Journal of Evidence-Based Dental Practice
Volume 8, Issue 3 , Pages 139-143, September 2008

Emerging Issues in Dentistry: Caring for Patients in the Absence of Evidence

Private practice; adjunct faculty, University of New Mexico School of Medicine; Advanced Education in General Dentistry Residency, Albuquerque, NM, USA

Article Outline

Treatment planning and communication with patients require caution when evidence is weak or absent.

Key Words: clinical decision support, periodontal disease, pregnancy outcome, absence of evidence, treatment plan

 

Many issues in dentistry have weak or no evidence to support definitive treatment decisions. Nevertheless, treatment decisions must be made. The mission of evidence-based dentistry (EBD) to accumulate, evaluate, interpret, and communicate information for patients continues even when there is a dearth of good evidence. When an explicit answer to our clinical question is unavailable, using existing evidence appropriately is crucial for making treatment choices and communicating with patients. This article proposes a plan for decision making and communication when dealing with emerging issues in dentistry. A patient scenario is presented demonstrating the EBD process as an alternative to the common practice of relying solely on tradition or experience.

Hippocrates (460-370 BC) wrote “Life is short, and the Art long; the occasion fleeting; experience fallacious, and judgment difficult. The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate.”1 While we cannot “make the patient cooperate” we can certainly influence decisions to accept the best treatment through patient education and communication of the best evidence. Unfortunately, the converse is also true; we can misinform patients and cause damage, violating another precept of Hippocrates, nonmalfeasance.

If the best evidence is to impact treatment plans, we must access, evaluate, compile, and present the evidence compellingly. This is especially true in emerging issues where there is weak evidence and patients may be more vulnerable to misinformation and quackery. By preparing a script with well-ordered evidence in advance of patient consultation, a cogent presentation is possible. In this way a good clinical decision is more likely and the patient is better prepared to accept the consequences of the decision.

A recent qualitative study developed a theory of 4 primary information domains influencing the dentist (Figure 1).2 While we use all of these domains, EBD practice encourages greater emphasis on research evidence.3

•Tradition: In the early stages of a dental career there is a tendency to rely on tradition. Tradition is the accumulated institutional knowledge in dentistry and basic skills acquired as part of dental education and training. It is also evident when dentists rely on each other for information on diagnosis and treatment.

•Experience: Tradition may be supplanted by clinical experience in practice as confidence increases. Accumulated experience is applied in problem solving in more mature clinical practices. The relative isolation of most dentists encourages experience as the most common information domain. On the down side, experience leads to inertia, which may be antagonistic to change.

•Evidence: New information informs and influences clinical decisions. As dentists gain the necessary skills to critically appraise and apply research evidence, this domain should gain ascendency over tradition and experience. The evidence-based practitioner recognizes that avoiding bias is more likely after evaluating global literature than when relying solely on clinical experience. Good research evidence has the advantage of the ethical application of the scientific method to problem solving.

•Reason: Clear thinking and application of reason are foundational to all information domains in clinical decision making. Reason involves logic, as well as rational and analytic thought. It is the basis of good clinical judgment.

The aim of EBD is the timely translation of research into practice.4 From the perspective of the practicing dentist, EBD is a way to quickly and accurately answer clinical questions. EBD acknowledges the time-sensitive nature of evidence, which means decisions made today may be different from yesterday's decisions if new evidence has emerged. This may cause uneasiness when reflecting on past clinical decisions, but it should encourage confidence when today's decision was informed with the best current information. Dentistry practiced this way becomes a dynamic discipline, not merely a science or an art.

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Description of System 

Treating patients in the absence of evidence requires working with and communicating uncertainty without compromising care. This process (Figure 2) is a slight modification of common models.5 The following patient scenario demonstrates how I use the process.

