Evidence-Based Dentistry

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How do you know what you know? Did someone else just tell you it was so? Perhaps you just figured it out for yourself? Or maybe you read about it in a textbook or a peer-reviewed journal? What is Evidence-Based Dentistry (EBD) anyway, and how do we know which evidence is good enough to rely on?

We spent a couple of hours in our literature review course yesterday with Midwestern’s resident dentist scientist, Dr. John Mitchell. He helped us to define and understand EBD in a way that was palatable. His lecture is what inspired me to write this post today.

Do you believe in Santa Claus?

We spend our entire lives believing things that simply aren’t true. Much of the time it doesn’t matter, because the consequences of some beliefs are insignificant. For example, many of us believe that people in Columbus’ time thought the Earth was flat. Really, this couldn’t be further from the truth, and it is such a common misconception that it has a name: the Myth of the Flat Earth.

But what happens when the things we are wrong about do have consequences, such as in healthcare? Don’t we owe it to our patients to know why we do things they way we do? Is it good enough to do something simply because that’s how it’s been done for ages? If my professor told me to do it that way in dental school, shouldn’t I go the extra mile for my future patients and ask the professor why? More importantly, shouldn’t we ask ourselves why we do anything as dentists?

In Malcom Gladwell’s book Outliers he popularized the 10,000 hour rule. With 10,000 hours of deliberate practice, anyone can achieve mastery at a given skill. What many people don’t know about the 10,000 hour rule is that it finds its origins in a study conducted by K. Anders Ericsson, Ralf Th. Krampe, and Clemens Tesch-Romer. Their study was titled The Role of Deliberate Practice in the Acquisition of Expert Performance.

Unfortunately, the media and the general public both fail to notice the most important operative word in Gladwell’s 10,000 hour rule and the study from which it is based. Your practice must be deliberate. Doing something wrong over 10,000 hours will make you very good… at doing it wrong.

So what is deliberate practice, and how what does that have to do with Evidence-Based Dentistry?

Here’s what Anders and his colleagues had to say about deliberate practice:

The most cited condition concerns the subjects’ motivation to attend to the task and exert effort to improve their performance.

As future dentists, we will be required to take Continuing Education (CE) courses to ensure that we maintain clinical competency and keep up with new standards. But this is only a minimum. To be truly competent practitioners of EBD we should evaluate ourselves and ‘exert effort to improve our performance’ continuously.

How do you continuously improve when you’re already perfect?

Obviously this is a tongue-in-cheek rhetorical question. But it illustrates an important point. How many dentists have actually achieved perfection? I’m guessing somewhere right around zero. Yet how many dentists are no longer continuously improving? I’m hoping it’s also a low number, but I suspect that it is much higher than the number who have actually achieved perfection.

Dentistry is a continuous learning process. There are new technologies, techniques, and standards emerging all of the time. Our profession is not an immutable textbook that was written in stone. No, we are subscribers to a profession that is submitting new articles on a daily basis. Both literally and figuratively.

In order to be a truly evidence-based profession we must keep up with the avalanche of new information. But that’s okay, because much of what is published is only going to make our jobs easier.

Maybe there was no good answer for this health condition or that treatment option in the past. In the future there may be.

Maybe there’s a better explanation now just waiting to be discovered in the latest issue of a dental journal. Or, perhaps we learn that we have been doing things wrong all this time.

Hey, for all I know, I learned from someone who had bad ideas and I will pass those on to my patients if I don’t seek out proper evidence.

Dr. Mitchell said to us yesterday that evidence is what separates a trade from a science-based profession. In the trades you do what you are taught because that’s what worked for the person teaching you.

There is no major plumbing or carpentry journal that I am aware of. Sure, they have magazines, but these are not peer-reviewed publications, a subject I will cover shortly.

What is good evidence, anyway?

We are bombarded with biased information every day. Even articles about science or health are often highly editorialized. So where do we turn for the best evidence when caring for our future patients? Well, much like the food pyramid, there is a guide to the various levels of evidence.

Evidence-Based Dentistry pyramid

As the quality of evidence increases, the quantity decreases. If expert opinion is the very bottom level, what does that tell you about all of those newspaper editorials and magazine articles written by journalists with little to no background in the field?

That is the world from which our future patients will derive most of their information, and it will often conflict with our best evidence. It is up to us to educate our patients. We can only do that if we stay current ourselves.

Our evidence should come from peer-reviewed sources. A peer-reviewed journal is one where published articles were reviewed by experts in the same field as the author of the article.

A magazine columnist writing about science or health is typically not an expert in the field about which they are writing. And although their editor may be an expert grammarian, they too usually lack expertise in the fields of health and science.

There is no peer-review process where experts in the field can critique a magazine column before it is printed. This is why magazines get so many things about science and health wrong. Unfortunately, it is also why so many myths about health and science persist in the general population. Without a peer-review process, readers rely upon the expertise (or lack thereof) of the journalist writing the article.

Where can I find good evidence?

Some good online resources include:

Of course, knowing what to look for is important too. Bibliometrics is the statistical analysis of written publications and it is frequently used to score various publications according to their Impact Factor (IF). A journal’s IF is a good measure of how frequently it is cited, as well as how long those citations stay relevant in the field.

To find a journal’s IF you can use Thompsen Router’s Journal Citation Reports (JCR) tool. Your school library will likely have a way for you to search the JCR index. Also, many journals will publish their IF on their own website. A high quality journal will have a higher IF rating.

Dr. Mitchell urged us to avoid journals with an IF below 1.0. That said however, I should mention that although a journal’s IF may be low it can still contain articles with a high IF. If an article is cited frequently then it may still be worth exploring further.

Go forth and multiply!

I hope that this article has shined some light on the subject of Evidence-Based Dentistry. It is extremely important that we all do our part to practice EBD, and that we also hold each other to a high standard of excellence. To maintain the public trust we should do our best to stay current and work hard to ground our profession in peer-reviewed research.

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