The Art and Evidence?
Dentists have long taken pride in applying the art of dentistry in a manner consistent with the scientific evidence. Patients have benefited from the results of this combined pursuit. In recent years, there has been an increased emphasis on evidence-based dentistry (EBD)—so much so, that the concept is an identified requirement in the curriculum standards provided by the ADA's Commission on Dental Accreditation (CODA).1 In one sense, this seems to be a push to downplay the art of dentistry, while placing an increased emphasis on the science. But, even if that is a hidden agenda (I am not advocating that it is), is that the reality of this effort?
The accreditation standard states that, “EBD uses thorough, unbiased systematic reviews and critical appraisal of the best available scientific evidence in combination with clinical and patient factors to make informed decisions about appropriate health care for specific clinical circumstances.” And indeed, much time, money and effort has been expended to increase the volume and quality of scientific evidence available to utilize in this pursuit. In addition to academic and corporate researchers, an increased number of private practitioners are also participating in research networks. Many of our professional academies support journals with volunteer reviewers and editors who contribute significant amounts of their lives to the accumulation and publication of this knowledge. But, how effective is the production of volumes of information at influencing how dentistry is practiced? How much value does this body of literature have if it does not really impact the evidence-based care of our patients? When does the evidence in that literature warrant making changes? Often, changes are not seen until an overwhelming body of scientific evidence demands that clinical decisions are altered. Until that point, one could argue that clinical decisions are made based on old scientific evidence and dentistry is being practiced as an art form.
The 2nd edition of the unabridged Random House Dictionary of the English Language includes 16 entries for the word “art”. The first of these is “the quality, production, expression, or realm, according to aesthetic principles, of what is beautiful, appealing, or of more than ordinary significance.” Another entry states, “skill in conducting any human activity.” I would contend that, regardless of scientific pursuit, data collection and reporting, dentistry can never be distanced from being a form of art. What we do as clinicians is a human activity, requiring the development of significant skill in order to optimally provide facial form, function and esthetics for those in need. So, the focus of this journal, and all others providing pieces of scientific evidence, should be to continue to enhance the skill-level of clinicians. Although the clinical aspects of dentistry will continue to change and be more and more impacted by the development of technology and robotics, the human interaction and activity must never go away. The art of dentistry will always be present.
With that said, I return to the question: When should the scientific evidence warrant a change within the skill set of a practitioner? I suspect that some practitioners use the argument of dentistry as an art form to resist making changes. Certainly, I have heard students justify clinical decisions based on “that is what ‘Dr. X says’ has been done for years.” Making a clinical decision based upon “it has always been done that way,” will often provide an outcome that is predictable and therefore comfortable for a practitioner. My years of practicing dentistry have taught me the value in being comfortable with systems and treatment recommendations. But, along with the significant advantages of being comfortable, there is a danger in that comfort. Although providing predictable care, is it the best care that could be provided? Indeed, sometimes there is evidence available to elevate the quality of care, but the evidence is resisted, because it threatens the practitioner's level of comfort.
But, this coin has another side. There are times when clinical decisions are altered, based on trends and marketing strategies, rather than the available evidence. The CODA document clarifies that EBD “…requires the judicious integration of systematic assessments of clinically relevant scientific evidence….” So, the evidence must be produced, but it is the systematic assessment of that evidence that should drive changes in our clinical decisions. One valid argument to resist change based on the literature is uncertainty about how much evidence and what kind of evidence should exist before changes are embraced. A single study supporting a new approach in clinical practice should not be viewed as adequate evidence to make a change. The scientific method demands that results be repeatable in different places by different people. Understanding the need for systematic review of the evidence should help us gain confidence as to when it is appropriate to alter the decisions that we make in our clinical dentistry.
There exist examples of this issue being challenged on both sides. On the one hand, systematic reviews of significant bodies of evidence have supported changes in clinical decisions that some continue to resist (the use of school-based pit & fissure sealants comes to mind2). Conversely, there are systematic reviews of significant bodies of evidence that seem to indicate caution should be exercised in adopting a change, while many seem to have already done so (“simple” adhesive systems might fall here3–4). Knowing when, where and how to apply increased knowledge remains a distinctly human activity.
Indeed, there is a growing body of scientific evidence and an increasing number of systematic reviews of that evidence. But, such evidence will never be useful unless properly applied in the clinical environment. The skill required in applying new knowledge to the care and well-being of people remains in the hands of human beings; the art of dentistry is alive. Keep it well.