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In this month’s letter, ADEA Executive Director Dr. Rick Valachovic explains why we need to get up-to-speed on evidence-based practice.

Dr. Richard Valachovic

Evidence-Based Dentistry: Time to Extend the Curve

Last December, I was contemplating how to approach this month’s topic when an email arrived from Dr. Phil Stashenko, President of The Forsyth Institute, with an interesting proposition. Would ADEA be interested in collaborating on the development of training programs in evidence-based dentistry for dental educators?

This opportunity couldn’t come at a better time. As we enter an era of increased accountability in health care delivery, evidence-based dentistry, or EBD for short, is becoming imperative. Before I explain why, let me clarify what is meant by evidence-based dentistry.

The term describes the practice of considering three distinct factors prior to treating patients: (1) the best available scientific evidence; (2) the clinician’s judgment based on past experience; and (3) the patient’s needs and preferences. Developing our students’ clinical judgment is and always has been intrinsic to the dental education enterprise. While we need to do more when it comes to teaching our students to appreciate their patients’ perspectives, the patient’s needs and preferences are largely beyond our control. This leaves finding and appraising the available scientific evidence, which is what most educators have in mind when they talk about teaching EBD.

Why has teaching EBD taken on so much urgency? To start with, the amount of available evidence on how best to care for our patients is growing faster than we can absorb it. Hundreds of clinical trials are published annually in dentistry alone, making it impossible to keep abreast of every new scientific finding. Traditional continuing dental education (CDE) courses, while valuable, cannot possibly keep practitioners up-to-date with all the new developments that might be relevant to their practices.

“When we have new knowledge generated daily, we need a better way to keep up,” says Dr. Rick Niederman, a leading guru on EBD. “We need a simple mechanism for self-renewal, self-education, and I think training in evidence-based dentistry provides people with that facility.”

Rick, who is Director of the Center for Evidence-Based Dentistry at The Forsyth Institute, codirects two highly respected courses in EBD. One is a collaboration between Forsyth and the Centre for Evidence-Based Dentistry in England, and the other is a collaboration with the ADA Center for Evidence-Based Dentistry™.

Despite their similar names, these are independent organizations. That said, they share a common purpose: to analyze and share evidence derived from the best scientific research and to equip practicing clinicians with the skills and knowledge they need to apply evidence-based practices in the field.

I called Rick last month to find out what inroads EBD is making in the dental practice and dental education communities. To start with, I wanted to get a sense of how many of us are currently practicing EBD.

“I think everybody believes that they practice evidence-based dentistry, and in a way, everybody does,” Rick told me. “The challenge, however, is how old that evidence is, and what is the level of that evidence? Is it evidence from 20 years ago based on a case report, or is it evidence from today based on a systematic review of 10 randomized controlled trials that include 10,000 people? That’s a big difference.”

As Rick pointed out, variations in dental treatment have been documented in several scientific journals, including the Journal of Dental Education (JDE), indicating that approaches to care are far from uniform. Why, for instance, are only 40% of dentists prescribing sealants when systematic reviews have demonstrated their high effectiveness?

“We don’t do what we could do,” Rick asserts, “because we’re not aware. There’s just too much information to keep up with. Evidence-based dentistry provides a mechanism for distilling out the good stuff.”

While dental educators seem well aware of the importance of EBD, many of our schools and programs are just beginning to integrate EBD in their curricula. This lag is hardly surprising since most faculty members are just now gaining experience in methodically providing evidence-based care. If you are among this majority, fear not. From what Rick tells me, most of us—not just those of us in dentistry, but all health professionals—are in this same boat. Referencing the so-called S-curve, which characterizes the diffusion of innovation, Rick gave me his impression of where the academic community stands in relation to EBD.

“In terms of acceptance, we are well along on the curve, but in terms of application, I would guess we haven’t even gotten to the S-curve.”

I suspect Rick’s impression applies to most places, but not everywhere. Some of our member institutions have made a strong commitment to teaching EBD and are sending their recent graduates into the field with well-honed EBD skills. Our community also boasts some innovative approaches to training established dentists to use EBD. The ADEA CCI Liaison Ledger profiled several of these efforts in two of its 2012 issues, and this month’s JDE has several articles devoted to this topic. With this foundation, I am optimistic that many more of us will be taking steps that will extend the S-curve by the end of 2013.

So what moved Rick to get out ahead of the curve?

“As a dental student, I always had the feeling that the clinical instruction was opinion-based. Consequently, treatment plans varied with each instructor’s philosophy of care. As a result, neither the patient’s needs and circumstances nor the evidence supporting the outcomes and costs of alternative interventions were routinely considered.”

In the 1990s, Rick joined the faculty at Harvard School of Dental Medicine, where he had another revelation that set the stage for his subsequent devotion to EBD. “I came upon a journal, Evidence-Based Medicine, and I thought, ‘Wow! This really makes sense. It translates science in a meaningful way from a clinician’s perspective.’”

Before long Rick booked a trip to England to take a course in evidence-based medicine at Oxford University. Once back at home, he immediately put the training to use as he set about developing a four-year curriculum in EBD at Harvard.

The American Association of Dental Schools, as we were known prior to 2000, gave Rick an award for his development of that curriculum, and the recognition proved a sign of things to come. Rick began collaborating with a colleague in the United Kingdom, Dr. Derek Richards, to develop the intensive EBD course for practitioners that Oxford still offers to this day, and together they cofounded the journal Evidence-Based Dentistry. They also wrote an EBD textbook, which Rick uses in the ADA/Forsyth course on EBD. This one-week intensive course is offered every fall in Cambridge, Massachusetts.

The course provides a wonderful opportunity for individual clinicians who want to become skilled in EBD. While dental educators are welcome and encouraged to take part, Rick and I agree that until a critical mass of faculty members are trained in EBD, it is unlikely to thrive in an academic context. To this end, I hope that we will find opportunities for ADEA to work with our colleagues at Forsyth and other academic dental institutions in moving this field forward. If you want to get a flavor of what can be done on your campus in the meantime, the ADEA CCI Liaison Ledger might be a good place to start.

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