Not Just in the "Ivory Tower": Research in Your Office for Your Patients!

Not Just in the "Ivory Tower": Research in Your Office for Your Patients!

Gary C. Anderson, D.D.S., M.S.,* Patrick Foy, D.D.S.,** Douglas Shamp, D.D.S.,*** D. Brad Rindal, D.D.S.,† and Patricia Glasrud, R.D.H., M.P.H.‡:
Past and present members and staff of the Taskforce on Evidence-Based Dentistry of the Minnesota Dental Association: Dylla J, Foy P, Jason C, Johnson N, L’Abbe S,  Miller J, Powers J, Quiram  P, Rindal DB, Shamp D, Templeton B, Diercks D, Glasrud P, Hanson L, Kramer L, and Anderson GC, Chair.
 
 
Introduction
The Minnesota Dental Association, as a component of the American Dental Association, has always supported oral health research necessary to support the quality patient care provided by  its members. For the MDA, this commitment has grown locally over the past few years and has resulted in an opportunity for members of the MDA to become directly involved in clinical  research. This research is directed and accomplished by dental practitioners investigating clinically relevant problems through practice-based research within a national network supported by a  $68 million grant from the National Institute of Dental and Craniofacial Research. It is truly an opportunity to make a difference. This is the story of how this opportunity came about and how  you and your staff can involve your practice.
 
Evidence-Based Dentistry
The first step along this path came with a growing sense of the value of evidence in health care in general. Evidence-based health care first evolved as evidence-based medicine (EBM) and  was perhaps most clearly defined by Sackett et al as “Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values.”1 At its core, EBM was built on the concept of grading the quality of evidence — i.e., “all evidence is not equal” — and it was made feasible with the large databases and search engines of the digital age. Evidence- based health care began to impact dentistry at the end of the 20th century and was defined by the American Dental Association as “Evidence-based dentistry (EBD) is an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the  dentist’s clinical expertise and the patient’s treatment needs and preferences.”2 The ADA also made significant investments in EBD, including the launch of the ADA’s website for its Center for  Evidence-Based Dentistry in March 2009.3  EBD uses a formalized methodology to develop answerable clinical questions, direct the search of digital databases, and analyze the relevant  evidence. One outcome of EBD is the development of systematic reviews, which “systematically locate, appraise, and synthesize evidence from scientific studies to obtain a reliable over view.  The aim is to ensure a review process that is comprehensive and unbiased” as compared with traditional literature searches.2 
 
EBD and the Minnesota Dental Association
The Minnesota Dental Association also had the foresight to directly address the issue at a “grass roots” level when its House of Delegates in 2006 passed a resolution from the Dental Marketplace Committee to appoint an ad hoc Evidence-Based Dentistry Task Force “to develop a process to increase dentists’ understanding, utilization, and development of ‘evidence-based  dentistry,’ in consultation with the American Dental Association and the University of Minnesota School of Dentistry.”4 
 
The members of the EBD Taskforce have been active since 2007 with  presentations on EBD for dental societies and study clubs throughout Minnesota. In addition, members have attended and presented at the annual ADA EBD Champions Conferences in  Chicago, Illionis beginning with the first session in 2008.3 These activities have continued to the present. 
 
The task force’s first symposium related to EBD, “EBD and Beyond!”, was attended by more than 100 on October 12, 2007. Former Senator David Durenberger presented the keynote address  regarding changes on the horizon for health care. Leaders of the dental insurance industry provided the rest of the program, as a major concern of the practicing community has been that  EBD may be used by third party payers to unduly influence treatment decisions made by dentists and their patients. Dr. Sheila Riggs, at that time CEO of Delta Dental of Minnesota, made the  case for dental diagnostic codes. Dr. Fred Eichmiller, vice-president of Delta Dental of Wisconsin, talked about changes in dental benefit sets based on evidence. Dr. Craig Amundson, at that time Dental Director of HealthPartners Dental Group, presented on caries risk assessment and its application in practice. The symposium was co-sponsored by the Minnesota Dental Association  and the University of Minnesota School of Dentistry.
 
