Guest Perspective: The Evidence-Based Dentistry (EBD) Imperative

Dr. Richard Niederman, Director, Center for Evidence-Based Dentistry, The Forsyth Institute

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Classically, evidence-based dentistry (EBD) is defined as the integration of the current best evidence with the practitioner’s clinical experience and the patient’s values and circumstances for the purpose of improving health. That formula makes sense in practice, but translating it to the educational arena poses challenges.

So we start with a changing evidence base, and we rely on the student’s evolving clinical expertise and understanding of human needs to integrate these three areas to improve health. EBD requires faculty to spend significantly more time learning how to find and evaluate the current best evidence, and teaching students howvaluate this information. In one sense, EBD directly addresses the individual responsibility we have as faculty—and that we promote to our students—of being lifelong learners. 

In our work at the Forsyth Institute Center for Evidence-Based Dentistry, we’ve found that clinicians routinely overestimate the extent and accuracy of their knowledge. One example comes from the most common preventive measure for caries: fluoride. There are eight different fluoride delivery systems. Depending on the choice, each system can reduce caries by 15 to 80%. On average, the clinicians we’ve surveyed estimate that they know six of the eight. However, we find that they only know two to three, and they have little or no knowledge of the fluoride systems’ effectiveness. 

In a broader context we know that caries, periodontal disease, and oral cancer are the most common and largely preventable oral maladies. Yet prevention is underutilized, and when these conditions are treated, treatment varies widely. These large variations in practice patterns appear to depend on the location where one was trained. Further, when current theories of education and behavior are implemented, practice patterns appear to be largely refractory to change.  

Here is another common clinical example of the distance between what we know and what we do (e.g., the underuse of pit and fissure sealants). Although some 50 years of data—and a number of guidelines and systematic reviews produced during the last several years—continue to demonstrate sealants’ effectiveness, less than 40% of dentists use sealants, but they have no hesitation in routinely providing fillings. This pairing highlights the overuse, underuse, and misuse of health care procedures articulated by the Institute of Medicine (IOM) in its 1999 report To Err is Human: Building a Safer Health System.  

While some schools are fortunate to have faculty members trained in EBD, most schools lack this expertise. To address the deficit, in 2009 the American Dental Association (ADA)   partnered with the Forsyth Institute to offer an annual one-week intensive course  in evidence-based dentistry for both clinicians and educators. Topics include asking precise, structured clinical questions; searching literature rapidly; critically appraising published human trials; and, to facilitate EBD implementation in practice and teaching, calculating both number needed to treat for intervention trials and likelihood ratio for diagnostic trials.

With more than 500 clinical trials published each year in each of the clinical specialties, it is critical that all faculty in all of our schools develop fluency in EBD and revise their curricula to convey this skill set to our students.  The scientific knowledge base will continue to grow, whether we access it or not. If we don’t make use of it, we will find ourselves embarrassed by our students and our patients. Said differently, EBD skills are a subset of the technological and social media landscape. Our ability or inability to use these skills enhances or hampers our ability and our credibility as learners and teachers. 

And finally, the Affordable Care Act (ACA) explicitly supports evidence-based care. And while controversy abounds about ACA implementation, the U.S. Supreme Court, in publications entirely separate from the ACA, also explicitly supports evidence-based care, as my colleagues and I discuss in a recent paper. Thus, in addition to the new Commission on Dental Accreditation (CODA) standard requiring that our students demonstrate competency in evidence-based care, there is also a legal imperative for faculty and schools to practice EBD and convey the methods for finding and implementing the current best evidence to our students. 

Looking ahead, and thinking about lifelong learning, evidence-based care is not an end in itself.  Our next step is implementation of evidence-based care that improves both the quality and value of the education and care we provide. The 2001 IOM report, Crossing the Quality Chasm: New Health System for the 21st Century defines quality as the integration of the evidence for safe and effective care with efficient, personalized, timely, and equitable care.  Some call this integration of evidence and quality to improve health “value-based” care. Evidence-based dentistry brings us closer to this ultimate objective.