Inscriptions—August 2019

10 INSCRIPTIONS | August 2019 There is no doubt in anyone’s mind that dentistry should be practiced according to evidence-based scientific principles. In theory this premise makes sense, but the theory is actually difficult to crystalize into practice. What exactly are the evidence-based scientific principles? How should they be applied? A good place to start is ADA’s definition of Evidence- Based Dentistry 1 : “Evidence-based Dentistry 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, together with • The Dentist’s Clinical expertise and • The Patient’s Treatment Needs and Preferences” Let’s discuss the clinical applications of each point. Scientific Evidence First, is the problem of finding clinically relevant scientific evidence as found in academic journals. What constitutes evidence? “Much of the scientific literature, perhaps half, may simply be untrue,” says Richard Horton, Editor of Lancet 2 . He notes that a great deal of scientific literature is “afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance.” According to Tina Saey of Science News 3 there are twelve reasons why research goes wrong: 1. Pressure to publish 2. Impact factor mania 3. Contamination 4. Bad math 5. Sins of omission 6. Biologic variability 7. Peer review doesn’t work 8. Some scientists don’t share 9. Research results unreported 10. Sloppy procedures 11. Errors 12. Fraud “This is chilling information,” says Gil Ross, former Executive Director of the American Council on Science and Health: “Our edifice of scientific progress, the peer-reviewed medical/ scientific literature, is a can of worms rather than the gold standard we thought it to be 4 .” One cannot look at academic literature without consideration of underlying agendas. It is important to uncover why the research was done, who funded the research and what motivated publication of the article. Astute clinicians also recognize that statistical results usually create a bell curve, with the majority falling in the middle. “Statistics embody averages, not individuals” says Dr. Jerome Groopman 5 , author of How Doctors Think. What about those individuals on the outskirts of the bell curve? The treatment protocol as outlined in the research may not be suitable for outliers. Clinical Expertise The second ingredient for evidence- based dentistry is the dentist’s clinical expertise. It is so important that a dentist be well rounded with multiple treatment options to offer patients— or at least to know about them for appropriate referral. It is becoming increasingly common for dentists to concentrate on proficiency in a specialized area of dentistry. While it is great to be an expert in one treatment modality, dentists should avoid becoming a “one-trick” pony. It is not uncommon for experts to overstretch their discipline rather than to offer alternatives or referrals that might be better. There is an alarming trend of extraction and implant placement for teeth that can be saved easily with classical crown and bridgework. Many dentists are not confident with crown and bridgework and they feel much more comfortable placing implants. But lack of proficiency in crown and bridge is not a justification for extraction and implant placement. A common joke is that dentists call their vocation “practice” because maybe one day they will get it “right.” While the joke is guaranteed for a chuckle, it is the absolute truth. Dental Practice is a continual striving for excellence in order to do better work. ACLINICIAN’SPERSPECTIVE ONEVIDENCE-BASED PRACTICE MEMBER DENTIST Edward Feinberg, DMD 2019 FALL CONFERENCE SPEAKER CONTINUED ON 12