Dental Practice-Based Research and the MDA
On October 30, 2009, the Taskforce was responsible for another half-day symposium, “Practical Research for Clinical Excellence: Be Better, Be Smarter, Be Part of the Process!” Dr. Julie  Frantsve-Hawley of the ADA’s Center for Evidence-Based Dentistry spoke about EBD resources provided by the ADA.3 However, the remainder of that symposium was dedicated to a topic  which had become increasingly important to the members of the EBD Taskforce, “practice-based research”. 
 
One of the concerns of those involved in EBD since the early stages of its development has been the limited quantity of high quality, clinically relevant research. Most simply, promoting the  value of high quality, unbiased searches for the best evidence is a tough sell when the resulting best evidence is not that good or is not applicable to the clinical setting. The task force had become increasingly aware of the value of practice-based research — that is, clinical research in the dental practice setting — as one means of addressing this shortcoming. Beginning in  2005, the NIDCR began to support dental practice-based research with the establishment of three practice-based research networks (PBRNs). The three networks, administered from the  University of Alabama at Birmingham, the University of Washington, and New York University, were funded for a total of $75 million. The objective was to connect practitioners with experienced clinic investigators to conduct short-term clinical trials in oral health treatments, prevention, and dental materials.5 Cliniciandirected, practice-based research has been shown in  medicine to result in findings better accepted by the practicing community and to close the gap between research and clinical practice.6 Interestingly, the Minnesota tradition for participation  in practice-based research was established many years ago by the Minnesota Academy of Family Physicians, which did much early work in developing practice-based research in medicine.
 
The  Dental Practice Based Research Network (DPBRN) led by Dr. Gregg Gilbert at the University of Alabama has had a significant Minnesota connection since its inception. Initially established through the HealthPartners Research Foundation, this grew to include 91 dentists and dental specialists and 10 dental hygienists from throughout the dental community of Minnesota and  supported a number of notable clinical investigations.8 The MDA’s EBD Task Force included members who had become very active in the DPBRN, which resulted in a growing awareness of  practice-based research as a source for clinically relevant research to support EBD. 
 
Dr. Pat Foy, past MDA president and member of the Executive Committee of the National Dental PBRN, and Dr. Doug Shamp, MDA and National Dental PBRN member, have been two of the task  force’s most active participants in practice-based research. The following discussion provides insight into why they became involved and the personal and professional benefits they have  enjoyed in the process. 
 
Q: How and why did you first become involved in practice-based research?
Dr. Foy: Back in 2005, Dr. Brad Rindal had a booth at the Minneapolis Midwinter Meeting representing the NIH funded Dental Practice- Based Research Network, and he was recruiting dental  professionals to participate in practice-based research. At the same time, NIH was helping the ADA fund their EBD.org website. I was skeptical and curious about why the government was  spending all this money in these new directions, so I signed up to investigate and attempt 
 
Dr. Shamp: I had a patient with osteonecrosis of the jaw (ONJ) in my office, and a colleague (Dr. Brad Rindal) told me he was involved in a study of patients with ONJ. As a general dentist I  had not thought much about P-values or statistical analysis since dental school, but I reluctantly agreed to take part. Our office had a very positive experience, and so we have participated  in several research projects since. I enjoyed the fact that researchers doing practice-based research wanted my data, and I wanted research that applied to and reflected “real” dental office  situations.
 
Q: How did your staff react when you got involved in the network doing research in your practice?
Dr. Shamp: When I first brought up the subject, I got some “here we go again” feelings from the staff about another one of my “new ideas”. The process was easily folded into our office,  and the staff very shortly felt they were a part of something more than just dentistry as usual. Being part of a process to not only better our knowledge, but helping others at the same time  developed a “win-win” attitude for all of us. 
Dr. Foy: We all had a sense of pride knowing that our practice is contributing to and advancing dental research that will eventually help our profession improve patient care. Betty, our office  manager, took it upon herself to administer and track all patients who were in the research studies. She made my participation relatively painless and seamless. We were also compensated  fairly for the extra work filling out questionnaires and data sheets. 
 