Scenario: A 28 year-old female patient presents to our office with the chief complaint of “bleeding gums.” The patient is early in the first trimester of pregnancy. This is her second pregnancy after suffering a midterm miscarriage about 2 years ago. The patient is taking prenatal vitamins and crystallized ginger for nausea associated with morning sickness. Oral examination reveals moderate periodontal disease (PD) with generalized gingival erythema, isolated 4- to 6-mm pockets, and bleeding on gentle probing. Her dental history indicates sporadic care. The patient has confided to the dental assistant that after reading an online article she began to wonder if she has “gum disease,” which, according to the article could explain the problems with her last pregnancy. She asks us if she has gum disease and with obvious emotion asks, “Is there anything [she] can do to prevent another miscarriage?”

Problem: The problem is locating, evaluating, and communicating the latest information on the relationship between PD and pregnancy outcome (PO) with the end result that the patient will make an informed decision about care.

If we believe it is at least as important to say the right things to patients, as it is to skillfully perform the correct procedures, then we need the best evidence before we offer an answer. At this point we should have no problem telling the patient we would like to research the medical literature related to her question to get the best, most up-to-date information. Sometimes a quick chair-side computer search is possible, but it may be better to ask the patient to return in a day or two, giving us time to “study the latest research.”

Questions: Although a patient problem often yields only one clinical question, it is just as common to find a number of interconnected clinical questions. In this case there are several questions, but time and focus leads to the following 3. Are patients with periodontal disease more likely to have poor pregnancy outcomes compared with patients with a normal periodontal condition? In patients with PD, does periodontal treatment improve PO? Is treatment of PD safe in pregnant women?

Search: A quick search of PubMed on March 1, 2008, with MeSH terms “periodontal disease” AND “pregnancy outcome” limited to reviews gave 21 references. Reading available abstracts of reviews in the past 5 years provided 6 systematic reviews (SRs) (Table 1). Other articles contained reviews but without methodological elements consistent with SR guidelines.12 Full-text articles of each of the reviews were secured and reviewed.

Table 1. Systematic reviews of periodontal disease/pregnancy outcomes
AuthorYearTypeConclusion
Conde-Agudelo et al62008SR and meta-analysis of observational studiesPD during pregnancy increased risk of preeclampsia compared with women without PD.
Vergnes and Sixou72007SR and meta-analysis of observational studiesLikely association between PD and preterm low birth weight. Possible benefit from intervention
Xiong et al82007SR and meta-analysis of observational studies and randomized controlled trialsInsufficient evidence to support periodontal treatment during pregnancy for the purpose of reducing adverse PO.
Vettore et al92006SR of case-control, cohort and clinical trialsNo sound scientific justification to recommend screening of periodontal disease in pregnant women as a means to reduce adverse pregnancy outcomes.
Khader and Ta'ani102005SR and meta-analysisPD increases risk for preterm birth and low birth weight. No evidence that treatment of PD will reduce risk of preterm birth.
Scannapieco et al112003SR of case-control, cohort and randomized controlled trialsPD may be a risk factor for pre- birth weight. Periodontal intervention may reduce adverse pregnancy outcomes.

SR, systematic review; PD, periodontal disease; PO, pregnancy outcome.

Evaluate: Several SRs addressing our first question are available, but the quality and strength of the evidence are mixed. Numerous case-controlled studies and cohort studies exist, but there are few randomized controlled trials as reflected in the SRs. Prospective interventional studies generally provide better evidence, but they are more difficult and may pose ethical dilemmas. Heterogeneity of studies was a problem because of differences in how periodontal disease was measured, the populations included, confounding health factors, and determination of pregnancy outcomes. These make it difficult to combine studies through meta-analysis. There was no overall consensus, although a positive association between PD and unfavorable PO appears to exist. All studies concluded the evidence was weak. Our conclusion was the weak association of PD with PO was not sufficient to prove causation.

Our second question seeking evidence for improving PO prognosis through PD treatment is no clearer. Some studies showed treatment of PD during pregnancy resulted in better outcomes while other studies showed no effect. A weakness in the evidence is the heavy reliance on small interventional studies. Small studies may show improvement with treatment without reaching statistical significance. Nevertheless, in light of the evidence we could not conclude treatment of PD improves PO.

