I appreciated the January JADA article by Drs. Amid Ismail and James Bader, "Evidence-Based Dentistry in Clinical Practice," because we are all often frustrated when we try a new product that we have read about or heard about, and we do not get the results we expected. As health care professionals, it is important that we have ready access to good, reliable and independent studies on the many techniques and products we use every day.
However, I am concerned that getting completely on the medical bandwagon for an "evidence-based approach," with an emphasis on randomized and double-blind studies, has some significant pitfalls for dentistry.
Not everything can be evaluated by that approach. That is because dentistry is still, and always will be, an art as well as a science. Dentistry has fundamental principles that must be applied, just like surgical medicine. In dentistry and surgical medicine, there is no doubt that one of the most significant variables is the skill of the clinician with regard to his or her ability to execute the technical procedures.
Surgical medicine and dentistry are very different from internal medicine. We understand that one can easily construct randomized, blinded and controlled studies for a new pharmaceutical agent. Medical researchers can take a randomized patient population, give coded pills or injections to blinded patients, and then statistically analyze their response. We understand that there is always a placebo factor in every medical and dental encounter, and it is essential to understand where the effect of the relationship between the practitioner and patient ends, and the effect of the treatment begins and ends.
However, in medicine they do not pretend to do double-blind studies for surgical procedures, simply because surgeons cannot be blinded from what they are doing. In surgery, various procedures are tried and outcomes compared, but the ultimate judge is the response of the patient.
When a surgical procedure is based on sound biology and has been proven to stand the test of time and have merit, the procedure should be performed and included in the protocols, and thus it becomes a standard of care.
The authors select occlusal treatment as an example of a procedure that has been applied without "evidence-based protocols" to prove that it is safe and effective. To prove their point, the authors quote an article by Forssell and colleagues,1 a literature review of studies on the effectiveness of occlusal treatment on temporomandibular dysfunction, or TMD. The authors state that the studies do not prove that there is a direct relationship between bite treatment and TMD.
Below is part of the conclusion from the Forssell and colleagues article1 (the italics are mine):
The overall quality of the trials was fairly low, the mean quality score was 0.43/1.00 (range 0.12–0.78). The most obvious methodological shortcomings were inadequate blinding, small sample sizes, short follow-up times, great diversity of outcome measures and numerous control treatments, some of unknown effectiveness. Splint therapy was found superior to 3, and comparable to 12 control treatments, and superior or comparable to 4 passive controls, respectively. Occlusal adjustment was found comparable to 2 and inferior to one control treatment and comparable to passive control in one study. Because of the methodological problems, only suggestive conclusions can be drawn. The use of occlusal splints may be of some benefit in the treatment of TMD. Evidence for the use of occlusal adjustment is lacking. There is an obvious need for well designed controlled studies to analyze the current clinical practices.
The fact that the writers could not solve bite problems is only proof of the lack of standards in the studies. The reality is that there is a 75-year history of dentists researching, documenting and providing this type of treatment for their patients.
Thousands of articles have been published and hundreds of textbooks written by such noted and dedicated dental practitioners and researchers as Peter Dawson, Parker Mahan, L.D. Pankey, Peter Neff, Charles Stuart, Bob Lee, Clyde Schyler and on and on. Tens of thousands of dentists who have studied with these leaders provide appropriate and effective bite treatment for their patients that does succeed in relieving head, neck and facial pain.
The authors ignore that entire body of literature and history of patient success, and instead focus on a weak attempt to fit occlusal treatment into the same category of treatment as giving some patients antibiotics and others sugar pills to see what happens.
The only valid evidence-based conclusion that Drs. Ismail, Bader and Forssell can possibly draw is that the studies mentioned were completely void of any standards and are therefore worthless. There is no valid evidence—just a set of studies in which the exact criteria are not clear and the evidence procedures are nonexistent.
The problem is that these supposedly evidence-based studies do not account for the ability and/or any prejudice of the operator. Constructing a bite splint and adjusting the bite or equilibrating teeth is not a standardized, off-the-shelf process, like a bottle of pills that can be randomized and blinded. I do not think that anyone would argue that these two services require a very high level of technical skill. In addition, unless the exact end point is reached, the results are not conclusive.
If you examine the backgrounds of the authors of studies that do not validate the effectiveness of bite splints and occlusal equilibration, are they practitioners who have a history of continuing education and clinical success with bite treatment? If they do not, and if one is truly interested in an evidence-based approach, you would have to throw out the entire study based on the questionable ability of the operators to, in fact, achieve the required end point that they are professing to study.
I am all in favor of many aspects of evidence-based dentistry, but I am not in favor of using it as a veil to attack dental treatment that has been proven over 75 years by thousands of dentists on tens of thousands of patients.
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