Q: What has been the benefit of your involvement?
Dr. Shamp: When the results of the ONJ study were published, I called a mini staff meeting and explained the data we helped to collect. The staff was really engaged and proud to be contributors. Our data mattered to them. Patients are almost universally supportive that their dentists are doing front line research. 
Dr. Foy: I was fortunate to be elected to a member of the Executive Committee (EC) of the DPBRN. The EC is a small body of practicing dentists who vote on what is studied and funded.  That vetting process has made me a much more critical thinker and has improved my skills of incorporating the principles of EBD into my dental practice. My participation and the results of  certain studies have not only changed how I practice day to day, changed my verbiage, but have improved my informed consent procedures. One study that measured “patient satisfaction”  illuminated the “disconnect” between the patient and doctor when both were asked whether enough information was provided to the patient before a specific procedure. Even though the  dentist and the patient knew in advance that they would be questioned about the replacement of a restoration, the patients indicated that they did not feel they had enough information  about the procedure about 60% of the time. So now before I proceed with a dental procedure, I ask, “Do you have enough information about today’s procedure?” before I proceed with what  we had planned. I think this has improved my informed consent process, and patients have been given a better opportunity to clarify in their minds what will happen during the appointment. 
 
Q: How has your participation changed your office’s approach to patient care?
Dr. Foy: Evidence-based, or “science-based”, care is what we think we have been taught, but many of our procedures are based on traditions and experience. Every day we are presented  with many clinically relevant questions where there are no clear-cut answers or well-documented solutions. The dentist and his professional staff only want to do what is best for their patients, but sometimes the answers are not readily available. We are challenged to find out “what is right?” We have the opportunity to be part of a well-managed diverse network of  dentists that generates the evidence that will improve patient care. We are challenged to pose the most clinically relevant questions that will advance dentistry to a higher standard of care  that is based on real dentists doing real-life dentistry. Unfortunately, insurance claims data and inappropriately applied clinical guidelines have already influenced the dental marketplace in  ways that do not necessarily improve patient care. I see a great potential for the National Dental PBRN to improve patient care and hope many of my colleagues will participate in future  studies. You will learn something, and it is the right thing to do. 
Dr. Shamp: We look at incoming information more critically and have developed ways to seek out credible evidence, as opposed to accepting as fact the “sales pipeline” or information of that  type. For instance, recently the broadcast media reported on a study that linked the risk of intracranial meningioma to exposure of dental X-rays.9 Due to our more critical approach since  being involved in the DPBRN, I looked at the study and found what I thought were some issues with study design. It made me “ready” for the questions that I knew we would get from our  patients. The first thing I explained to our patients was that all dental radiation exposures were of concern, and our office was doing as much as possible to reduce exposures. Next, I  explained that the study was retrospective and subjects with an intracranial meningioma were asked to recall how often they had X-rays previously, a very unreliable way to measure dental  radiation exposure. In fact, none of our patients I spoke with could remember with any certainty their own past dental X-ray experience, which helped them recognize the limited value of that study’s results. Our ability to evaluate research is much better since our participation in practice-based research. 
 
The National Practice-Based Research Network: An Opportunity for the Members of the MDA
The funding cycle of NIDCR for the three original PBRNs ends in 2012. As the next phase of support for practice-based dental research, the NIDCR put out a request to the three original PBRNs  for proposals to develop a successor, a single consolidated national PBRN (RFADE- 12-002). This award was granted to the original DPBRN led by Dr. Gregg Gilbert at the University of Alabama  at Birmingham in the form of a $66.8 million, seven-year grant to form a National Dental Practice- Based Research Network (National Dental PBRN).10 The new National Dental PBRN has an  administrative hub in Birmingham, Alabama and six regional research nodes at Rochester, New York; Gainesville, Florida; Birmingham, Alabama; San Antonio, Texas; Portland, Oregon; and most  importantly for the MDA, in Minneapolis, Minnesota. 
 
