Never settle about evidence: Search for high-quality dental research to support clinical objectives

By Lynne Slim, RDH, BSDH, MSDH

An Atlanta suburb is my hometown. I love living in the Southeast. I also cherish my job as a dental hygiene clinician, and I dedicate three days a week to my patients in a Kennesaw, Georgia, general dental practice. The dental team is committed to providing compassionate, affordable care in a relaxed setting.

Like most clinicians, my relationship with my patients is based on trust. I put my patients' welfare above my own self-interests. Recently, I greeted a patient who presented with severe emotional pain; he was grieving the loss of his beloved adult son, who was shot in the face and killed by a complete stranger. At the time, I was healing from intense emotional pain in my life, and I felt my patient's pain in a way that only someone who has also known the depths of despair can understand. As this particular father struggled with the loss of his son, he found a way to honor his son's life in a compassionate way that shows deep, loving concern for others. In other words, he chose to carry the universe instead of being crushed by it.

How did my grieving patient find a way out of his all-consuming, black hole of grief? For starters, he created a university endowment fund at his son's alma mater, and he hosted a series of fundraising events. I surprised him during one of his recare visits by donating money toward the endowment. The very next week, he presented me with an inspirational rubber wristband that read, "Never settle."

Those words, "Never settle," have a special significance for our profession, and it is part of the glue that holds us together when our professional integrity is threatened, especially when we're feeling disheartened about a professional issue or about some aspect of our career that has changed.

I credit the late Eminent Professor Michele L. Darby, RDH, MS, for inspiring me to pay this message forward and to share some of her advice to the dental hygiene profession about advocating for autonomy and expertise in dental practice.

In the April 2013 RDH magazine column that I dedicated to Professor Darby, she reminded us that midlevel providers such as nurses, physician's assistants, and dental hygienists are positioning themselves to solidify our place in cost containment and quality improvement.¹ Playing a major role in the delivery of care, especially as health care continues its reform under the Affordable Care Act, our profession will continue to evolve.

High-value care delivery is becoming more important, and consumers and commercial insurance service plan companies are seeking value for their spending.^1,2 On the public health front, public programs such as Medicaid and CHIP are likely to continue driving an increased demand for accountability and health outcomes, especially with their growing emphasis on cost-savings.²

Evidence for solving challenges

• Zoe is an RN who is in charge of a medical-surgical unit in a midsize acute care facility in Arizona. An 85-year-old patient with cancer and dementia died from asphyxiation when her head became trapped between the side rails and mattress on her bed. Zoe now wonders if the rail position was correct and questions if it should have been placed in the up position on her patient's bed, but the standard procedure was what was taught to nurses in school for many years.

• Tina is an RDH whose mother lives in the memory care section of an assisted living home. Her mother has type 2 diabetes, and her periodontium is quite inflamed in spite of specific caregiver instructions to improve oral hygiene, including chlorhexidine gluconate oral rinse (0.12%). In addition, her HbA1c is creeping up from 7.0 to over 8.5. Her overall physical inactivity combined with poor nutrition has resulted in lethargy and bouts of major depression, which is prevalent among individuals with diabetes. Her mother's dentist and hygienist recommended SRP X 4 at her last recare. Tina is consulting with a colleague who has expertise in dental hygiene procedures for seniors with cognitive disabilities (before scheduling SRP), but she is also considering something the dentist suggested about A1c improvement from nonsurgical periodontal treatment. Tina decides to review the literature about improved glycemic control following SRP as a research project for her degree research methodology class at Old Dominion University.

Incorporating new scientific evidence

Evidence-based practice is the new kid on the block in dentistry and dental hygiene. But the biggest punch has been in medicine. It's a critical component of health care, making evidence-based nursing and medical practice a growth industry for almost 20 years.³ In 1992, the medical community announced the emergence of "a new paradigm for medical practice."

Included in the new paradigm was a combination of systematic reviews and meta-analysis to ensure that medical education and therapy were as effective as possible.⁴ In simple terms, a systematic review (SR) is designed to answer a defined research question by collecting and summarizing all empirical (verifiable) evidence that fits very specific criteria. A meta-analysis (MA) is the use of statistical methods to summarize the results of these studies.

Single studies are not very reliable, and it's important to reserve judgment about a study until you have sought out experts to help assess the findings of the study and their importance. A revolutionary, life-altering study today may turn out to be insignificant tomorrow, because studies are fraught with errors. Sometimes the people interpreting data from studies are not objective and skilled in this area.

In addition, it's important to recognize that what's factual today may be obsolete tomorrow, as new scientific knowledge grows by a factor of 10 every 50 years! Facts you learned in school may have been overturned and are now out of date.

Outdated clinical practice

Learning how to find the appropriate evidence on which to base a practice isn't easy, but the medical community doesn't have a monopoly on its application in health care. Dental hygienists are very capable of "moving the cheese" and developing practice models based not on tradition, intuition, and experience, but on a more scholarly approach to clinical decision-making that includes reviewing relevant research.

