How big of a role will dental hygiene have in evidence-based dentistry?
by Cindy Quinn, RDH, BS
I want to share my epiphany from last year and, hopefully, force others from the molehills of mediocrity within dental hygiene practice. After 31 years in dentistry, I finally connected the dots. To advance professionally, hygienists need to focus on the mountains of opportunity that abound in the global practice of evidence-based decision making, not wait for the office to purchase the next technological wonder. We need to foster cooperative education among colleagues, which encourages professional growth and contribution, rather than wait for our dental practices to embrace change. Let me demonstrate my point.
Several months ago, I undertook a random survey to uncover the criteria that fellow dental hygienists used in selecting fluoride for the practice. I have summarized their responses into eight different statements:
- I use fluoride varnish because it is new.
- I use fluoride foam for four minutes because I learned it that way in school.
- I recommend a daily fluoride rinse and fluoride toothpaste when brushing.
- I ask the dentist to write a prescription for fluoride gel if the patient is cavity prone.
- I trust my rep's suggestion for the best fluoride.
- I choose the fluoride with the best taste.
- I choose the lowest-priced product.
- I give patients a quick, one-minute rinse while waiting for the dentist's exam.
Notice that no one used data to substantiate his or her decision, and no one explained his or her selection as the “most effective” in specific situations. Why?
Sometimes I think that many dental hygienists live their lives under a rock. They do not expose themselves to the wide variety of information in dental and dental hygiene journals regularly, and they rarely venture out on the slippery slope of debate. They often avoid rocking the boat in their dental practices. They cling to outdated knowledge or take promotional information as rock-solid facts. Historically, dental hygienists have had limited resources for objectivity outside of their initial professional education, except for anecdotal evidence or costly subscriptions to peer-reviewed dental journals and scientific literature. I contend that professional ignorance has actually limited the progress of this profession. I also believe that it has confused dental hygiene patients, as they compare preventive and periodontal services with neighbors and friends.
Having worked as a corporate manager and writer for the dental industry, as well as an educator, I feel like I have a broader overview of clinical care than those who have spent their careers in patient care. However, I never valued the potential of this profession until I attended the Third International Conference on Evidence-Based Dentistry at the ADA headquarters. It was titled, “Managing Dental Health in a Connected World,” and it focused on evidence-based dentistry and its related concept of Clinical Decision Support (CDS). For clarity, the ADA's policy statement defines evidence-based dentistry as an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical history, with the dentist's clinical expertise and the patient's treatment needs and preferences.
CDS is the mechanism for accessing credible, filtered knowledge to support clinical judgment during this era of information explosion. These data include new research findings and successful techniques performed in other countries across a variety of disciplines. On the surface, CDS looks like a rudimentary implementation project — automate and embed information into a searchable database. The emerging field of dental informatics, a subset of biomedical informatics, stands well positioned to handle that responsibility.
The motivation is there. It is logical to assume that data coordination would reduce the costs of care and medical errors, from which almost 100 people die daily. This database could probably reduce the length of time that it takes for research findings to merge into clinical practice, usually thought to take about 17 years. CDS could also reduce the redundancies and inefficiencies that frequently occur in health care. Yes, the motivation is there, but the challenge is also huge.
The ADA conference presented several obstacles that affect the implementation of CDS and, therefore, evidence-based decision making. These obstacles include:
- Academic advances in technology
- Coding differences between medicine and dentistry
- The ultimate definition of “enough evidence”
It is estimated that only 17 dental schools currently have electronic dental records in the United States. Few feature coursework in dental informatics, which currently requires extensive dental knowledge plus information technology expertise. Many schools have not yet introduced an evidence-based approach to clinical dentistry, so students graduate without sufficient knowledge of the resources available for effective clinical decision support.
The variability of procedures and dental semantics also presents a hurdle. The American Medical Association has designed and integrated a system for diagnostic codes, known as SNOMED. In contrast, the American Dental Association uses a system of procedure codes. Dr. James Leake, a dentist, clearly defined the value of diagnostic codes in his Journal of the Canadian Dental Association article titled, “Diagnostic Codes in Dentistry — Definition, Utility, and Developments to Date.” He described diagnostic codes as computer-readable descriptors of patients' conditions, consisting of a series of alpha characters or numbers, or a combination of both.
Dr. Leake further suggests the practicality for a programmed computer that could produce a summary of the diagnoses for the practitioner to review with the patient and give him or her to take home — a means of communicating diagnostic information accurately in terms the patient can understand. Diagnostic codes allow standardization that tracks clinical outcomes and monitors best practices when used to record services in the patient chart, prepare invoices, or bill third-party carriers.
