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Putting the evidence first

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Page 1: Putting the evidence first

EDITORIAL

Putting the evidence firstDavid L. Turpin, Editor-in-Chief

Seattle, Wash

The most recent AAO House of Delegatesadopted an official definition of evidence-baseddentistry for the clinical practice of orthodon-

tics. “Evidence-based dentistry (EBD) is an approachto oral health care that requires the judicious integra-tion of systematic assessments of clinically relevantscientific evidence, relating to the patient’s oral andmedical condition and history, with the dentist’s clini-cal expertise and the patient’s treatment needs andpreferences.”1

This process integrates the best research evidence,clinical expertise, and the patient’s treatment needs—3critical components in evidence-based practice. Youcan determine the best treatment and have the ability tocomplete it, but, without patient acceptance, it doesn’tmatter. The situation is different when a patient agreesto have a procedure, but the evidence does not supportit. If the procedure is new or the research is incomplete,use of the best evidence might be the only option. Butwhat if several systematic reviews state that the proce-dure is unacceptable for correcting the problem andbetter alternatives are available? According to the rulesof evidence-based practice, you should tell the patient.

Mindful of this potential dilemma, the AAO Houseof Delegates charged the AAO and its Council onScientific Affairs (COSA) to identify systematic re-views and meta-analyses on various orthodontic topics.Summaries of the findings provide a wealth of infor-mation for the practicing orthodontist. When currentresearch data are insufficient, they will be identified forfuture funding.

The next time you examine an adult patient whoasks what can be done to “cure” snoring and problemsrelated to obstructive sleep apnea, you might want toknow more about this subject. The following is asummary of a Cochrane Collaboration review.

Sleep apnea is characterized by recurrent episodes ofpartial or complete upper airway obstruction duringsleep, leading to a variety of symptoms includingexcessive daytime sleepiness. The current first choicetherapy is continuous positive airway pressure that

Am J Orthod Dentofacial Orthop 2005;128:4150889-5406/$30.00Copyright © 2005 by the American Association of Orthodontists.

doi:10.1016/j.ajodo.2005.08.028

keeps the upper airway patent during sleep. However,this treatment can be difficult for patients to tolerateand comply with on a long-term basis. Oral appli-ances have been proposed as an alternative to con-tinuous positive pressure therapy. They keep theupper airway open by advancing the lower jawforward or keeping the mouth open during sleep.This review found insufficient evidence to recom-mend oral appliances as first choice therapy forsleep apnea. When an active oral appliance wascompared with an inactive oral appliance, therewere improvements in daytime sleepiness andapnea/hypopnea severity. However, oral appli-ances proved less successful than continuous pos-itive pressure in decreasing sleep disorderedbreathing. When an oral appliance was effective intreating sleep apnea, it was preferred to continuouspositive pressure by some patients. Oral appliancesmay be more effective than corrective upper air-way surgery.2

Another systematic Cochrane review questions theeffectiveness of penicillin to guard against bacterialendocarditis before an invasive dental procedure.

There is no evidence about whether penicillin pro-phylaxis is effective or ineffective against bacterialendocarditis in people at risk who are about toundergo an invasive dental procedure. There is a lackof evidence to support published guidelines in thisarea. It is not clear whether the potential harms andcosts of penicillin administration outweigh any ben-eficial effect. Ethically, practitioners need to discussthe potential benefits and harms of antibiotic prophy-laxis with their patients before a decision is madeabout administration.3

COSA is working to fulfill the House of Delegates’expectations. Your patience and support are importantin this project. Please let me hear from you.

REFERENCES

1. AAO House 2005 Resolutions; 16-05 EBDTF, 27-05 COSA, and28-05 COSA.

2. Lim J, Lasserson TJ, Fleetham J, Wright J. Oral appliances forobstructive sleep apnea. The Cochrane Database of SystematicReviews 2004, Issue 4, Art No. CD004435.

3. Oliver R, Roberts GJ, Hooper L. Penicillins for the prophylaxis ofbacterial endocarditis in dentistry. The Cochrane Database of

Systematic Reviews 2004, Issue 2, Art. No. CD003813.

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