were updated by telephone in August 1994. Four of the responding organizations currently have clinical guidelines and another three are in the process of developing them. Among these eight, three have formal plans and timetables for revisions and one has a formal dissemination plan. Thus, seven of 10 primary professional dental organizations have or soon should have some form of practice guidelines (Table 2). Two of the organizations that have not developed clinical practice guidelines might not be expected to do so. The American Academy of Oral Pathologists and the American Board of Dental Public Health do not represent specialty disciplines with a principal emphasis on providing clinical treatment. The surveyed organizations displayed a range of responses to the concept of practice guidelines. The most active organization in this regard, the American Association of Oral and Maxillofacial Surgeons (AAOMS), has engaged in an extensive effort to establish a process for the development, review and dissemination of practice parameters. The AAOMS maintains that parameters are necessary to assure continuous

quality improvement and that unless oral and maxillofacial surgeons actively participate in the development of such parameters, the "AAOMS membership may be confronted with documents that do not reflect the realities of their clinical environment."7 Other organizations also have developed guidelines. The American Association of Endodontists (AAE) has guidelines for endodontic treatment procedures and related dental conditions. The American Academy of Pediatric Dentistry (AAPD) publishes a reference manual yearly for its members. This manual includes information of interest to the specialty and, in particular, describes quality assurance criteria for pediatric dentistry as well as clinical guidelines. The American Academy of Periodontology (AAP) developed its first set of practice parameters for seven periodontal conditions and treatments in 1994. After subjecting the guidelines to external review, the AAP Board of Trustees granted final approval and subsequently published the set of parameters in June 1995. (Editor's note: No additional update can be provided, as the authors did not have time to review the AAP parameters before publication of this article.) Several other organizations have expressed interest in developing guidelines. At its 1994 annual session, the American Association of Orthodontists passed a resolution supporting the development of clinical practice parameters for orthodontics (S. Bowers, personal communication, August 1994). The American Academy of Prosthodontics also has indicated an interest in developing guidelines but to

CLINICAL PRACTICEm TABLE 2

American Academy of Pediatric Dentistry

Each guideline revised every three years

Developing dentition, pulp therapy, behavior management, restorative dentistry, TMD,

Guidelines are part of Academy's referenace manuial40

periodontics, sedation

American Association of Endodontists

revisions

Endodontic exam, diagnosis, treatment plainning and enidodontic services

American Assoclatlon of Orthodontists

Yes

In

American Dental Association

Yes

Twelvre clinical conditions

ongoing

process

In 1994, the AAO created a 10member task force to de-velop clinical practice parameters for orthodontics.

In 1991, the ADA developed practice parameters for oral health care conditions that were not approved by its House of Delegates. Resuxmption of the practice parameters initiati-ve was endorsed by the House of Delegates at the 1993 ADA ann-ual session. The ADA Dental Practice Parameters Committee de-veloped 12 sets of parameters that were approved by the ADA House at the 1994 annuial session. These parameters were disseminated to the profession in the spring of 1995.

Information for the American Academy of Oral Pathology and the American Board of Dental Public Health is not included because these organizations do not represent disciplines routinely delivering direct clinical treatment. t H. E. Donnell, personal communication, August 1994.

*

JADA, Vol. 126, August 1995

1137

CLINICAl PRACTICE date has not begun this work. The Academy of General Dentistry has not developed guidelines but has stated that "any parameter of care established for the entire dental profession should be condition-based; equally applicable to all dental care providers; universally accepted within the profession; and developed by the American Dental Association with appropriate representation by the affected communities of interest" (H.E. Donnell, personal communication, August 1994). Although the American Board of Dental Public Health has not established standards or guidelines per se, it has been active in efforts to establish public health goals or targets to help guide policy decisions. The ADA began a program to develop practice parameters in 1989. A draft of the first parameter, which deals with oral health care conditions, was rejected by the ADA House of Delegates at the 1991 annual session.8 The issue of resuming practice parameter development was reconsidered and approved by the ADA House of Delegates at its 1993 annual session (D. Ellek, personal communication, August 1993). During that session, the ADA House approved a parameters development process and created the Dental Practice Parameters Committee. The DPPC subsequently drafted proposed parameters for caries and periodontal disease based on "clinical experience of dentists, the experience of other dental organizations ... , and when needed, commissioned papers reviewing the current literature. ...."9 Drafts were reviewed by a consensus conference of 35 dentists and by 1138 JADA, Vol. 126, August 1995

