what do we want to know?

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EVIDENCE-BASED ORTHODONTICS What do we want to know? Greg J. Huang Seattle, Wash T he American Dental Association (ADA) re- cently released its 2005 Research Agenda, 1 which lists over 70 topics that have been deemed “Research of Importance to the Practicing Dentist.” The mission statement for the document reads as follows: “A major objective of the Association is to promote a good quality of life by improving the oral health care of the public and encouraging optimal health behaviors. To achieve this objective, it is imper- ative that the Association take a leading role in pro- moting, conducting, and critically reviewing research on topics related to dentistry and its relationship to the overall health of the individual. The Association should serve as a facilitator of the national dental research effort, help determine the priority of topics for research and ensure the timely dissemination of information to the profession.” I was impressed by this mission statement because it articulates the leadership role that the ADA has assumed with regard to all aspects of science in dentistry. There is sometimes a disconnect between the science and the practice of dentistry, and the ADA should be commended for attempting to integrate them. It is not an easy task, because many dentists rely heavily on the opinions derived from their practices (experience-based) and espoused by recognized experts (eminence-based) to assist them in their treatment decisions. Often, the literature is simply overlooked. It takes courage for the ADA to list some of these issues because, in a sense, it is an admission that the profession has less than perfect knowledge. For in- stance, “identification of appropriate and inappropriate drug regimens and indications for antibiotic prophy- laxis” was listed as an urgent area for investigation. When I was a dental student (almost 20 years ago), my instructors insisted that we follow the antibiotic pro- phylaxis guidelines as if they were written in stone. I have subsequently learned that this is not the case; the guidelines have evolved over the years. A recent Cochrane Collaboration review 2 suggests that we have very little good evidence to premedicate at all. This was quite a shock to me, because it is contrary to what I was taught and have practiced. Thus, it seems appropriate that the ADA is calling for immediate research on this topic. Medicine has sometimes had complete reversals in techniques and approaches, and dentistry is not immune to major upheavals. The antibiotic prophylaxis issue is interesting from another standpoint—we have guidelines from the American Heart Association for managing dental pa- tients. Most of us are happy to have these guidelines because they help us provide what is thought to be the most current and appropriate care for these patients. Although dentists are happy to have these guidelines for the important issue of antibiotic prophylaxis, they often do not welcome guidelines for other areas of their practices. It is thought that practice guidelines might negatively affect a health care provider’s treatment options or be used by insurance companies to limit coverage. These are both valid points, but I have always been puzzled that the intended benefits of guidelines— current and appropriate care—are often ignored. The National Guideline Clearinghouse, 3 a comprehensive database of evidence-based clinical practice guidelines and related documents, already houses thousands of guidelines on all aspects of medical care on its website, including over 100 dental guidelines. In the ADA’s mission statement above, the ADA has acknowledged that the dissemination of information is a critical element to successfully integrating research into prac- tice, and guidelines might assist with this effort. The ADA has also emphasized its role as a facili- tator in the national dental research effort. Recently, the National Institutes of Health has funded 3 centers to develop practice-based research networks in general dentistry. 4 Over the next 7 years, these networks will attempt to accomplish goals very similar to those described in the mission statement. The networks will recruit practicing general dentists to help develop questions of importance to general dentistry. These same dentists will receive training on research methods and then participate in research networks to answer the questions they have developed. This new model for Assistant professor, Department of Orthodontics, University of Washington, Seattle. Reprint requests to: Dr Greg J. Huang, Department of Orthodontics, University of Washington, HSC Box 357446, Seattle, WA 98195; e-mail, ghuang@ u.washington.edu. Am J Orthod Dentofacial Orthop 2005;127:648-9 0889-5406/$30.00 Copyright © 2005 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2005.04.018 648

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Page 1: What do we want to know?

EVIDENCE-BASED ORTHODONTICS

What do we want to know?Greg J. Huang

Seattle, Wash

The American Dental Association (ADA) re-cently released its 2005 Research Agenda,1

which lists over 70 topics that have beendeemed “Research of Importance to the PracticingDentist.” The mission statement for the document readsas follows: “A major objective of the Association is topromote a good quality of life by improving the oralhealth care of the public and encouraging optimalhealth behaviors. To achieve this objective, it is imper-ative that the Association take a leading role in pro-moting, conducting, and critically reviewing researchon topics related to dentistry and its relationship to theoverall health of the individual. The Association shouldserve as a facilitator of the national dental researcheffort, help determine the priority of topics for researchand ensure the timely dissemination of information tothe profession.”

I was impressed by this mission statement becauseit articulates the leadership role that the ADA hasassumed with regard to all aspects of science indentistry. There is sometimes a disconnect between thescience and the practice of dentistry, and the ADAshould be commended for attempting to integrate them.It is not an easy task, because many dentists relyheavily on the opinions derived from their practices(experience-based) and espoused by recognized experts(eminence-based) to assist them in their treatmentdecisions. Often, the literature is simply overlooked.

