Rarely does scientific research translate readily into clinical dental practice in a timely manner. When I agreed to participate in a study as a Practitioner Investigator in the Dental Practice-Based Research Network (Dental PBRN), I went through an unexpected mental conversion, and I am now a very enthusiastic supporter.
Initially I was skeptically curious about such a program, reasoning that if it was driven by either the insurance industry or by the government, then it would threaten or intrude into my private practice. I perceived that this would be a method to institutionally restrict specific dental procedures — time restrictions on frequency of radiographs, for example. Having been a dentist for more than a quarter of a century, I never seemed to welcome influences from outside our dental association or our particular dental school. I honestly was enticed to get involved in the PBRN more out of investigative curiosity than out of an earnest belief that this new research model would work.
What Is a “PBRN?”
In 2005, Congress funded three dental practice-based networks at about $25 million each for seven years in an effort to try to duplicate the success that medicine has had with practice-based research. As was found in medicine, dental research conducted solely in academic settings has not translated very quickly or practically into daily dental practice. The practice-based approach to research hopes to produce study results that will be accepted and more readily adopted by practicing dentists, and thereby improve our patients’ oral health and add meaningfully to scientific evidence in a timelier manner.
The PBRN in which I participate is based in Birmingham at the University of Alabama and is one of the three funded by the National Institute for Dental and Craniofacial Research (one of the National Institutes of Health). This Dental PBRN is measuring “real world” clinical dental results on live patients around the globe. The Dental PBRN is a diverse network of dentists from Minnesota, Washington, Oregon, Alabama, Florida, Georgia, Mississippi, Norway, Denmark, and Sweden, coming from very different practice styles (private fee-for-service, HMO, government-sponsored clinics, and others). This broad diversity creates a strength in numbers and perspectives that guarantees a high degree of credibility.
As my interest and activities as a Practitioner Investigator increased, I have had the privilege of serving as an Executive Committee member in the Dental PBRN. I realize the great potential that practice-based research has to improve the oral health of our dental patients worldwide. With statistical documentation of measurably better health outcomes, it is increasingly apparent that this experiment in the dental research process itself can change how we practice dentistry in the future. I wholeheartedly believe that this kind of research can help us make better clinical decisions. As a result, we could see increased collaboration between academicians and clinical dentists working together to generate relevant research questions and discovering new ways to improve oral health.
A Day in the Life of One Dentist’s PBRN Participation
One study that I participated in was tracking “Why, when, and with what material would you as a dentist restore a previously unrestored tooth surface”, or, put another way, “What makes you, as a dentist, finally pick up a dental drill?” Paper or web-based questionnaires are filled out on the first 50 consecutive patients for whom you are initially restoring a new tooth surface. For each specific patient you are compensated a small fee for your trouble in completing the extra paperwork. The questions answered on each restoration are about two pages long, and after a couple of patients, the process becomes routine and not very time consuming.
This study has been completed, and in it nearly 10,000 restorations were placed by 229 practitioners from around the globe. I was one of that 229. The data is still being analyzed, but some of the data was shared at an all-network meeting in Atlanta, Georgia last May. It was the most beneficial professional meeting I have ever attended. Once we as practitioners developed good rapport and trust, we then shared and compared our diagnostic techniques. Initially the thinking was that there would be a wide range of variances and differences of opinions, but after the floodgates opened, we as dental professionals all sought out what truly would be in the best interests of the patients.
Follow-up studies will track the success of these restorations. I suggest as well that readers visit the ADA’s website on Evidence-Based Dentistry and check out the three-circle diagram. Ironically, I have been using a similar diagram to explain how “evidence” should be used in patient care. The evidence is not intended to replace a patient’s choice or clinician’s skills, but is intended to add more credible information during treatment decisions. We all believe the freedom of both the patient and the dentist to choose treatment for a specific case should not be restricted or pre-determined.
The Alphabet Soup of PBRNs and EBD
Dentistry sometimes seems to be more “art” than “science”, often due to the preponderance of our use of anecdotal evidence and case reports rather than rigorous systematic studies. On the other hand, many clinicians are skeptical of “evidence-based” dentistry because of the often erroneous conclusions drawn by third-party payers using only claims data. The American Dental Association has put considerable effort into promoting and supporting EBD. After attending the ADA’s “Champions of EBD” in May 2008 and exploring the new EBD section on the ADA’s website (www.ebd.ada.org), my enthusiasm for practice-based research is even stronger. The very idea that my dentist colleagues and I can be involved in asking and answering tomorrow’s clinical questions has the potential to revolutionize not only patient care, but improve our profession’s public and political image as a profession grounded in scientific evidence.
A Good Investment
Many may be surprised that our federal tax dollars are supporting such a dramatically innovative approach in Evidence-Based Dentistry, but this is the type of research that honestly will save money in the long run. Discovering valid, relevant evidence on best practices and determining what techniques and procedures actually improve patients’ oral health can only benefit us all. Investment in practice-based research should be a high priority to improve the health of the patients we serve, so creating credible dental evidence that will be widely and immediately transferable into dental practices seems to me to be a no-brainer. Therefore, I hope our national lawmakers continue to fund such programs, and I encourage the expansion of practice-based research to accelerate the rate of developing good evidence in dental care. Currently, I cannot see a better way to extend optimal dental health to people around the world.
*Dr. Foy is a general dentist in private practice in Minneapolis, Minnesota.