a mail survey of selected dentists before final revision. At its 1994 annual session, the ADA House of Delegates approved parameters for 12 dental conditions (Res. 36H-94).1" Government agencies. A second category of practice guidelines are those developed under the sponsorship of a public agency. Federal agencies often assemble experts in various areas to develop reports that result in consensus criteria, recommendations or guidelines for clinical decision making. Nearly a decade ago, a panel of dental experts convened by the Food and Drug Administration developed patient selection criteria to be used when scheduling dental radiographs." After reviewing the available literature and consulting experts, the panel produced a report and guidelines that were subsequently disseminated in the dental literature.12"13 The National Institutes of Health have sponsored six consensus-development conferences on dental topics: dental implants,14" 5 removal of third molars,'6 clinical applications of biomaterials,17 dental sealants in the prevention of tooth decay'8 and anesthesia and sedation in the dental office.19 While the results of these conferences are not guidelines per se, the consensus statements reflect much of the same careful, evidence-based review involved in guideline development. The placement and replacement of dental restorations, which accounts for most dental care expenditures, was the focus of a conference supported by the National Institute of Dental Research entitled "Criteria for Placement and Replacement of Dental Restorations."20

An international group of dental researchers, educators and practitioners addressed the issues and produced a series of summary statements, 10 specif-. ic criteria for placement and replacement of restorations and recommendations for research and educational intervention. Government agencies such as the Indian Health Service, the Department of Veterans Affairs and the armed services manage health care delivery systems that include a number of providers and have a defined population for which they are responsible. Accordingly, these organizations have developed protocols for managing clinical situations. As part of its quality assurance protocol, for example, the Indian Health Service has developed community-based guidelines for its primary and secondary preventive activities. This protocol lists the specific interventions expected of an Indian Health Service site functioning in a community setting. Another example of the use of clinical guidelines in a governmental program is the adaptation of the American Academy of Pediatric Dentistry's guidelines by the Alaska Head Start Health Improvement Initia-

tive.2' Nonprofit organizations. A third category of guidelines results from efforts sponsored primarily by nonprofit organizations. Most notable among these are the American Heart Association's recommendations for antibiotic prophylaxis to prevent bacterial endocarditis in patients considered to be at risk for bacteremia.22 First published in 1965, the guidelines have been revised several times. Although some controversy still surrounds these guidelines,

CLINICAL PRACTICE

tiowever, literature review was used whenever the parameters development committee judged it necessary to supplement clinical knowledge and experience. Parameters were developed using professional consensus through the coordinated efforts of a

the development committee or an asseml of colleagues. Based on the mail review panel's recommendations, the dental practice parameters committee made final revisions and then submitted the finished parameters to the ADA House of Delegates. The House adopted the 12 parameters in October 1994. The dental practice parameters committee requested literature re-

oroad geographic regions ot dental practice. All 12 of the parameters will be examined for their usefulness after they have been disseminated to the dental community and dentists have had expenrence with them. The ADA regards the parameters as dynamic documents that will be updated and revised as knowledge and practice evolve. a Dr. Ellek is manager, ADA Office of Quality Assessment and Improvement, Council on Dental Benefits Programs.

JADA, Vol. 126, August 1995 1139

CLINICAL PRACTICEthey are broadly acknowledged as the standard for managing patients at risk for bacterial endocarditis from dental procedures. Other organizations. Two other types of organizations have developed or are in the process of developing guidelines that may have far-reaching effects within dentistry. First, claims submission requirements and reimbursement policies of third-party payers serve as de facto guidelines and influence clinical decisions. Second, clinical protocols developed by dental group practices or managed care organizations also will influence patient care decisions of the growing number of providers affiliated with those

organizations. HOW DO AVAILABLE DENTAL GUIDELINES MEASURE UP TO WHAT IS EXPECTED?

