Dentistry

EBM v. OBM

Broadway Dental Care2 Comments

So if EBM means evidence based medicine what does OBM mean?

bury_your_head_in_the_sand

OBM = Ostrich-Based Medicine (substitute whatever you like for the last bit, be that medicine, healthcare, dentistry) where we ‘bury our heads in the sand’ to the consequence of our individual and collective actions.

No one individual can have enough personal knowledge and experience to constantly be giving the best advice to their patients and once we check our ego’s in at reception and admit that to our serves several things happen:

 

What we thought was best advice last year may not be anymore. Getting feedback in healthcare can take years before the consequences of our actions can be seen.

 

What we read, hear and see may not always be true.

As health-care professionals using a few basic research tools, we must question everything no matter how eminent the source. If someone says they have the evidence (politicians love to use the evidence word) we must have the courage to ask them to openly disclose it for critical appraisal. A lot of times their evidence is weak, second-hand or anecdotal.

EBM is about taking the ‘best available evidence’ not ignore everything except randomised controlled trails. Then taking into account our personal experience and skill sets apply that information to the situation in hand, this is the ‘black art’ as Dr Brian Goldman like to call it. Another thing to mention is that most published evidence is presented based on an average value for a group of people and we need to interpret that data and apply it to the individual.

Freakonomics on Bad Medicine

Here are the links to three great podcasts on evidence-based medicine.

freak

http://freakonomics.com/podcast/bad-medicine-part-1-story-98-6/#disqus_thread

Bad Medicine, Part 2: (Drug) Trials and Tribulations

http://freakonomics.com/podcast/bad-medicine-part-3-death-diagnosis/

Reading the comments section is quite interesting as it highlights a lot of the problems with evidence-based medicine (EBM). Once both the profession, industry, and patients become comfortable with the realities of uncertainty, feedback and our personal biases then understanding the philosophy behind EBM become clearer.

How trendy are dental implants?

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The simple answer is ‘very‘.

If you type ‘missing teeth‘ into Google the dominant treatment mentioned on the first page of results is ‘implant‘.

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Why is this?

Is it a better treatment for missing teeth than other options such as dentures and conventional bridges? In a Cochrane Review (which is an independent rigorous review of the quality and validity of healthcare research) the answer was a little disappointing for those of us expecting a clear cut answer. Their conclusion was:

“AUTHORS’ CONCLUSIONS: Based on trials meeting the inclusion criteria for this review, there is insufficient evidence to recommend a particular method of tooth replacement for partially edentulous patients.”

First, let’s look at the trend in published literature from Medline (the main database for medical research) and as we speak nine times more papers are published in 2015 on dental implants than any other main-stream clinical technique for dealing with missing teeth.

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Currently,9 times more papers are published last year on dental implants than any other clinical technique for dealing with missing teeth. The biggest difference between old-school conventional dental treatments and implants is money. Unlike dentures and bridges implant treatment involves working in collaboration with the pharmaceutical/biotech industry who are capable of directly and indirectly sponsoring the research, and research is very expensive. This has been studied and been shown to potentially positively bias the result in about 30% of cases. 

Combine this with direct and more importantly indirect marketing and it can appear to the lay person there is only one GOLD STANDARD treatment, implants. The alternative treatment options don’t get the same amount of exposure. For indirect marketing, the modern term is astroturfing summed up nicely in this TEDx talk by Sharyl Atkinsson.

TAKE HOME MESSAGE: Dental implants are very good but so are all the other major treatment options done correctly. They just dont get as much exposure. The important message in evidence-based dentistry is that the treatment option, be that implant, denture, bridge or nothing must match up with:

  • The best research evidence
  • The clinical expertise of the team both clinical and technical
  • The patient’s expectations, preferences, ability to comply with the treatment, personal circumstances, finances both now and for future maintenance.

As an example implants might be the best option to restore a missing front tooth following a skiing accident where all the other teeth are perfect, a baby-boomer with lots of old failing fillings and crowns might benefit best from a new bridge and where there are many missing teeth a denture may still be the best treatment option.

Before you chose make sure you have discussed all the sensible options with your dentist and don’t be afraid to ask those awkward questions.

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It took 32 years. Better late than never

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On Saturday I matriculated (became a student) at Oxford University. Matriculation is the ceremony at which new students are entered into the register (matricula) of the university, at which point they become members of the university. Oxford requires matriculants to wear academic dress (subfusc) during the ceremony hence the long gown, dark suit and white bow tie.

Why, you may ask am I becoming a student again at 50? The answer is quite simple, after 28 years of full time clinical dentistry I would like to pass a little of my experience on. Basically continuing the quest for the defining the difference between ‘bad luck and bad practice’.