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Incorporating evidence-based dentistry into clinical practice
Evidence-Based Care Incorporating evidence-based dentistry into clinical practice Background.—Evidence-based dental practice is defined as the integration of experience and expertise with a critical analysis of relevant clinical evidence obtained through systematic research and with a consideration of the patient’s needs and preferences. Thus the main aspects of evidence-based dental practice are the dentist’s expertise and clinical judgment, relevant clinical evidence, and patient considerations. Dental practitioners generally support the concept of using evidence-based dental disease prevention and treatment but have been slow to incorporate the principle into practice. Challenges to transferring evidence-based dentistry into practice and specific barriers to this process were explored. Possible solutions were offered. Barriers to Implementation.—Clinicians face an uphill battle to handle the ever-expanding knowledge base. Most rely on systematic reviews, which identify all relevant material in the literature, define the key questions as well as inclusion and exclusion criteria, outline literature search parameters, and assess the quality of both the study and the data obtained. Even with a growing number of systematic reviews available, over half cannot respond to the key clinical question because the studies are too weak. Systematic reviews also cannot inform practitioners about new materials and techniques because they change so rapidly. Implant design materials, tooth-colored restorative materials, and adhesives are undergoing constant alteration. Sales representatives provide marketing pieces that make claims that are not necessarily evidence-based, but some practice consultants view sales representatives as key providers of information. Clinicians, faced with a paucity of quality systematic reviews, are forced to rely on clinical trial and error or commercial market information. Clinicians must also deal with nonreferred journals and marketing information that blurs the distinction from valid published systematic reviews. It is possible that the amount of relevant clinical evidence is so poor or the questions so unrelated to clinical issues that evidence-based dentistry is apparently not being used. To address this problem of dental information overflow, the number of sys-
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tematic reviews that address well-defined and clinically relevant key questions must increase. What about the guidelines that are developed from systematic reviews? Are they to be slavishly followed in clinical practice? Practitioners must decide if they should adhere firmly to any guidelines or follow their personal judgment. Some practitioners may be unaware of guidelines, some may disagree with them, some may lack confidence in the expected results, and some may choose to remain inert rather than change. Patient preferences are generally based on personal desires and insurance benefits. Patients today are, by necessity, becoming well-informed consumers. Commercial enterprises are marketing products directly to patients, yet these materials change so rapidly that the information may have changed and no longer be applicable. There are simply too many new generations of composites, adhesives, veneer materials, and implants on the market. Not all have evidence to support their use. In addition, third-party payers may suggest, when denying coverage of certain services, that they are not clinically sound or scientifically based. Insurance providers do not generally focus on patient satisfaction when defining care parameters. They give the impression to patients that they define appropriate care through their regulations and coverage, even though their decisions are often contradictory to the evidence obtained in well-performed studies. Faced with all these barriers, clinicians may not be motivated to change the way they practice. Many of the procedures chosen and decisions made are based on financial concerns. External factors out of the control of the clinician can also influence practice, including lack of access to certain equipment or cost-prohibitive changes in facility design. Clinicians must also deal with the issues of insufficient staff support, poor reimbursement policies, rising operational costs, and increased liability.
Implementation of Evidence-Based Care.—Although patient care clearly could be improved by using evidencebased dental practices, the main barrier to implementation is a lack of respect and appreciation between the various sides involved. Academicians and advocates of evidencebased dentistry do not acknowledge that much of the evidence is not clinically relevant or is weak. A better ability to define clinically relevant key questions would allow such persons to work more closely with clinicians. A substantial increase in the quality and quantity of clinically relevant systematic reviews is essential. All parties should become more cognizant of patient expectations and outcome satisfaction issues. Discussion.—Various barriers have prevented the timely inclusion of evidence-based dentistry into clinical practice. The information supplied in the process should be coupled with clinical judgment and patient preferences to yield optimal dental practices.
Clinical Significance.—Efficiently applying the growing body of dental knowledge into effective dental practice remains the goal of evidence-based practice. Inertia among practitioners, an explosion of dental knowledge and technology, failure to understand patient desires and expectations, and the influence of insurance providers are among the barriers. Nonetheless, it is an idea whose time has come and come it will.