We evaluated the guidelines available for dental conditions using a modified form of the IOM's desirable guideline attributes (Table 1). Many of the guidelines lack sufficient detail to permit comprehensive analysis. However, the following section examines the guidelines for which there is sufficient detail to permit evaluation. Professional dental organizations. The AAOMS's parameters are intended to "reflect practice considerations for nine designated areas of oral and maxillofacial surgery."7 The process for developing and disseminating these parameters is the most advanced of any employed by a professional dental organization. For each of nine specific areas of care, indications for care, therapeutic goals, factors affecting risk, standards of care, performance assess1140 JADA, Vol. 126, August 1995

ment indices and favorable outcomes are presented clearly and concisely in the guidelines. The guidelines appear to have sufficient clinical applicability and flexibility, although the extent to which they are useable and used in the field remains to be determined. A brief bibliography accompanies each of the nine care areas, but specific clinical evidence supporting each area is not cited and there is no general discussion assessing the strength of the scientific evidence for each area. The AAOMS has received a grant from the AHCPR to disseminate the parameters, and the project includes assessment of the diffusion of the parameters and associated changes in oral surgeons' use of treatments. Initial results from the project suggest that dissemination has been successful at least in terms of practitioner awareness.23 In 1994, the AAE published its manual "Appropriateness of Care and Quality Assurance Guidelines."24 These guidelines consist of three sections each and are brief and straightforward. The first section under each guideline discusses the "appropriateness" of the procedure. The information contained in that section is similar to that called for by the IOM Committee, as it addresses issues related to clinical applicability and flexibility by noting exclusions, complications and indications. The second section provides a brief description of the procedure. The final section, "objectives," essentially describes the desired immediate outcomes. A general reading list is included but not directly referenced to specific aspects of the guideline. The validity or strength of the evidence as well

as the risks, benefits and costs are not specifically addressed. The AAP has guidelines for 10 conditions, treatments or activities within the discipline. These guidelines, developed by committees primarily from within the specialty, are reviewed and updated on a regular basis. When appropriate, guidelines have been reviewed by joint committees including individuals from other specialty organizations. In the typical guideline, the objective of the procedure or activity is described. Treatment planning issues, including indications and exclusions, also are noted. Generally, the technical aspects of the procedure are outlined. Outcomes are described in terms of clinical objectives listing shortterm and long-term clinical outcomes. References are included at the end of each section but not directly attributed to statements in the body of the guideline. The strength of the scientific evidence and professional consensus are alluded to inconsistently, as are the health benefits and risks. The 12 sets of parameters approved by the 1994 ADA House meet few of the IOM Committee's desirable attributes. These parameters are based principally on the opinion of the parameters development committee, supplemented by panel reviews, using unstructured and untested consensus methods.9'10 Because no references are included, the extent to which the parameters are grounded in the scientific literature is not indicated. The validity, reliability and clinical applicability of the products are yet to be determined. Government agencies. The FDA guidelines on patient selection for dental radiograph

CLINICAL PRACTICEprocedures possess many of the attributes recommended by the IOM panel. The recommendations describe the population for whom the selection criteria are most appropriate. In addition, they review specific patient selection criteria that result in recommended radiographic usage determined by patient age and risk factors. The recommendations appear to be sufficiently flexible and identify exclusions such as pregnancy and radiographs taken for solely administrative reasons. The recommendations are supplemented by a series of criteria and recommendations for radiographic equipment, materials and practice processes. The report includes a thoughtful synthesis of issues related to biological hazards, exposure, diagnostic yield and patient risks. Risks and benefits of various radiographic surveys for specific patients are considered as well. The recommendations are presented in a logical, clear format; a grid describing recommended ordering practices by patient risk category and patient age is accompanied by a list of modifying factors and descriptions of clinical situations. Reliability among practitioners remains unknown. The criteria for the replacement of dental restorations are logical and clearly presented.20 They include appropriate descriptions of patient risk indicators. Some of the criteria are based on scientific evidence, while others are based on consensus opinion. The extent to which the full set of recommendations was disseminated within the United States was limited. Nonprofit organizations. The most recent recommendations from the American Heart