To further complicate matters, different regions of the United States, as well as other countries, use different terms for diagnoses. For example, myocardial infarction, MI, and heart attack are used interchangeably. This presents problems with data tracking. Any deviations from standard terminology, including misspellings, are not recognized. To enable integration of appropriate data, the nomenclature must be consistent.
The ADA Board of Trustees has recommended a set of diagnostic codes for dentistry that has the acronym of SNODENT (www.SNODENT.org), a system for Systemized Nomenclature of Dentistry that mirrors its medical counterpart, SNOMED. SNODENT has been integrated into SNOMED-CT, but there is considerable work to be done before accurate analysis and quality can be expected.
Another obstacle pointed out in the conference encompasses the definition of “enough” evidence. The big question in debate is, “At what point is there adequate evidence by which to base clinical decision support?” Answers vary widely. Past examples concerning the health benefits of Phen-Fen or beta-carotene supplements stand as a stark reminder of misguided information that served as evidence for health-related decisions. What organization or agency in dentistry should shoulder the responsibility for these decisions?
Table 1 provides an overview of evidence-based dental organizations already in place, though an agreed-upon infrastructure does not exist.
Most professionals recognize the plethora of published information that is available which, in some ways, creates another obstacle. It is impossible to remain abreast of the dental complications related to various syndromes, deficiencies, and surgeries that fill the medical wards. Patti DiGangi, RDH, a continuing-education presenter, uses her medical history as a prime example in her courses. She looks healthy, thinks healthy, and behaves healthy! Yet her medical history lists 14 medications, Hashimoto's thyroiditis, and thyrotoxic myopathy. Does anyone know her risks for dental treatment off the top of their head? Hashimoto's is an immune system dysfunction in the same category as lupus. Now, what adjustments need to be made in her care? Using this example alone, Patti drives home the need for “an immediate, easily accessible method to get good evidence-based information.”
Due to the aforementioned obstacles, the pace of interest in evidence-based dental decision making in the United States has moved slower than a bag of rocks. At the conference, I met a handful of hygienists in a room of more than 300 professionals. I suspect that many practicing hygienists are not familiar with or do not even understand the procedures involved in evidence-based dentistry or CDS.
How can they understand their value in this process? Yet, it is a logical extension of their role as prevention and oral health education specialists.
How can hygienists play a role in advancing CDS? Think about it. Collectively, hygienists are capable of moving mountains, and I have several suggestions as to how to accomplish that:
• The Internet — When you have two hours, search for evidence-based dentistry (EBD), evidence-based education (EBE), evidence-based decision making (EBDM), or oral health systemic reviews. The computer will generate hundreds of entries, many of them peer reviewed, with one more interesting than the next. Hygienists will wish that they had set aside two days, rather than two hours. For an overview on searching, take the Boston University tutorial on EBD resources (www.medlib.bu.edu/tutorials/ebm). The online database called PubMed (www.pubmed.gov) is a service of the U.S. National Library of Medicine that provides citations from Medline and other life science journals, known for its unfiltered information.
The Internet also features topic groups. For example, Lynne Slim, RDH, hosts a Periodontal Therapy Group, at www.yahoogroups.com/group/periotherapist. This is a group for dental professionals interested in discussing evidence-based periodontal therapy and advanced dental hygiene practice, including laser therapy.
Lynne says, “Members of the group include dentists, dental hygienists, and periodontists, and we debate a variety of topics. The challenge with EBDM is that many dental practitioners have never studied research methodology and I believe that it affects their decision-making. My hope is that someday all dental and dental hygiene students will study research methodology and biostatistics so that we can all be on the same page.”
There are also listserves that represent a cohesive group of professionals who discuss a variety of interesting topics. You may discover other hygienists who share your passion for a specific subject.
• Relevant journals — The Journal of Evidence-based Dental Practice, published by Elsevier, presents “timely, original articles, as well as reviews of articles on the results and outcomes of clinical procedures and treatments.” The journal emphasizes objectivity (www.jebdp.com). Another journal, Evidence Based Dentistry, is published by the Nature Publishing Group (www.nature.com/bdj). It is an international journal that publishes peer-reviewed, scientific research papers and letters that are checked for accuracy prior to publication.