The National Dental PBRN in time will provide important findings which have been missing from the evidence base of dental care, evidence that will lead to improved patient care in the future.  In addition, as has been noted by Drs. Foy and Shamp, there are many intangible benefits to the entire dental team which will impact the sense of mission for any dental clinic. The Minnesota  Dental Association has made a commitment to support the National Dental PBRN based upon our unique experiences as an Association. 
 
The EBD Task Force looks forward with great enthusiasm to a large participation by the MDA’s membership. To this end, the MDA will provide a symposium for its membership and their office  staffs on the morning of October 12, 2012. The symposium will provide background on practice-based research as well as information regarding enrollment and participation in the new National  Dental PBRN, and will be held at the University of Minnesota’s Continuing Education and Conference Center. We encourage your attendance, including that of all staff members. More information regarding registration will be provided in future MDA publications and e-mails (Figure 1). To enroll in the National Dental PBRN, visit www.NationalDentalPBRN.org. Previous participants in the DPBRN should re-enroll due to revised enrollment questions, the need to update information, and the opportunity to submit ideas for research studies. For more information  or to speak with your Midwest Region staff about participation or a study idea you wish to share, please see the contact information in Figure 2 
 
References
1. Sackett DL, Richardson WS, Rosenberg W et al. Evidence-Based Medicine: How to Practice and Teach EBM. London: Churchill Livingston, 1997.
2. “About EBD”, ADA Center for Evidence-Based Dentistry: http://ebd.ada.org/about.aspx (accessed June 16, 2012)
3. American Dental Association’s Center for Evidence-based Dentistry website: http://ebd.ada.org/ (accessed June 16, 2012)
4. 2006 House of Delegates Manual, Minnesota Dental Association, Minneapolis, Minnesota. 
5. Pihlstrom BL, Tabak L: The National Institute of Dental and Craniofacial Research: research for the practicing dentist. JADA 2005;136:728-737.
6. Nutting PA: Practice-based research networks: building the infrastructure of primary care research. J Fam Pract 1996;42:199-203.
7. Solberg LI, Cole PM, Seifert MH: The Minnesota Academy of Family Physician’s Research Network: a vehicle for practice-based research. Minn Med 1986;69:599-601. 
8. Dental Practice-Based Research Network website: http://www.dentalpbrn.org/home.asp (accessed June 18, 2012)
9. Longstreth WT Jr, Phillips LE, Drangsholt M, Koepsell TD, Custer BS, Gehrels JA, van Belle G: Dental X-rays and the risk of intracranial meningioma: a population-based case-control study.  Cancer 2004;100:1026-1034
10. NIH News, Thursday, April 12, 2012: National Institutes of Health, National Institute of Dental and Craniofacial Research: http://www.nih.gov/news/health/apr2012/nidcr-12.htm (accessed
June 22, 2012)
 
 
* Dr. Anderson is chair of the Minnesota Dental Association’s Evidence-Based Dentistry Task Force and a member of the faculty of the School of Dentistry, University of Minnesota. Email is  anders018@umn.edu.
** Dr. Foy is a past president of the Minnesota Dental Association, a member of the Executive Committee of the National Dental PBRN, and a private practitioner in Minneapolis, Minnesota. 
***Dr. Shamp is a member of the National Dental PBRN and a private practitioner in Maple Grove, Minnesota. 
†Dr. Rindal is a past president of the Saint Paul District Dental Society, Midwest Regional Director of the National Dental PBRN, and practices with HealthPartners Dental Group in Saint Paul,  Minnesota. 
‡Ms. Glasrud is the past Director of Policy for the Minnesota Dental Association.