Association for antibiotic prophylaxis for the prevention of bacterial endocarditis are presented clearly and in sufficient detail for use by practitioners.25 Types of cardiac conditions as well as dental or surgical procedures considered to put patients at risk are clearly identified.26 The recommended prophylactic regimens are categorized by pharmaceutical agent and patient risk status. These guidelines seem to possess most of the desired attributes for clinical guidelines. Due to the ethical problem of assigning patients to a control group, randomized clinical trials have never been conducted to confirm or disprove the need for antibiotic prophylaxis in patients deemed at risk.25 However, a recently reported casecontrol study suggests substantial protective efficacy from use of these guidelines.27 Other organizations. The extent to which payers have developed formal treatment guidelines to support and explain their reimbursement policies has not been documented. Similarly, the extent of "in-house" guideline development among dental group practices is impossible to determine. In both instances, however, anecdotal information would suggest that development is occurring at least as quickly as for other professional interest groups. For example, Blue Cross/Blue Shield has several de facto guidelines that specify the circumstances under which certain treatment procedures are considered to be reimbursable. We reviewed an example of this type of guideline, one developed by Blue Cross/Blue Shield for periodontal procedures.28 The guideline includes a discussion of the clin-

ical condition, available treatment procedures and payment limitations for the various classifications of periodontal disease. The scientific basis for the guideline is not addressed. One dental group practice is developing drafts of eight guidelines for clinical treatments and conditions (management of edentulous spaces; diagnosis of interproximal caries on unrestored teeth; management of complex restoration of a single tooth; management of third molars; determination of recall intervals for permanent, primary, transitional or adult dentitions; and management of periodontal disease) (T. Marshall, Park Dental, Minneapolis, personal communication, August 1994). These guidelines were prepared by members of the practice's professional dental staff and are being evaluated by external reviewers. Each guideline is presented as a flow diagram and is supplemented with annotations describing the issues to be considered in each step. Conditions that require special consideration under the guideline are noted. A description of the process used to develop the guidelines and the scientific evidence on which the recommended approaches are based are not included. DISCUSSION

Regardless of the final characteristics of health care reform, the development and use of guidelines will continue to grow. In fact, six of eight major health care reform bills introduced in 1994 called for the development of clinical guidelines.29 Although professionwide involvement in guideline development has evolved relatively slowly, most dental organizaJADA, Vol. 126, August 1995 1141

CLKIINICAl PRACTICE tions currently are engaged in this activity. Among the guidelines that have been developed-both those prepared by professional associations and those created by other organizations-none possess all of the desirable attributes outlined by the IOM Committee on Clinical Practice Guidelines. Many of the existing guidelines lack detailed analyses of the available literature, fail to include patient preferences and rely primarily on expert opinion. As a result, there are few valid and practical clinical guidelines, according to the IOM's standards, available for use by practicing dentists. Most of the existing guidelines in dentistry are based primarily on consensus among selected professionals, with limited scientific support drawn from outcomes studies. The lack of outcomes information in dentistry is arguably part of the reason for the paucity of clinical guidelines.30 Some outcome information may be garnered from long-term clinical trials that studied treatment delivered by experts; however, results of effectiveness studies would be more helpful. Effectiveness studies demonstrate the outcomes obtained by typical dentists treating typical patients. Until the outcomes of effectiveness studies are available, it will be difficult to achieve broad professional consensus, much less to ensure validity of guidelines. Therefore, the profession must encourage growth of current efforts, including practice-based research.3 The guideline development activities of many groups within organized dentistry seem to be built on earlier quality assessment efforts. Although practice 1142 JADA, Vol. 126, August 1995

guidelines and QA may seem to share many common characteristics, they are for the most part very different. For example, QA is centered around retrospective analysis primarily of the structural and procedural aspects of care, with the goal of rating the acceptability of a "product" delivered in a dental practice. Typically, QA protocols are not based on information from outcome studies, and they rely heavily on criteria that often are implicit rather than explicit. For example, one set of quality criteria were developed by identifying those characteristics of a dental practice "that will be accepted by the people or institutions being reviewed."32 In addition, a well-known set of focuses on a limited number of quality criteria purported to measure outcomes focused on the characterization of restorations, such as marginal integrity, contour and restoration surface texture.33 These characteristics cannot be directly translated into outcomes such as tooth loss, function and so on. In essence, QA criteria tend to focus on immediate and intermediate measures of the technical aspects of procedures, rather than longterm outcomes of care. Guidelines, on the other hand, are decision aids that are based on evidence of outcomes whenever possible and are designed for use prospectively in improving decisions concernig treatment. Thus, while QA criteria may provide a starting point for guideline development, the distinctions in purpose and foundation must be acknowledged to avoid confusion and misunderstanding. As suggested earlier, the de facto guidelines prepared by carriers and those developed by