When assessing benefits to treatment we must always consider possible harms of therapy. This leads to our third question: Is treatment of PD safe in pregnant women? The most common initial treatment for moderate PD is scaling and root planing (SRP).13 It has been established that SRP may cause bacteremia.14 Bacteremia involving group B streptococcus is thought to contribute to chorioamnionitis, endometritis, and sepsis, as well as to preterm labor and premature birth.15

Some have postulated that normal functions such as chewing may cause bacteremia in patients with PD, apparently negating the argument of risk from SRP,16 but a recent study found chewing does not cause bacteremia in patients with PD17 leaving a sense that bacteremia from SRP may be a unique risk. Reason tells us SRP may lead to bacteremia and increase the chance of poor PO.

Asking a periodontist and an obstetrician about treatment of PD during pregnancy led to the advice that SRP is probably not a problem, but the domains of tradition and experience are hardly the affirmation EBD seeks. Another query of the evidence using the MeSH terms “pregnancy outcome AND root planing AND harm” returned only 1 study, by Offenbacher et al.18 After eliminating the term harm, 2 additional studies were found (Table 2).

Table 2. Results of second search
AuthorYearTypeConclusion
Offenbacher et al182006Pilot study (N = 67), randomized controlled trialTreatment was safe. PD improved, PO improved
Michalowicz et al192006Randomized controlled trial (N = 823)Treatment improves PD and is safe, PO was unaffected
Sadatmansouri et al202006Randomized controlled trial (N = 30)Treatment of PD eliminated preterm, low birth weight infants.

PD, periodontal disease; PO, pregnancy outcome.

All studies concluded the procedure was safe. Two of the studies were small and did not include power calculations. One study by Michalowicz et al19 included 823 women and found periodontal condition improved in the treatment group, but without significant differences in PO between the treatment and delayed-treatment groups. There were no studies showing negative effects of SRP on PO. Even though no SRs have been completed, we concluded the evidence from randomized controlled trials supports the safety of SRP during pregnancy.

Script: When developing our script we need to remember the difference between association and causation. We cannot tell the patient whether PD caused her first miscarriage. Likewise we cannot tell her that periodontal treatment will improve her PO. We can tell our patient that SRP, the most common initial treatment for PD, appears to be safe during pregnancy.

In light of the evidence it would be careless and unethical to hold out periodontal treatment as a preventive solution to the tragedy of miscarriage. Because of the level of uncertainty in this case, the selection of words is important when communicating the evidence to the patient. I find it useful to write a scripted answer to the patient's questions before the return visit. I don't recommend reading the script to the patient, but the script can help organize our thoughts. It may also be prudent to give a written summary of our discussion to the patient to reinforce the oral presentation. The summary, including literature references, should be kept in the patient chart as evidence of what was discussed.

Treatment plan: The patient is able to decide whether to treat her periodontal disease with the knowledge of our current best evidence. This evidence-based decision goes well beyond a perfunctory “informed consent.”

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Discussion 

Careful evaluation of our best information sources may yield a frustrating weakness in the current evidence for answering a clinical question. I find this a common result of queries regarding emerging issues in dentistry. Because of practice inertia, it is tempting to fall back on the informational domains of tradition and experience, but these are inadequate for the EBD practitioner. Cautious interpretation of existing evidence helps us avoid misleading the patient and results in an ethical treatment plan.

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Conclusions 


1.The EBD protocol offers a systematic approach to problem solving in clinical dentistry.

2.Even in cases where evidence is weak the EBD protocol can be employed to develop the best answer for clinicians.

3.By using a carefully worded script, the best evidence can be communicated to patients.

4.Considering patient preferences and values in addition to the evidence leads to an evidence-based treatment plan.