Kao RT: The challenges of transferring evidence-based dentistry into practice. Calif Dent Assoc J 34:433-437, 2006 Reprints available from RT Kao, 10440 S De Anza Blvd, Suite D-1, Cupertino, CA 95014
Analyzing tongue cleaners’ effect on halitosis Background.—Halitosis, which is a disagreeable odor of expired air, can be subdivided into physiologic or pathologic varieties. Physiologic halitosis is not associated with any specific disease or pathologic condition. Pathologic halitosis results from an oral infection. In the oral cavity, anaerobic and predominantly gram-negative bacteria degrade amino acids and produce malodorous volatile sulfur compounds (VSCs). Bacteria are found in the gingival crevices, periodontal pockets, and furrows on the tongue’s surface. A Cochrane systematic review, which promotes evidencebased outcome studies, was undertaken to determine the effectiveness of tongue scraping or cleaning compared to other methods of halitosis control. Methods.—Randomized controlled clinical trials (RCTs) were the only studies considered. Primary outcomes included self-expressed or perceived results and organoleptic (detected by the human nose) assessments. Secondary out-
comes were measured using a halimeter, portable sulfide monitor, or gas chromatography. The RCTs were found through a search strategy developed by MEDLINE. The subject search was combined with phases 1 and 2 of the Cochrane Optimal Search Strategy for RCTs as revised by the Cochrane Oral Health Group to include research techniques suitable for oral health research. The review authors graded the selected studies and assessed those reporting RCTs according to grading criteria developed for the Cochrane Handbook for Systematic Reviews of Interventions. Inconsistencies between the review authors were discussed and resolved. Any studies not conforming to the inclusion criteria were disregarded. Randomization was deemed adequate if it involved a computer-generated or table of random numbers, drawing lots, coin-toss, card shuffling, or dice roll. Participants who were active smokers; who took long-term medication; and who had systemic diseases, removable dentures, dental caries, active periodontitis, or
Table 3.—Baseline measurements/mean value/percentages (SD) for various methods of tongue cleaning Time after intervention
Baseline Immediately after intervention 5 minutes 10 minutes 15 minutes 20 minutes 25 minutes 30 minutes 35 minutes
Tongue cleaner
Tongue scarper
Toothbrush
P value
194 (80) 115 (61); 58 (11) 125 (65); 63 (11) 133 (66); 67 (12) 148 (72); 75 (12) 165 (75); 84 (10) 186 (80); 95 (6) 196 (79); 100 (2) 198 (82); 101 (1)
197 (81) 122 (67); 60 (12) 132 (72); 65 (12) 147 (81); 72 (12) 162 (86); 80 (11) 181 (89); 90 (9) 194 (86); 98 (6) 198 (81); 101 (1) 199 (82); 101 (1)
195 (83) 133 (68); 67 (9) 143 (71); 72 (7) 155 (74); 78 (7) 171 (80); 87 (6) 189 (84); 96 (5) 197 (83); 100 (1) 197 (83); 101 (1) 197 (83); 101 (1)
<0.001 <0.001 <0.001 <0.001 <0.005 Not significant >0.05 Not significant >0.05 Not significant >0.05
Volume 52
Issue 2
2007
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Dental Abstracts
tematic reviews that address well-defined and clinically relevant key questions must increase. What about the guidelines that are developed from systematic reviews? Are they to be slavishly followed in clinical practice? Practitioners must decide if they should adhere firmly to any guidelines or follow their personal judgment. Some practitioners may be unaware of guidelines, some may disagree with them, some may lack confidence in the expected results, and some may choose to remain inert rather than change. Patient preferences are generally based on personal desires and insurance benefits. Patients today are, by necessity, becoming well-informed consumers. Commercial enterprises are marketing products directly to patients, yet these materials change so rapidly that the information may have changed and no longer be applicable. There are simply too many new generations of composites, adhesives, veneer materials, and implants on the market. Not all have evidence to support their use. In addition, third-party payers may suggest, when denying coverage of certain services, that they are not clinically sound or scientifically based. Insurance providers do not generally focus on patient satisfaction when defining care parameters. They give the impression to patients that they define appropriate care through their regulations and coverage, even though their decisions are often contradictory to the evidence obtained in well-performed studies. Faced with all these barriers, clinicians may not be motivated to change the way they practice. Many of the procedures chosen and decisions made are based on financial concerns. External factors out of the control of the clinician can also influence practice, including lack of access to certain equipment or cost-prohibitive changes in facility design. Clinicians must also deal with the issues of insufficient staff support, poor reimbursement policies, rising operational costs, and increased liability.