It takes courage for the ADA to list some of theseissues because, in a sense, it is an admission that theprofession has less than perfect knowledge. For in-stance, “identification of appropriate and inappropriatedrug regimens and indications for antibiotic prophy-laxis” was listed as an urgent area for investigation.When I was a dental student (almost 20 years ago), myinstructors insisted that we follow the antibiotic pro-phylaxis guidelines as if they were written in stone. Ihave subsequently learned that this is not the case; the

Assistant professor, Department of Orthodontics, University of Washington,Seattle.Reprint requests to: Dr Greg J. Huang, Department of Orthodontics, Universityof Washington, HSC Box 357446, Seattle, WA 98195; e-mail, [email protected] J Orthod Dentofacial Orthop 2005;127:648-90889-5406/$30.00Copyright © 2005 by the American Association of Orthodontists.

doi:10.1016/j.ajodo.2005.04.018

648

guidelines have evolved over the years. A recentCochrane Collaboration review2 suggests that we havevery little good evidence to premedicate at all. This wasquite a shock to me, because it is contrary to what I wastaught and have practiced. Thus, it seems appropriatethat the ADA is calling for immediate research on thistopic. Medicine has sometimes had complete reversalsin techniques and approaches, and dentistry is notimmune to major upheavals.

The antibiotic prophylaxis issue is interesting fromanother standpoint—we have guidelines from theAmerican Heart Association for managing dental pa-tients. Most of us are happy to have these guidelinesbecause they help us provide what is thought to be themost current and appropriate care for these patients.Although dentists are happy to have these guidelinesfor the important issue of antibiotic prophylaxis, theyoften do not welcome guidelines for other areas of theirpractices. It is thought that practice guidelines mightnegatively affect a health care provider’s treatmentoptions or be used by insurance companies to limitcoverage. These are both valid points, but I have alwaysbeen puzzled that the intended benefits of guidelines—current and appropriate care—are often ignored. TheNational Guideline Clearinghouse,3 a comprehensivedatabase of evidence-based clinical practice guidelinesand related documents, already houses thousands ofguidelines on all aspects of medical care on its website,including over 100 dental guidelines. In the ADA’smission statement above, the ADA has acknowledgedthat the dissemination of information is a criticalelement to successfully integrating research into prac-tice, and guidelines might assist with this effort.

The ADA has also emphasized its role as a facili-tator in the national dental research effort. Recently, theNational Institutes of Health has funded 3 centers todevelop practice-based research networks in generaldentistry.4 Over the next 7 years, these networks willattempt to accomplish goals very similar to thosedescribed in the mission statement. The networks willrecruit practicing general dentists to help developquestions of importance to general dentistry. Thesesame dentists will receive training on research methodsand then participate in research networks to answer the

questions they have developed. This new model for
Page 2: What do we want to know?

American Journal of Orthodontics and Dentofacial OrthopedicsVolume 127, Number 6

Huang 649

dental research offers many advantages. For instance,many practicing dentists are skeptical of universityresearch. In this model, dentists will actually be theinvestigators. Thus, they have ownership of both thequestions asked and the subsequent results. Anotheradvantage is that the answers from this research modelshould be more generalizable to larger populations ofdentists, because the studies will not be conducted byonly 1 investigator at 1 site. The networks will alsoenable the recruitment of more subjects, and this can beof great value when conditions or outcomes are rare.The ADA should monitor these new networks closely,because they can provide a tremendous opportunity forconducting future dental research.

The ADA mentioned assisting with the criticalevaluation of literature. This is an essential step, toidentify areas that have good scientific support andthose that need more research, and has often been mostclosely linked with evidence-based practice. However,an evidence-based approach truly relies on all of thesteps that the ADA mentioned in its mission statement.It is a circle of science, which consists of identifyingquestions, conducting research, critically evaluating thefindings, disseminating information, and then identify-

ing new questions.

The ADA is poised to lead general dentistry into theevidence-based era, and the dental specialties canbenefit from its model. What do we want to know inorthodontics? Let’s survey our members and ask whatthey believe the important questions are. Then, let’s becreative in finding ways to fund the research andanswer these questions. Let’s conduct well-designedstudies, possibly with the practice network model, andthen systematically review the results to obtain theevidence-based answers. Let’s disseminate this infor-mation to all orthodontists and then let’s ask themagain—what do you want to know?

REFERENCES

1. 2005 ADA Research Agenda. http://www.ada.org/prof/resources/positions/research.asp#research. Accessed April 28, 2005.

2. Oliver R, Roberts GJ, Hooper L. Penicillins for the prophylaxis ofbacterial endocarditis in dentistry. The Cochrane Database ofSystematic Reviews 2004; issue 2: art. no. CD003813. pub 2.

3. National Guideline Clearinghouse. Available at http://www.guideline.gov/. Accessed April 28, 2005.

4. NIDCR Awards Grants for New Practice-Based Initia-tive. Available at: http://www.nidcr.nih.gov/NewsAndReports/NewsReleases/NewRelease033/2005.htm. Accessed April 28,

2005.