A Guest Blog Post by Dr. Alexandre da Veiga Jardim, DDS; Clinical Professor at Universidade Paulista – Goiânia, Brazil.
As part of a series of guest blog posts by various orthodontic colleagues from around the world, I’m grateful today to my colleague Dr. Alexandre da Veiga Jardim from Brazil, for taking the time to share with us here at The Orthodontic Notefile, his thoughts and personal views on a very important and current topic; Evidence-based Orthodontics. I’ll leave you to read his guest post below.
“Science doesn’t exist to be admired, but to be questioned”
In 1985, David Sackett, main exponent of the Evidence Based Medicine movement, commented in the Moyers Symposium that orthodontics was behind such specialties as acupuncture, hypnosis, and homeopathy and on par with Scientology!
Those were hard words but not unfair ones. For many years, orthodontics had suffered from the same evil as medicine: anecdotal studies, lack of hierarchy on evidence, of scientific rigor and appropriated investigation methods. If you have read through this and already think this text is not for you because it focuses on scientific articles, think again: you might be the one whom this text was really meant for.
Where do the things you do in your practice come from?
Even if you find it hard to read scientific articles, or just prefer to attend lectures and congresses, know that you also depend on them. They are the only source of innovation in any healthcare profession. Any kind of therapy nowadays must pass through the scientific community’s appreciation and critical evaluation. If you don´t read scientific articles, you are just letting other people read and appraise them for you. You give up the right to evaluate the evidence by yourself. You let someone else decide for you.
Nowadays there is a trending demand that every lecturer be based on more credible data than personal opinion. And still, the same principles of critical evaluation apply to any lecturer. Not everything said from the tribune (or pulpit?) is a stone-written truth, and we still must question and be critical about it.
What is an evidence-based practice?
An evidence-based practice does not mean reading articles. It´s “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients”. That includes accepting new practices with better and proven cost-benefit relationship, refuse new practices with lack of credible evidence and abandon practices already been used that have no valid evidence.
As Trisha Greenhalgh (in her excellent book, How to read a paper) has put it, follow these steps:
- To convert our information needs into answerable questions (i.e. to formulate the problem).
- To track down, with maximum efficiency, the best evidence with which to answer these questions – which may come from the clinical examination, the diagnostic laboratory, the published literature or other sources.
- To appraise the evidence critically (i.e. weigh it up) to assess its validity (closeness to the truth) and usefulness (clinical applicability).
- To implement the results of this appraisal in our clinical practice.
- To evaluate our performance.
It´s a bit like playing Sherlock Holmes: We can never be certain of the crime, but we can use evidence to reach the best conclusion. That conclusion is a mixture between our clinical expertise, scientific evidence, common sense and patient opinion.
An evidence based approach will give you more safety, because it has been thoroughly tested in many patients. That is a safety measure in case of litigation, because you are backed up by evidence in case the worst happens (The Michigan case might have been different, for example).
Are all studies good studies?
Here is the catch: we can´t blindly generalize studies results for every patient, they are not just numbers and statistic. Studies are flawed by design, which is why it is so important to evaluate critically what we read. Unfortunately that is an art lost in many graduation programmes, even though it is a skill in increased demand from our clinicians in this new evidence based era.
It has been estimated that 90% of the published studies won´t bring any change to our clinical practice or are not useable. We must learn to sift through what is useful and what must be discarded. Although quite difficult, we can watch for common pitfalls in health studies:
- Small samples
- Wrong study design
- No control group
- The initial protocol had to be changed during the study
- Wrong statistical analysis
- Conclusions do not reflect the study results
I don´t need evidence, I have clinical experience
Bias is the systematic error, the induction of “contaminated” results (in our practice or studies). Although studies are not free from it, it is much more frequent in our clinical setting.
It is easy to forget 20 interventions that failed, when the twenty-first has an outstanding result, or to see a difference between two types of treatments that aren´t there.
Who hasn´t had a concept learned in their orthodontic residence which has at least once been challenged? Isn´t our first reaction confrontation with this new concept? “How is it possible that what I have learned is wrong?”. All the above are examples of bias in our daily clinical life.
Well carried studies can minimize the tendency of bias to achieve a more “pure” result. That is an important point we must weight when confronting studies with our clinical experience.
We should not follow studies blindingly neither stubbornly deny their power. A balance is needed.
How are we today?
In 1994 David Sackett spoke once again at the Moyers Symposium. The results of orthodontics first randomized clinical trial, Keeling´s study on early Class II treatment were just being presented and this time, Sackett´s words were more encouraging: “All orthodontists should look with pride on these trials, for they mark the entry of your profession into the ranks of the scientific health disciplines”.
So, are you an evidence-based orthodontist?
Dr. Alexandre da Veiga Jardim, DDS, is a Clinical Professor at Universidade Paulista – Goiânia, Brazil. He also manages his own orthodontic blog Ortodontia Descomplicada .