Recommendations for Clinical Practice
Dr. Peter Triolo
Following the annual meeting of the Academy of Operative Dentistry in February of 1996, the Executive Council of the Academy, led by then President Dr. Joel Wagoner and President- Elect Dr. John Reinhardt, charged the Special Project Committee with the formation of a consortium to develop guidelines for what should be currently taught at our dental schools by Operative Dentistry Departments/Divisions/Sections. During the course of that year the new committee was recruited to discuss the charge and form a plan for the development of these guidelines. Contact was made with a number of members of the Academy and others who have been involved in developing guidelines for various dental schools. The original committee formed to address this charge was composed of Drs. Thomas Berry, Richard McCoy, Craig Passon, James Summitt, Edward Swift, Jr. and Peter Triolo, Jr.
The first meeting of the committee was held during the Annual Meeting of the Academy in February 1997. Our discussions during that meeting led us to the consensus that it was best to approach our charge as “Recommendations for Clinical Practice”. These recommendations would be based upon quality research taking into consideration such factors as common practice, prudence, ethical judgment, etc. As we began to develop our plan it became apparent that this committee of the Academy and the Operative Section of the American Association of Dental Schools shared many common goals. All members of the committee were also members of the section. This project is definitely pertinent to both organizations and both will benefit from this endeavor. We therefore presented our proposal to both Executive Councils and each approved the project and supplied funding.
During the Annual Meeting in 1997, the Executive Council of the Academy expanded membership of the committee to include a number of private practitioners and a representative from our European membership. We added Drs. Murray Bouschlicher, Richard Kloehn, William Morris and Nairn Wilson.
A subcommittee meeting was held in San Antonio, Texas in October of 1997. At that time the subcommittee developed a flowchart for the committee process (fig. a) and another flow chart for specific recommendation process (fig b). We also developed a list of topics for recommendations to be developed (table a) and working definitions for the committee (table b).
The entire committee met in Chicago at the Annual Meeting of the Academy in 1998. At that time we reviewed the recommendation process flow chart and made some minor modifications. We appointed two subcommittees to begin drafting the recommendations for, what in our opinion were, the two most important topic areas: fissure caries and smooth surface caries. To help in gathering information on what was currently being considered for practice and teaching, the Committee developed a survey that was distributed through the Section to all dental schools as the national agenda for the Consortium of Operative Dentistry Educators regional meetings. Results of this survey were utilized in the development of the first recommendation and will continue to be used for subsequent recommendations. The fissure caries subcommittee met in October of 1998 and wrote the first draft of the fissure caries document. The draft was distributed to all members of the committee for review of format and content.
During the 1999 annual meeting of the Academy the committee reviewed the document and determined that a number of changes needed to be made and that references were required for a number of the statements. The committee determined that rather than completing all 12 recommendations, the appropriate course of action would be to complete the fissure caries recommendation and submit it to the Council for it’s approval, then publish the document in the Operative Dentistry Journal. We anticipate receiving feedback from reviewers and readers of the document that will improve the subsequent recommendations. We reworked the document during the summer of 1999 to its present form.
Our intent throughout this process was to follow the initiative of evidence-based health care. According to Gray there are five levels of evidence relevant to clinical decision making. In dentistry rarely is evidence of the highest (first) order available, so clinicians have to use the next highest level of evidence available. Knowing that one level of evidence is better than another is important when making decisions about the treatment of patients. The levels of evidence are:
|Level||Strength of evidence*|
|1.||Strong evidence from at least one systematic review of multiple well designed randomized clinical trials.|
|2.||Strong evidence from at least one properly designed controlled trial of appropriate size.|
|3.||Evidence from well designed trials without randomization, single group pre-post, cohort, time series or matched case-controlled studies.|
|4.||Evidence from well designed non-experimental studies from more than one center or research group.|
|5.||Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees.|
*From: J.A. Muir Gray (1997) Evidence-based health care – how to make health policy and management decisions. New York, Churchill Livingstone. P. 61.
The process of evidence-based health care has three important steps according to Ismail, Bader and Kamerow (systematic reviews and the practice of evidence-based dentistry: professional and policy implications. J AM C DENT, 66:1. Pp 5-12, 1999). The first is asking a clinically relevant question that, if answered, can help clinicians to provide better care to their patients. The second is a systematic review of all the evidence that may help to answer a clinically relevant question. The third step is to transfer the evidence-based conclusions into practice which is the purpose of this project.