managed care organizations may have substantial effects on the profession. The relative effects of these two types of guidelines will depend on the future structure of the dental care delivery system. Guidelines promulgated by managed care organizations may be considered as having broader potential effects than carriers' guidelines in that they suggest what treatment a patient should receive, rather than the treatments for which a provider will be reimbursed. In this respect, in-house managed care organization guidelines are similar to those developed by any other dental interest group. However, the effect of such guidelines on practitioners might be more pronounced. Currently, guideline development among managed care groups indicates attention to many of the issues included in the IOM list. In fact, at least one managed care organization has recognized the need for better information before guideline development and has started an in-house outcomes research program to obtain the crucial information for guidelines they wish to develop (F. Lombardo, Metro Dental Care, Burnsville, Minnesota, personal communication, August 1994). While several dental specialty organizations are working to establish outcomes studies and guidelines for treatments and conditions within their specialties, the bulk of activities performed by general dentists remained unaddressed until recently by any group developing guidelines.10 Thus, the profession needs to continue to refine guidelines for "routine" restorative and preventive procedures. Except for the AAOMS parameters, the dissemination

CLINICAL PRACTICE strategies for current guidelines also have not been clearly delineated. In the past, formal dissemination usually ended with the publication of a report that often does not appear in the periodic literature read by the target audience of clinical practitioners. For example, while broadly acknowledged as being the standard of care, with endorsements from the American Dental Association and the American Medical Association, the AHA guidelines have a relatively low rate of compliance.3435 Reprints and summaries of the guidelines may or may not enjoy more widespread attention. Moreover, little is known about the extent to which the guidelines actually alter practitioner behaviors and even less is known about the effect of altered practitioner behavior on the ultimate outcome, patient well-being. From a policy perspective, improvement in patient outcomes must be the measure of guidelines' impact. CONCLUSION

As interest continues to grow, it is likely that there will be large numbers of guidelines promulgated by a variety of organizations. It is also likely that these guidelines may conflict with each other and may vary widely both in their validity and applicability. Thus, it will be essential that the ADA or some other organization follow the example of the AMA and establish a clearinghouse to rate practice guidelines using the attributes developed by the 1OM.36 Such a clearinghouse could evaluate the methods used to develop guidelines, rate their validity and assess their value to the practicing dentist. In summary, before adopting

guidelines developed by any organization, dentists must make sure that the guidelines possess the desirable attributes shown in Table 1. Otherwise, dentists may find themselves using decision aids that are not valid, reliable or practical, thereby compromising the care of their patients. m Dr. Shugars is a professor, University of North Carolina School of Dentistry, Department of Operative Dentistry, CB No. 7450, Chapel Hill 27599-7450. Address reprint requests to Dr. Shugars. Dr. Bader is a research professor, University of North Carolina School of Dentistry, Chapel Hill, and Cecil G. Sheps Center for Health Services Research, Chapel Hill.