Implementation of Evidence-Based Care.—Although patient care clearly could be improved by using evidencebased dental practices, the main barrier to implementation is a lack of respect and appreciation between the various sides involved. Academicians and advocates of evidencebased dentistry do not acknowledge that much of the evidence is not clinically relevant or is weak. A better ability to define clinically relevant key questions would allow such persons to work more closely with clinicians. A substantial increase in the quality and quantity of clinically relevant systematic reviews is essential. All parties should become more cognizant of patient expectations and outcome satisfaction issues. Discussion.—Various barriers have prevented the timely inclusion of evidence-based dentistry into clinical practice. The information supplied in the process should be coupled with clinical judgment and patient preferences to yield optimal dental practices.
Clinical Significance.—Efficiently applying the growing body of dental knowledge into effective dental practice remains the goal of evidence-based practice. Inertia among practitioners, an explosion of dental knowledge and technology, failure to understand patient desires and expectations, and the influence of insurance providers are among the barriers. Nonetheless, it is an idea whose time has come and come it will.
Kao RT: The challenges of transferring evidence-based dentistry into practice. Calif Dent Assoc J 34:433-437, 2006 Reprints available from RT Kao, 10440 S De Anza Blvd, Suite D-1, Cupertino, CA 95014
Analyzing tongue cleaners’ effect on halitosis Background.—Halitosis, which is a disagreeable odor of expired air, can be subdivided into physiologic or pathologic varieties. Physiologic halitosis is not associated with any specific disease or pathologic condition. Pathologic halitosis results from an oral infection. In the oral cavity, anaerobic and predominantly gram-negative bacteria degrade amino acids and produce malodorous volatile sulfur compounds (VSCs). Bacteria are found in the gingival crevices, periodontal pockets, and furrows on the tongue’s surface. A Cochrane systematic review, which promotes evidencebased outcome studies, was undertaken to determine the effectiveness of tongue scraping or cleaning compared to other methods of halitosis control. Methods.—Randomized controlled clinical trials (RCTs) were the only studies considered. Primary outcomes included self-expressed or perceived results and organoleptic (detected by the human nose) assessments. Secondary out-
comes were measured using a halimeter, portable sulfide monitor, or gas chromatography. The RCTs were found through a search strategy developed by MEDLINE. The subject search was combined with phases 1 and 2 of the Cochrane Optimal Search Strategy for RCTs as revised by the Cochrane Oral Health Group to include research techniques suitable for oral health research. The review authors graded the selected studies and assessed those reporting RCTs according to grading criteria developed for the Cochrane Handbook for Systematic Reviews of Interventions. Inconsistencies between the review authors were discussed and resolved. Any studies not conforming to the inclusion criteria were disregarded. Randomization was deemed adequate if it involved a computer-generated or table of random numbers, drawing lots, coin-toss, card shuffling, or dice roll. Participants who were active smokers; who took long-term medication; and who had systemic diseases, removable dentures, dental caries, active periodontitis, or
Table 3.—Baseline measurements/mean value/percentages (SD) for various methods of tongue cleaning Time after intervention
Baseline Immediately after intervention 5 minutes 10 minutes 15 minutes 20 minutes 25 minutes 30 minutes 35 minutes
Tongue cleaner
Tongue scarper
Toothbrush
P value
194 (80) 115 (61); 58 (11) 125 (65); 63 (11) 133 (66); 67 (12) 148 (72); 75 (12) 165 (75); 84 (10) 186 (80); 95 (6) 196 (79); 100 (2) 198 (82); 101 (1)
197 (81) 122 (67); 60 (12) 132 (72); 65 (12) 147 (81); 72 (12) 162 (86); 80 (11) 181 (89); 90 (9) 194 (86); 98 (6) 198 (81); 101 (1) 199 (82); 101 (1)
195 (83) 133 (68); 67 (9) 143 (71); 72 (7) 155 (74); 78 (7) 171 (80); 87 (6) 189 (84); 96 (5) 197 (83); 100 (1) 197 (83); 101 (1) 197 (83); 101 (1)
<0.001 <0.001 <0.001 <0.001 <0.005 Not significant >0.05 Not significant >0.05 Not significant >0.05
Volume 52
Issue 2
2007
85