Evidence based dentistry or exclusive based dentistry?

Hello, and welcome!

I'm planning to blog here about dentistry, evidence, research, teaching, patient care and other stuff.  Hopefully it will be of interest to someone and if not, maybe just by getting some of this stuff down on e-paper it will be (at the very least) fun to feel like I'm sharing some of the amusing stuff and maybe it will stop me feeling so narked about some of it!

Please forgive any inaccuracies (and let me know about them), they are unintentional...

Let's just start with last week - well last week was a funny old week.

Evidence-wise, it began with a Sunday Times article on the Hall Technique (and mentioning the FiCTION Trial ) being picked up by several other papers (Daily Mail Deccan Herald and Topnewshealth).  The numerous inaccuracies were despite my best efforts to send information that was short, to the point (uninflammatory!) and accurate.  This is something we apparently just have to live with; there is no way of seeing these articles before they are actually out in the public domain.

But what does it matter?

Well, I think it does.

Take the Hall Technique (since I know it well!), and yes, since you ask, I probably am biased as I have researched it but I try to present the evidence with (as Ben Goldacre would put it) sunlight on it,  we are asking dentists to consider changing their practice and seal in decay.

Here are 2 perspectives:

The general public's point of view.  A look at the comments at the end of the Mail online article linked to above, shows the limited understanding people have of what is actually going on in their mouth when we're 'doing' dentistry.  Here's just one of these comments:

"Sealing in bacteria is a recipe for a health disaster! We already have root canal work doing the same thing - infection sealed in seeps bacteria into your blood stream and will attack the heart in particular! A decaying tooth is decaying because of bacteria - there is huge amounts of research indicating just how dangerous that can be!"

Yes, it's anecdote and I've picked it out particularly, but it is difficult for us to imagine we can suddenly jump into full blown Evidence Based Dentistry and expect our patients to have a deep and considered understanding of why we might consider changing our practice, especially with something we've been doing for a long, long time (I think it's around 150 years that we've been getting decay out of teeth one way or another before plugging the hole with something).

Taking the evidence into practice idea further and some of the barriers (this time from the profession's perspective) - I was given, today, a copy of an editorial from the American Association of Paediatric Dentistry by the CEO of the AAPD called "What Distinguishes the United States".  It follows on from a joint meeting in September between the AAPD  and the Royal College of Surgeons in Edinburgh.  By all accounts the meeting was a great success and there was much sharing of ideas.  But Dr John Rutkauskas says

"Yes, we know that bad British and Scottish teeth is a good joke, but it is not an unfounded stereotype"

(Just a cheap jibe and of no real consequence).  What is interesting is that he dismisses the idea of sealing caries into teeth saying:

"Can we imagine informing our parents that we are placing a crown over an untreated, decayed tooth...".

 In the AAPD society's journal a systematic review of partial caries removal in primary teeth expresses this perspective well, with the text:

"Since the maintenance of carious tissue beneath restorations after partial removal of demineralized dentin is still seen with caution and skepticism by most professionals, the objective of the present review was to discuss the rationale for the use of this technique as an alternative for the control of dentinal caries in primary teeth."

(Ribeiro CCC et al. Pediatr Dent 2012;34:39-41).  Ribeiro's conclusion will come as no surprise to cariologists and falls in line with a growing number of systematic reviews, all pointing in the same direction:

"The favorable outcomes of partial caries removal in a single session support the indication of this modality as a definitive alternative restorative treatment for the primary dentition."

As healthcare providers, we have a duty to see beyond our prejudices and consider the evidence and its relationship to our patients wishes (and in the case of children their ability to cope with different treatments).  So when 39% of children with Early Childhood Caries, who have had a general anaesthetic to have their dental treatment carried out, require further treatment within a year, (Pediatr Dent 2012;33(7):510-514), perhaps those authors' conclusions

"The R rate (39%) observed is consistent with earlier reports.  Novel approaches are needed to improve relapse prevention".

should resonate more strongly than they are likely to, if history is anything to go by...

PS I promise I will not blog about the Hall Technique incessantly!!!!