This article is based on one section of a

background paper prepared for the Institute of Medicine study titled "The Future of Dental Education." Portions of the work have been supported by the Institute of Medicine and grant HS06669 from the Agency for Health Care Policy and Research. 1. Field M, Lohr K, eds. Guidelines for clinical practice: From development to use. Washington, D.C.: National Academy Press; 1992. 2. Sherer J. Parameters of care. AGD Impact 1990;18(9):4-10. 3. Eddy DM. Practice policies-Guidelines for methods. JAMA 1990;263:1,839-41. 4. Eddy DM. Designing a practice policy: Standards, guidelines and options. JAMA 1990;263:3,077-84. 5. American Medical Association, Office of Quality Assurance and Medical Review. Directory of practice parameters. Chicago: AMA1994. 6. Field M, Lohr K, eds. Clinical practice guidelines: Directions for a new program. Washington, D.C.: National Academy Press; 1990. 7. American Association of Oral and Maxillofacial Surgery. Parameters of care for oral and maxillofacial surgery: A guide for practice, monitoring and evaluation. J Oral Maxillofac Surg 1992;50(7)(Supplement No. 2):1-175. 8. Berry J. Parameters project ends in '91 House. ADA News 1991; Nov. 4:1,11,14. 9. Spaeth D. Parameters group "surprised" at progress of first meeting. ADA News 1994;Feb. 21:1, 21. 10. Jakush J. House OKs 12 parameter sets. ADA News 1994;Nov. 21:3,9. 11. Food and Drug Administration. The selection of patients for x-ray examinations: dental radiographic examinations. Rockville, Md.: FDA, 1987; HHS publication no. 88:8273. 12. American Dental Association, Council on Dental Materials, Instruments, and Equipment. Recommendations in radiographic practices: An update, 1988. JADA 1989;118:115-7. 13. Matteson S, Joseph L, Bottemley W, et al. The report of the panel to develop radiographic selection criteria for dental patients. Gen Dent 1991;39:264-70. 14. National Institutes of Health. Dental implants: benefit and risk. NIH consensus statement, 1978;1(3):13-9.

15. National Institutes of Health. Dental implants. NIH consensus statement, 1988;7(3):1-22. 16. National Institutes of Health. Removal of third molars. NIH consensus statement 1979;2(11)65-8. 17. National Institutes of Health. Clinical applications of biomaterials. NIH consensus statement, 1982;4(5):1-19. 18. National Institutes of Health. Dental sealants in the prevention of tooth decay. NIH consensus statement, 1983;4(11):1-18. 19. National Institutes of Health. Anesthesia and sedation in the dental office. NIH consensus statement, 1985;5(10):1-18. 20. Anusavice K. Quality evaluation of dental restorations: criteria for placement and replacement. Chicago: Quintessence, 1989. 21. Jones D, et al. Standards of care for Alaskan dental professionals extending oral health care to Head Start families. Anchorage, Alaska: Prevention Associates; 1993. 22. Dajani A. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1990;264:2,919-22. 23. Kelly J, Helfrick J, Smith D, Jones B. A survey of oral and maxillofacial surgeons concerning their knowledge, beliefs, attitudes, and behavior relative to parameters of care. J Oral Maxillofac Surg 1992;50(issue):50-8. 24. American Association of Endodontics. Appropriateness of care and quality assurance guidelines. American Association of Endodontists. Chicago: AAE;1994. 25. Digenea A. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1990;264:2,919-22. 26. Tan S, Gill G. Selection of dental procedures for antibiotic prophylaxis against infective endocarditis. J Dent 1992;20:375-6. 27. Imperiale T, Horwitz R. Does prophylaxis prevent postdental infective endocarditis? A controlled evaluation of protective efficacy. Am J Med 1990;88:131-6. 28. Blue Cross/Blue Shield of Massachusetts. Periodontal procedure guidelines. September 1, 1992. 29. Medical Mutual Insurance Company. Moving toward malpractice reform. Med View 1994; Summer:2-3. 30. Bader JD, Shugars DA. Variation, treatment outcomes, and practice guidelines in dental practice. J Dent Educ 1995;59:61-95. 31. Shugars D, Bader J. Appropriateness of restorative treatment recommendations: A case for practice-based outcomes research. J Am Coll Dent 1992;59(2):7-13. 32. Bailit HL. Quality assurance and development of criteria and standards. In: Burakoff RP, Demby NA, eds. Symposium on quality assurance, The Dental Clinics of North America. Philadelphia: Saunders;1985;29(3):457-63. 33. California Dental Association: Quality evaluation for dental care. Los Angeles: CDA;1976. 34. Nelson C, van Blaricum C. Physician and dentist compliance with American Heart Association guidelines for prevention of bacterial endocarditis. JADA 1989;118:169-73. 35. Sadowski D, Kunzel C. Recommendations for prevention of bacterial endocarditis: compliance by dental general practitioners. Circulation 1988;77:1,316-8. 36. Oberman L. AMA Panel on Guidelines sorts good from misguided. Am Med News 1994;37(2):1,27.

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