When I was a student at Fones School of Dental Hygiene, University of Bridgeport, I taught my clinical patients how to floss and brush, and there were no interdental devices other than wood sticks. We taught patients how to brush by demonstrating the modified Bass technique (after they were disclosed with red disclosing solution). There were no powered toothbrushes. Since then, high-quality research has shown that interdental brushes not only remove more plaque/biofilm than brushing alone, but some studies even show a positive, significant difference in the plaque/biofilm index when using interdental brushes compared with floss.³ When comparing manual toothbrushes to some powered toothbrushes, powered toothbrushes reduce plaque and gingivitis more than manual toothbrushing, short and long term.⁴

In order to explain why this approach to the delivery of care is important, I'm going to give a couple of hypothetical examples (see sidebar) and explain how an astute and dedicated clinician would seek new information. One example is in nursing and the other one is in dental hygiene. Always remain humble while seeking new information, and combine your efforts with a healthy dose of skepticism! Remember that knowledge bases have a half-life and are changing constantly. In addition, chat with experts who have experience in this area and always consider the patient's needs and preferences in order to maximize benefit and minimize harm.

It is very important for someone who is beginning to understand research to learn the difference between primary and secondary sources. Here's a good explanation of the difference between the two sources: guides.purduecal.edu/nur390_primary_secondary.

Reading between the lines

Evidence-based practice isn't just about research. Experience and real-life observation count and can be woven into the mix, if the goal is to improve the patient's overall health. For example, even though many of the perio/systemic links are not cause/effect, the common thread that ties them tightly together may be genetic, lifestyle, and/or behavioral factors. For example, how many times do we experience grossly obese patients who have bad habits such a drinking cola beverages all day long and who also have impaired fasting glucose with an increased risk of diabetes and associated macrovascular and microvascular complications?

"Best research evidence" is never sufficient to make a clinical decision. Dental hygienists always trade benefits and risks, inconvenience, and costs associated with alternative management strategies, and in doing so we consider the patient's values and preferences.⁶ Here's another example. In a meta-analysis of 70 clinical trials on the effectiveness of fluoride dentifrice versus placebo for the prevention of dental caries in children, the use of fluoride dentifrices has a caries-inhibiting effect on permanent dentition that averages (DMF surfaces) 24%.⁷

There is also some evidence, however, that the use of a fluoridated dentifrice by children under the age of one may be associated with an increased risk of developing fluorosis, with stronger evidence supporting the development of fluorosis in children under five to six years of age when using a 1,000 ppm fluoride toothpaste.⁷ Many parents of young children are now being told not to use a fluoride dentifrice by their pediatricians for fear of developing "white spot" lesions.

Collecting evidence

Learning how to search for "best" or strongest evidence is a learned skill. Systematic reviews (SRs) are quickly surpassing literature reviews as the preferred method of summarizing and synthesizing the appropriate research evidence.⁷ The main advantage of using a systematic review is a reduction in bias because a strict protocol is followed by the authors; however, they are no panaceas and SRs vary in quality.⁸ It's a great start, however, when researching a topic or asking a good question.

Literature searches are shaped by the question you ask, and many health-care professionals learn search strategies to ensure the best information or treatment is provided.⁸ It's not just about "Googling" information. Instead, it's all about understanding how to find the best information (strongest evidence available) by using a smart search strategy.

In addition to systematic reviews, clinical practice guidelines are a reliable source of evidence. Typically developed by government agencies such as the Food and Drug Administration, or professional organizations such as the American Dental Association, they are based on a comprehensive analysis of the evidence on a given topic.

Expert panels are gathered together to develop a clinical question to be answered, followed by inclusion/exclusion criteria, a comprehensive literature search, data analysis, and critical appraisal followed by clinical recommendations. A good example of an ADA clinical practice guideline on nonsurgical treatment of chronic periodontitis can be read online at ebd.ada.org/en/evidence/guidelines/.

We can learn so much from the nursing profession about best research evidence as it relates to the effectiveness and safety of dental hygiene interventions. Development of evidence-based practice in nursing/medicine began about 15 years ago and was fueled by the increasing public and professional demand for accountability in safety and quality improvement in services delivered. Our profession is woefully behind, as is leadership in this area. With all the advances in information technology and the daily onslaught of news media reports about research findings, patients enter operatories armed with "facts" they have discovered online, and they want answers to their questions.

Professor Darby, who is gone but not forgotten, wrote these words, which appeared in my 2013 column about her: "As our profession continues to mature and as the cost of care continues to climb, midlevel providers like nurses, physician assistants, and dental hygienists can seize the moment to solidify our place in cost containment and quality improvement."

We cannot reach the top rung of the professional ladder unless we adopt evidence-based dental hygiene. I feel pretty strongly that we're well on our way. Encourage ADHA to dedicate resources to a portion of their website and create a Center for EBDH Learning. Let's continue to lift our profession to new heights and remember to "Never settle."

Acknowledgement: Gail B. Stoops, RDH, BS, and Philips Oral Health Care for an educational grant to support this manuscript.RDH

LYNNE SLIM, RDH, BSDH, MSDH, is an award-winning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the Evidence-Based Dental Hygiene Group (EBDH) on LinkedIn. Evidence-based periodontal therapy will be part of the group's focus, and Lynne enjoys mentoring dental hygienists in EBDH. She can be reached at [email protected] or www.periocdent.com.