by Lynne H. Slim RDH, BSDH, MSDH
In writing about evidence-based decision making (EBDM), my thoughts have turned to searching for the truth. When writing about periodontal therapy and prevention, truth is my bias and it's not an easy task. The literature doesn't always give us a conclusive answer, and it's sometimes hard to translate research to point of care in the hygiene operatory. Also, there are varying levels of evidence, and a good research sleuth will search for higher levels of evidence such as large, double-blind, randomized controlled clinical trials and systematic reviews of the literature. Here's a personal example of what I mean, and pardon me if I bore you with some personal details. (I promise I'll be brief.)
Now that I've joined the over 50 crowd, it means I've also joined the millions of women who suffer from varying degrees of estrogen and progesterone deficiency. It's not exactly a picnic and requires a positive mental outlook and a determination to soldier on in the face of intense hot flashes and night sweats. (I read somewhere that hot flashes have been described as our inner child playing with matches!) I have read books by Suzanne Somers and Diane Schwarzbein, MD, who urge women like me to take compounded bioidentical hormones to help balance our hormones. I decided to approach this issue in an evidence-based way, and concluded that there is a lack of scientific evidence to show that these preparations are safe. The American College of Obstetrics and Gynecology released a statement in 2005 questioning the safety and effectiveness of compounded bioidentical hormone therapy, so I've decided to err on the side of caution and only take a dietary supplement to manage menopausal symptoms.* 1
The Women's Health Initiative (WHI) Estrogen plus Progestin Study was ended prematurely in 2002 because of a clearly greater risk of invasive breast cancer, cardiovascular disease, blood clots, and strokes among women who were taking equine estrogens plus a synthetic progestin.2 After ruling out synthetic hormones, I decided to look closely at the research on bioidentical hormones and discovered that there isn't any. There is also strong epidemiological evidence from Europe (http://www.millionwomenstudy.org) that showed similar findings to the U.S. Women's Health Initiative. The researchers looked at the effect of different types of hormone replacement therapy on the health of over one million women in the U.K. and found that current users of hormone replacement therapy experienced an increased risk of fatal breast cancer. The risk of breast cancer was substantially greater for estrogen-progesterone combinations.
If you're someone like me who's always searching for answers, you're not alone. One of the presenters at the Third International Conference for Evidence-Based Dentistry at ADA Headquarters in Chicago in May 2008 was a periodontist from San Francisco named George K. Merijohn, DDS. I've now read several feature articles written by Dr. Merijohn in the Journal of Evidence-Based Dental Practice, and his Web site (http://www.merijohn.com) makes it transparently clear that he practices what he teaches in his articles. It's refreshing to visit a dental practice Web site that not only focuses on wellness, but describes a unique approach of combining an evidence-based treatment philosophy with a commitment to strong ethical principles. In communicating with Dr. Merijohn by e-mail, it is also clear that he is committed to improved health care outcomes by using clinical decision support (CDS) online and in his practice chairside. CDS is a new term in dental hygiene that we are still grappling with and attempting to apply in clinical practice settings. In a nutshell, CDS provides practitioners, staff, patients, and consumers with electronic and chairside guidelines and tools (like risk assessment, position papers, and computerized reminders and alerts) that enhance decision-making. For example, Dr. Merijohn offers prospective patients who visit his Web site an opportunity to use a self-assessment tool called "My Gum Risk Analyzer™" which is designed to help patients better understand and participate in decision-making about gingival recession (CAL) and inflammation.
Dr. Merijohn understands something that most practitioners often forget: practitioner-patient relationships are an important key to dental practice success and patients need assurance that the practitioner will act in the patient's best interest. If a patient can participate in decision-making about a given procedure, it's a win-win all around. How does Dr. Merijohn accomplish this objective with his "Gum Risk Analyzer™"? In the Gum Risk Analyzer™, the participant answers a series of questions in six simple steps. What I especially liked about this risk assessment tool were the photos that showed varying degrees of mucogingival involvement. The risk assessment tool identifies local, lifestyle, and general health risk factors for mucogingival defects and gingival inflammation, and scores the participant's risk from low to medium to high risk.
Dr. Merijohn also utilizes newly developed chairside evidence-based CDS (EB-CDS) tools for topical fluoride, carious lesions, and attached gingiva to rapidly and effectively facilitate the clinical decision-making process.3 I have a copy of the Dental Chairside Guides™: Attached Gingiva tool that Dr. Merijohn developed. It's yet another example of his commitment to EB-CDS clinician tools, and the colorful, layered brochure is used by Dr. Merijohn and his staff when discussing the risks associated with a narrow band of attached gingiva. It is not yet commercially available, but the unabridged version is available in the tool reference article.4
The face of EBDM is changing rapidly, largely because dental and medical practitioners work in an increasingly more difficult information environment.5 Consumers are also driving the demand for more reliable information, and like practitioners, are frustrated with the information onslaught. One of the biggest areas of frustration for the average practitioner is how to rate information. Just whom do you trust to provide you with high quality, reliable information? SORT (which stands for Strength of Recommendation Taxonomy) is one way to "sort" through reams of information, and it was recently adopted by the Journal of Evidence-Based Dental Practice.6 It's a system that assigns a grade to evidence, and many major medical journals in the U.S. have adopted this system to simplify and improve health care decisions.
Dr. Merijohn has also written a number of articles about implementing EBDM in the private practice setting. In one, he writes about putting the patient first with compassion as our dominant management focus, and then goes on to discuss his personal journey with EBDM that forever changed his approach to periodontal therapy.7 He immersed himself in online resources such as the Cochrane Collaboration and PubMed literature searching tutorials, and he attended international EBDM conferences. As a result, he feels more confident in his clinical decision making and shares his knowledge and passion with a local study club that focuses on EBDM. He also emphasizes the expectations of today's dental consumers, especially the baby boomer and millennial marketplaces. These consumer savvy folks expect a high-end service, and they can easily check your knowledge base with a click of the mouse. Join Dr. Merijohn and the rest of us who accept the challenge of higher order thinking skills. The answers may not always be found in the scientific literature, but strong evidence, if available, will guide your treatment recommendations and product/equipment decision-making, and most important, keep your patients safe.
About the Author
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 periotherapist yahoo group www.yahoogroups.com/group/periotherapist. In addition, Lynne is the editor of the Sunstar Americas e-newsletter "The GUMline." Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at [email protected] or www.periocdent.com.
*Note: This is a personal decision and is not meant to influence any of you who are struggling with this particular problem. It's important to consult with your physician to determine what's right for you.
3. http://www.ada.org/prof/resources/ebd/conferences_champion.asp#presentations (accessed 8-11-08).
4. Merijohn GK. The evidence-based clinical decision support guide: mucogingival/esthetics making clinical decisions in the absence of strong evidence. J Evid Base Dent Pract. 2007 Sep;7(3):93-101.
5. Newman JG. Clinical decision support complements evidence-based decision making in dental practice. J Evid Base Dent Practice 2007; 7: 1-5.
6. Newman MG, Weyant R, Hujoel P. JEBDP improves grading system and adopts strength of recommendation taxonomy grading (SORT) for guidelines and systematic reviews; J Evid Base Dent Pract 2007; 7: 147-150.
7. Merijohn GK. Implementing evidence-based decision making in the private practice setting. Why do it? J Evid Base Dent Pract 2006; 6: 206-8.