• Continuing education — Imagine the impact of a panel discussion between clinical researchers, dental school faculty, dental products manufacturers, and dental association representatives at scientific sessions. The integration of expertise from a wide array of dental backgrounds could create a tidal wave of innovation. Consider the benefits of “applied learning” continuing-education credit rather than the typical lecture format in most dental meetings. Dental professionals could receive credit for time spent researching a particular topic in electronic literature. For example, if a clinician could access information on Hashimoto's thyroiditis and receive credit for his or her search during downtime in the office, imagine the powerful online database that could be built if these efforts were aggregated! A CME tracking device already exists, with point-of-learning software, in medicine (www.eeds.com).
As a group, I suggest that hygienists make evidence-based dental topics a demanded topic for future continuing-education presentations. In my classrooms, I have certainly seen better retention of materials when students pose a question and are guided to an appropriate resource in which to find their answer.
• Coursework — The American Dental Education Association's Commission on Change and Innovation encourages dental students to develop and use critical thinking skills. However, it has been difficult for faculty to teach these skills and evaluate students' skills in didactic basic science courses. Recognizing the value of critical thinking, the ADEA and the Academy for Academic Leadership jointly sponsored a critical thinking toolkit (www.adea.org).
Similarly, Article D of the American Dental Association Accreditation Standard 2-17 for Dental Hygiene Education Programs states, “Graduates must be competent in providing the dental hygiene process of care which includes the provision of patient-centered treatment and evidence-based care in a manner minimizing risks and optimizing health.”
Hygienists should emphasize the need for electronic records and newer technology in the dental hygiene programs in their area. The mindset of formal education must begin to shift from the mentality of “handed information at CE” to “knowing where and how to find pertinent information.”
Finally, I suspect that several hygienists would love to learn dental informatics. Currently, the handful of programs that exist want a dental school graduate to continue with studies in information technology. Why should hygienists be restricted from this course of study?
• Working groups — Decidedly, there is power in numbers. In 2003 to 2004, the California Dental Association developed an Evidence-Based Dentistry Action Plan (www.cda.org) for implementation of this valuable resource. I suggest that each state dental association develop a page on their Web site that addresses resources available for further study. The Dental Practice-Based Research Network has several collaborative groups that conduct studies and tabulate data for products and procedures in dental offices (www.dentalpbrn.org).
• Books and e-textbooks for background information — At a minimum, dental hygienists should read the recently released book, “EBDM: A Translation Guide for Dental Professionals,” by Jane Forrest, RDH, EdD, et al., which provides a guide through the process and develops EBDM skills. Other sources of reading material include ACP Pier by the American College of Physicians, and Clinic Evidence by the British Medical Journal.
To quote an April 2008 article by Nilima and Vendana in the Journal of Clinical and Diagnostic Research, “Research evidence helps to decide which interventions are the most effective. It should not replace our clinical findings from history and examination, but harness our clinical intuition from years of experience and help us recognize gaps and uncertainties in our knowledge.”
Where could the harnessed power of dental hygiene take the profession, through the use of evidence-based decision making? Would you rather be kicking pebbles or climbing mountains to get a better view of patient care?
What are we waiting for? It is time for hygienists to join together with data that is solid as a rock. However, this is not a task for one person. Forming an online resource of aggregate information takes teamwork from the profession. That is my challenge to this profession. Embrace an organized approach to EBD rather than accepting anecdotal evidence.
If forward-thinking hygienists select an area of interest, follow the research, and then present their findings, this profession can slowly build a matrix of research to support the decisions concerning which fluoride to use, which gum to chew (if any), and the value of additives in toothpaste. Admittedly, there is some training involved because we need to build bridges rather than create rock slides. At present, I believe that evidence-based dental decision-making principles have been the best-kept secret in dental hygiene. It is time to roll the boulder from the pathway to objectivity.
Table 1 — Organizations
- Agency for Healthcare Research and Quality — www.ahrq.gov
- American Dental Association Web site for Evidence-based information — www.ada.org/prof/resources/ebd
- Centre for Evidence-based Dentistry, Oxford, England — www.cebd.org
- Cochrane Database of Systematic Reviews and Cochrane Controlled Clinical Trials Register — http://mrw.interscience.wiley.com)= answers a specific clinical question
- Cochrane Oral Health Group — www.ohg.cochrane.org
- DARE: Database of Abstracts of Reviews of Effectiveness — assesses systematic reviews from a variety of medical journals
- Forsyth Institute: Center for Evidence-based Dentistry — www.forsyth.org/research/centers/evidence