by Lory Laughter, RDH, BS
You cannot pick up a magazine without finding an ad that has before-and-after pictures touting the amazing abilities of some dietary supplement, slimming jeans, or fat burner. You can’t even glance at the tabloid rack in the supermarket without viewing images that suggest a scientific basis for their outlandish claims. If you buy their lines of bull, we could all be better looking, smarter, and richer. But have you noticed that every “before” picture has a subject devoid of makeup and decent-fitting clothes? Every single “after” picture shows the same person with a stylish haircut, expensive clothes, and professionally applied face paint. Furthermore, the “after” shots are obviously retouched.
Although impressive to the uneducated eye, these attempts to lure people into buying products and ideas are merely gimmicks. Such gimmicks are not based on scientific fact and are totally devoid of solid research. Yet, even as educated and intelligent professionals, we often fall prey to their influence. Each of us has sat in a continuing-education class that was more of a show-and-tell session, in which photo after photo of amazing patient transformations are paraded on the big screen. A few years ago, I listened as a well-known and respected periodontist claimed to have “changed lives and personalities” with his technique for connective tissue grafting and laser gingivectomy ... and part of me even bought it. When one brave audience member asked about clinical studies, the doctor replied that the proof was right in front of us.
I am not denying that cosmetic dentistry can enhance self-confidence or make a person appear more attractive, but when we are talking about oral health, there must be more research presented than flimsy before-and-after pictures. We are health-care providers, not beauty experts. It is not necessary to be cynical about every idea or technique presented to us, but it is essential to ask questions and demand appropriate answers.
Dental hygiene is a science-based profession. We may not often be portrayed as the brainy ones by television shows or comedy routines, but the truth remains that we are highly educated individuals who all passed a science-based curriculum. But all too often we merely accept theories based on who said it or on an impressive PowerPoint presentation. Maybe it has been years or even decades since we sat in college and learned about research. Perhaps it is just easy to accept things that are spoken by someone prestigious. Both are excuses for not finding answers for ourselves.
There are basic facts about viable research that we must remember. One is that any outcomes of a project or study should be easily duplicated by others using the same methods and materials. A claim of growing human teeth in a petri dish is only valid if it can be repeated. If you are the only one who can produce the desired and claimed outcome, it isn’t research - it’s magic.
I remember all the hype about cold fusion during the 1980s. First came the excitement over a couple of scientists actually creating and observing cold fusion. I wasn’t sure what cold fusion was or how it would affect my future, but I was certain it was huge. Shortly afterward, the disappointment was overwhelming when it was reported that no other scientists could duplicate cold fusion. In the scientific world, repetition is necessary for acceptance - a principle we need to keep in mind when looking for support for our own ideas or when testing the theories of others.
More than one company claims to have interproximal cleaning aids that remove more plaque, reduce bleeding, and/or create healthier gums. And most of these reputable companies will provide excellent research and studies that prove the attributes of their products. I have heard hygienists claim that only woven floss will remove plaque or that waxed floss is too “slick” to be effective. Yet an afternoon spent on PubMed© revealed an interesting fact - the most effective oral cleaning aids are those that are actually used by the patients. When used outside of professional supervision, patient preference appears to be the most reliable indicator of product effectiveness. As more choices become available, perhaps more people will actually take the time to perform daily interproximal cleaning. What a concept - give people what they like!
Recently I have been reading about household solutions and plant extracts being used as oral irrigants. Even some nutritional supplements in liquid form are gaining popularity as antimicrobial agents for oral use. Not wanting to be a cynic without cause, I have spent hours reading journals (past and present) and typing keywords into Google™, PubMed, and other online search engines. It concerns me that so many claims are made without any clinical studies. Too many dental health providers are recommending products and home-care regimes based on testimonials and empty claims. Where are the double-blind studies, let alone meta-analysis? Health-care professionals should demand a higher standard than a catchy Web site before using or recommending any product.
In many of my searches, the only predetermined criterion for accepting a claim about the effectiveness of household cleaning products as safe oral antimicrobials was more than one study or one author showing similar results using the products as an oral irrigant. Not even this flimsy test could be met. When I did find some published information on the topic, it turned out to be a tutorial or simply a review of similar antimicrobial studies. Many people accept these techniques based solely on the name of the promoter.
Another important point to consider when looking for answers is not all studies are equal. Ideally, all claims and theories should be backed up by meta-analysis. However, this process can be long, expensive, and not easily understood by the general population. It is also possible to have a good meta-analysis of badly designed studies. While a meta-analysis can compensate for certain variances in measurements or sample sizes, it is still important to seek some of the original studies. Detective studies should be required in dental hygiene programs.
Systematic reviews of the literature are often the standard in acceptable medical and dental research. I am the first to admit that finding and then reading through the mountains of published research is overwhelming. Deciding which studies are worth consideration is even more exhausting. Systematic reviews of the literature can be done by anyone, but I find it most useful when they are published by someone knowledgeable about the subject matter and experienced in finding the flaws of any given study. It is important to pay close attention to methods and results - don’t just skip directly to the conclusions. Conclusions can be slanted by the author’s carefully chosen words.
Reviews and tutorials are often opinions and only loosely based on scientific evidence. Opinions are important - I am not suggesting we ignore them completely - but it is imperative to determine how the opinion was reached and what role it plays in our delivery of health care. Similarly, our own clinical experience is important in determining how to best deliver care to our patients, but we cannot pass off the experiences of one office or clinician as viable research. Our clinical experiences are useful in evidence-based decision making, not publishable as scientific fact.
Anyone can write a book with outrageous claims. Almost anyone can find an audience when presenting easy answers to complex health questions. It is not only acceptable but trendy to follow the theory of the day. Unfortunately, the most outlandish theories often garner the largest following. As a profession, we must promote science and rely on scientific methods of research for our answers. Let’s enjoy the wonderful before-and-after photos, but demand to know the science behind the amazing results. We are a profession of thinkers not easily swayed by pretty pictures and big words.
Lory Laughter, RDH, BS, practices in Napa and Sonoma, Calif., in both general and periodontal offices. She is a partner of Dental IQ, a team committed to arranging quality continuing education opportunities for Northern California. Through her involvement with Dental Hygienists against Heart Disease and other organizations, she hopes to bring a total health concept to the dental practice. You may contact Lory at [email protected].