Dr. Robinson presents very interesting concepts regarding the reporting of systematic reviews and, more specifically, the reporting of power toothbrush efficacy. The first issue centers on the application of statistics instead of the scientific method, while the second issues raises the question of manual dexterity as an unmeasured covariable in the reported studies.
By way of historical background, Sir Francis Bacon’s scientific method, as modified by Sir William Osler for medicine, was adapted by clinical epidemiologists and termed "evidence-based medicine" or "evidence-based health care."1,2 Evidence-based dentistry is defined as the integration for clinical decision making of 1) the best clinical evidence, 2) clinical expertise and 3) a patient’s values and needs.1,3 Thus, the results of the power toothbrush study represent only one-third of the three parts that require integration for appropriate clinical decision making.
Statistics are one subset of the evidence-based health care process and serve two purposes. First, statistics distill a wealth of information, to identify the overall results. In this case, they distill the results of some 30 randomized controlled clinical trials. (The randomized controlled trial optimizes the probability that people with outstanding and poor manual dexterity are equally represented in the power and manual groups.)
Second, statistics tell us that, "all other things being equal," the oscillating rotating power toothbrush is more effective than a manual toothbrush.
It is important to note that this approach to data distillation is currently regarded as the international standard for reporting of clinical trials in both medicine and dentistry.4
Also, by way of background, I am well familiar with the issues of manual dexterity, having cataloged the mechanics of toothbrushing and flossing (placement, angle and movement in all parts of the mouth) and quantified training patients in its accomplishment. Successful training takes, on average, one hour per patient.5,6
Bringing the foregoing together, the observant clinician will know whether a patient does or does not have good manual dexterity. If a patient does not have good manual dexterity, then the benefit of a power toothbrush may exceed the results of the systematic review. The converse is also true. If a patient has outstanding manual dexterity, the benefit of a power toothbrush may be less than the systematic review. This extrapolation requires clinical expertise. Finally, a patient may or may not feel the need for or value the benefit of a power toothbrush, and this viewpoint needs to be considered.
In sum, the results of systematic reviews can be applied to individual patients, but this application requires clinical expertise and knowledge of the patient’s values and needs. Conversely, without the results from systematic reviews, clinical decision making is like a stool with two legs.
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