EVIDENCE-BASED ORTHODONTICS

What do we want to know?Greg J. Huang

Seattle, Wash

The American Dental Association (ADA) re-cently released its 2005 Research Agenda,1

which lists over 70 topics that have beendeemed “Research of Importance to the PracticingDentist.” The mission statement for the document readsas follows: “A major objective of the Association is topromote a good quality of life by improving the oralhealth care of the public and encouraging optimalhealth behaviors. To achieve this objective, it is imper-ative that the Association take a leading role in pro-moting, conducting, and critically reviewing researchon topics related to dentistry and its relationship to theoverall health of the individual. The Association shouldserve as a facilitator of the national dental researcheffort, help determine the priority of topics for researchand ensure the timely dissemination of information tothe profession.”

I was impressed by this mission statement becauseit articulates the leadership role that the ADA hasassumed with regard to all aspects of science indentistry. There is sometimes a disconnect between thescience and the practice of dentistry, and the ADAshould be commended for attempting to integrate them.It is not an easy task, because many dentists relyheavily on the opinions derived from their practices(experience-based) and espoused by recognized experts(eminence-based) to assist them in their treatmentdecisions. Often, the literature is simply overlooked.

It takes courage for the ADA to list some of theseissues because, in a sense, it is an admission that theprofession has less than perfect knowledge. For in-stance, “identification of appropriate and inappropriatedrug regimens and indications for antibiotic prophy-laxis” was listed as an urgent area for investigation.When I was a dental student (almost 20 years ago), myinstructors insisted that we follow the antibiotic pro-phylaxis guidelines as if they were written in stone. Ihave subsequently learned that this is not the case; the

Assistant professor, Department of Orthodontics, University of Washington,Seattle.Reprint requests to: Dr Greg J. Huang, Department of Orthodontics, Universityof Washington, HSC Box 357446, Seattle, WA 98195; e-mail, ghuang@u.washington.edu.Am J Orthod Dentofacial Orthop 2005;127:648-90889-5406/$30.00Copyright © 2005 by the American Association of Orthodontists.

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guidelines have evolved over the years. A recentCochrane Collaboration review2 suggests that we havevery little good evidence to premedicate at all. This wasquite a shock to me, because it is contrary to what I wastaught and have practiced. Thus, it seems appropriatethat the ADA is calling for immediate research on thistopic. Medicine has sometimes had complete reversalsin techniques and approaches, and dentistry is notimmune to major upheavals.

The antibiotic prophylaxis issue is interesting fromanother standpoint—we have guidelines from theAmerican Heart Association for managing dental pa-tients. Most of us are happy to have these guidelinesbecause they help us provide what is thought to be themost current and appropriate care for these patients.Although dentists are happy to have these guidelinesfor the important issue of antibiotic prophylaxis, theyoften do not welcome guidelines for other areas of theirpractices. It is thought that practice guidelines mightnegatively affect a health care provider’s treatmentoptions or be used by insurance companies to limitcoverage. These are both valid points, but I have alwaysbeen puzzled that the intended benefits of guidelines—current and appropriate care—are often ignored. TheNational Guideline Clearinghouse,3 a comprehensivedatabase of evidence-based clinical practice guidelinesand related documents, already houses thousands ofguidelines on all aspects of medical care on its website,including over 100 dental guidelines. In the ADA’smission statement above, the ADA has acknowledgedthat the dissemination of information is a criticalelement to successfully integrating research into prac-tice, and guidelines might assist with this effort.

The ADA has also emphasized its role as a facili-tator in the national dental research effort. Recently, theNational Institutes of Health has funded 3 centers todevelop practice-based research networks in generaldentistry.4 Over the next 7 years, these networks willattempt to accomplish goals very similar to thosedescribed in the mission statement. The networks willrecruit practicing general dentists to help developquestions of importance to general dentistry. Thesesame dentists will receive training on research methodsand then participate in research networks to answer the

questions they have developed. This new model for

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dental research offers many advantages. For instance,many practicing dentists are skeptical of universityresearch. In this model, dentists will actually be theinvestigators. Thus, they have ownership of both thequestions asked and the subsequent results. Anotheradvantage is that the answers from this research modelshould be more generalizable to larger populations ofdentists, because the studies will not be conducted byonly 1 investigator at 1 site. The networks will alsoenable the recruitment of more subjects, and this can beof great value when conditions or outcomes are rare.The ADA should monitor these new networks closely,because they can provide a tremendous opportunity forconducting future dental research.

The ADA mentioned assisting with the criticalevaluation of literature. This is an essential step, toidentify areas that have good scientific support andthose that need more research, and has often been mostclosely linked with evidence-based practice. However,an evidence-based approach truly relies on all of thesteps that the ADA mentioned in its mission statement.It is a circle of science, which consists of identifyingquestions, conducting research, critically evaluating thefindings, disseminating information, and then identify-

ing new questions.

The ADA is poised to lead general dentistry into theevidence-based era, and the dental specialties canbenefit from its model. What do we want to know inorthodontics? Let’s survey our members and ask whatthey believe the important questions are. Then, let’s becreative in finding ways to fund the research andanswer these questions. Let’s conduct well-designedstudies, possibly with the practice network model, andthen systematically review the results to obtain theevidence-based answers. Let’s disseminate this infor-mation to all orthodontists and then let’s ask themagain—what do you want to know?

REFERENCES

1. 2005 ADA Research Agenda. http://www.ada.org/prof/resources/positions/research.asp#research. Accessed April 28, 2005.

2. Oliver R, Roberts GJ, Hooper L. Penicillins for the prophylaxis ofbacterial endocarditis in dentistry. The Cochrane Database ofSystematic Reviews 2004; issue 2: art. no. CD003813. pub 2.

3. National Guideline Clearinghouse. Available at http://www.guideline.gov/. Accessed April 28, 2005.

4. NIDCR Awards Grants for New Practice-Based Initia-tive. Available at: http://www.nidcr.nih.gov/NewsAndReports/NewsReleases/NewRelease033/2005.htm. Accessed April 28,

2005.