Box 1. Sample scripted answer to patient question

“Mrs M, our examination reveals you have moderate periodontal disease. This means you have inflamed gums and some loss of attachment between the gums and teeth. I have conducted a thorough search of the best scientific evidence related to periodontal disease and pregnancy outcomes in the world's medical–dental literature. This evidence shows a weak association between periodontal disease and poor pregnancy outcomes, but it does not show that periodontal disease causes miscarriage. We simply don't have enough data to say there is a cause-and-effect relationship. As you already know, many mechanisms have been proposed as factors in pregnancy outcomes. As far as treatment goes, we can provide treatment or refer you to a specialist for treatment of your periodontal disease. The evidence indicates that scaling and root planing is safe during pregnancy. Without intervention it is likely your gum disease will worsen over time, which will probably result in bone changes and tooth loss. Some sources indicate improved pregnancy outcomes after periodontal treatment during pregnancy, but others show no difference when treatment is performed. No studies have shown treatment to be harmful to the baby.”

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References 

  1. Adams F, translator. Aphorisms by Hippocrates. 1.1 eBooks@Adelaide. The University of Adelaide Library, University of Adelaide, South Australia 5005. Available at: http://ebooks.adelaide.edu.au/h/hippocrates/aphorisms/. Accessed February 9, 2008.
  2. Matthews J. Introducing evidence-based health care to a general practice dental residency: quantitative and qualitative assessment. [dissertation] Oxford, UK: University of Oxford; 2007;
  3. Muir Gray JA. Evidence-based healthcare—how to make health policy and management decisions. 2nd ed.. Edinburgh: Churchill Livingstone; 2004;p. 9
  4. Clarkson J. Getting research into practice—barriers and solutions. Caries Res. 2004;38:321–324
  5. Badenoch D, Heneghan C. Evidence-based medicine toolkit. London: BMJ Books; 2002;p. 1
  6. Conde-Agudelo A, Villar J, Lindheimer M. Maternal infection ad risk of preeclampsia: systematic review and meta-analysis. Am J Obstet Gynecol. 2008;198(1):7–22
  7. Vergnes JN, Sixou M. Preterm low birth weight and maternal periodontal status: a meta-analysis. Am J Obstet Gynecol. 2007;196(2):135;e1-7
  8. Xiong X, Buekens P, Fraser WD, Beck J, Offenbacher S. Periodontal disease and adverse outcomes: a systematic review. BJOG. 2006;113:135–143
  9. Vettore MV, Lamarca Gde A, Leão AT, Thomaz FB, Sheiham A, Leal Mdo C. Periodontal infection and adverse pregnancy outcomes: a systematic review of epidemiological studies. Cad Saude Publica. 2006;22(10):2041–2053
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  11. Scannapieco FA, Bush RB, Paju S. Periodontal disease as a risk factor for adverse pregnancy outcomes: a systematic review. Ann Periodontol. 2003;8(1):70–78
  12. Critial Appraisal Skills Programme (CASP). 10 questions to help you make sense of reviews. 2006 Public Health Resource Unit, Oxford, England. Available at: http://www.phru.nhs.uk/Pages/PHD/resources.htm. Accessed February 9, 2008.
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  14. Lafaurie GI, Mayorga-Fayad I, Torres MF, Castillo DM, Aya MR, Barón A, et al. Periodontopathic microorganisms in peripheric blood after scaling and root planing. J Clin Periodontol. 2007;34(10):873–879
  15. Zaleznik DF, Rench MA, Hillier S, Krohn MA, Platt R, Lee ML, et al. Invasive disease due to group B Streptococcus in pregnant women and neonates from diverse population groups. Clin Infect Dis. 2000;30(2):276–281
  16. Guntheroth WG. How important are dental procedures as a cause of infective endocarditis?. Am J Cardiol. 1984;54:797–801
  17. Murphy AM, Daly CG, Mitchell DH, Stewart D, Curtis BH. Chewing fails to induce oral bacteraemia in patients with periodontal disease. J Clin Periodontol. 2006;33(10):730–736
  18. Offenbacher S, Lin D, Strauss R, McKaig R, Irving J, Barros SP, et al. Effects of periodontal therapy during pregnancy on periodontal status, biologic parameters, and pregnancy outcomes: a pilot study. J Periodontol. 2006;77(12):2011–2024
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PII: S1532-3382(08)00115-2

doi:10.1016/j.jebdp.2008.05.011

Journal of Evidence-Based Dental Practice
Volume 8, Issue 3 , Pages 139-143, September 2008

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