How often do we ask ourselves why we still adhere to specific guidelines that we were taught many years ago?
Many articles in the dental literature propose treatment protocols based on findings from only a handful of participants, yet the "findings" in such articles are used to generalize treatment to all patients. Other protocols extrapolate data from medical texts and apply them to the practice of dentistry. We also use protocols that have been passed down through generations of dentists, without challenging their validity.
How often do we ask ourselves why we still adhere to specific guidelines that we were taught many years ago? A well-known and still-used recommendation is to wait six months after a patient’s myocardial infarction (MI) before providing dental care. The rationale behind this protocol is that these patients are at a very high risk of experiencing another acute coronary event within the next half year. This specific protocol is based on a study published almost 30 years ago. In that study, the authors attempted to determine the risk associated with major surgery for patients with impaired cardiovascular status.1
It is not clear, nor is it explained, how it is possible to compare the risk of adverse outcomes from surgery under general anesthesia for cardiac patients with routine outpatient dental care for the same types of patients. Furthermore, post-MI medical care and cardiac evaluation in 2006 differ greatly from those rendered in the 1970s. We know that for a patient with diabetes, the risk of experiencing an initial MI is the same as the risk of experiencing a second MI is for a patient without diabetes.
Thus, using the rationale for the "six months post-MI" protocol, we would have to wait six months to treat a patient with diabetes. It is almost as reasonable as asking what the difference is between an elephant. The erroneous belief that this is the safe protocol to be used in dentistry has prevented necessary dental care for a large cohort of patients. More recent data suggest that it might be safe to treat a patient who has had an MI after waiting only one month after the MI.2
Why do we practice the way we do, and who determines that what we do is the best way to do it? There may be several reasons for this dental-lore phenomenon, but some can be traced back to our dental education. For example, sometimes there was poor calibration between didactic and clinical instructors. Every faculty member on the clinical floor might have been reluctant to change a time-tested procedure based on new information taught in dental materials classes or selected/elective courses. Students may learn the scientific basis for a specific procedure but avoid implementing their newfound knowledge in order not to contradict the instructor. This deferential approach to learning is later reinforced on the continuing education circuit, where opinion leaders create a following of practitioners who are reluctant to challenge their "expert." Regrettably, there also are didactic and continuing education courses that are not changed or updated in a timely fashion.
Another pervasive problem is the lack of good quality courses for predoctoral and postdoctoral students and practitioners in evaluating and generating written materials. This is especially important for postgraduates, who are our future dental school instructors. Not all journals are created equal. Although the peer-review process is imperfect, it is an essential step in weeding out unsubstantiated and erroneous material. Regrettably, strict adherence to this practice is woefully lacking among many of the most-read dental magazines available today.
Other sources of information readily available to practitioners come from the World Wide Web, directly from manufacturers or from product newsletters. It is essential that readers, regardless of what they are reading, can clearly delineate the source of the material, determine the presence of any conflict of interest and assess the qualifications of the presenter of the material.
One of the proposed answers to dental-lore–based dentistry is evidence-based dentistry (EBD). At present, EBD can answer some, but not all, clinical questions. Unfortunately, too few authors are directly involved in preparing new evidence-based manuscripts, and researchers are not asking enough questions. Creating protocols that are evidence based is a slow and arduous process that requires intimate knowledge of a particular methodology that can answer clinically relevant questions. As soon as they are available, EBD guidelines need to be incorporated into our dental curricula. It is important to realize, however, that EBD guidelines will not tell the practitioner what to do. They are suggestions—not dictums on how to practice.
There are several good reasons to examine the dental literature routinely: to find solutions to specific patient-related problems, to review previously learned material, and perhaps simply to enjoy the pursuit of knowledge. Also, as with medical information, most up-to-date dental knowledge has a shelf life of no more than 10 to 15 years. This is understandable considering that, for the past 10 years, an average of 6,700 articles about dentistry and dental care have been published each year. This accounts only for articles in journals that are abstracted in the more common databases such as Medline and PubMed. Thus, even if a dentist has read one or two peer-reviewed journals every month since graduating from dental school five years ago, he or she still missed more than 33,000 articles written about and for dental professionals.
So how do we keep up with the most up-to-date, the most reliable and the most clinically relevant information? Concentrate on the most important questions that affect the way you practice dentistry. Search for the answers from reliable sources. Be selective and choose the most trusted and credible peer-reviewed journals to read. Challenge the conclusions of articles that you read, question the views of opinion leaders (both in journals and at continuing education courses), embrace newly emerging concepts and ideas, and adapt them to your own needs, skills, experience and patient population.
For our part, your JADA editors and staff are working to ensure that the information provided in your Journal is the best that dental science has to offer. We do not always succeed. We are fallible, but we never stop trying in the unending pursuit of excellence.
By the way, the difference between an elephant is that it can neither jump.
