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The Value of Clinical Decision Making Criteria

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Jeff BurgessIn the past 13 years a move has been made to develop scientifically based clinical guidelines to help dental professionals use evidence based decision making in their choices related to all manner of treatment procedures.  In fact, according to at least one source, if one searches the US National Guidelines Clearing House there are over 232 guidelines covering an extensive array of dental procedures. See:

http://www.nature.com/ebd/journal/v5/n1/full/6400243a.html
http://www.guidelinecentral.com/summary-specialty/dentistry
http://ebd.ada.org/ClinicalRecommendations.aspx

However there is considerable overlap related to the published guidelines and in relation to specific ‘national’ standards.

In Canada the ‘Canadian Collaboration on Clinical Practice Guidelines in Dentistry (CCCGD) was formed as a national autonomous organization to promote responsible clinical practice guidelines for Canadian dentists.  According to the ‘Journal of Evidence Based Dentistry’ as of 2004 this was the only evidence-based guideline group specific to dentistry (there are other organizations that include dentistry in their guidelines, such as the Scottish Intercollegiate Guidelines Network (SIGN) or the National Institute of Clinical Excellence (NICE)) but these latter groups cover the entire field of healthcare.

The creation of evidence based guidelines is important because they promote ‘best practices’ in clinical practice.  However they do not constrain what a clinician might ultimately choose to do with respect to treatment in a given circumstance.  A ‘guideline’ does not constitute a ‘standard’ of care but can and should be used to guide appropriate decision making.

An example of the importance of evidence based decision making is the study published in the Journal of the American Dental Association in 2012 (J Am Dent Assoc. 2012 Mar;143(3):241-52) titled ‘Evidence supporting the use of cone-beam computed tomography in orthodontics’.  Authors van Vjiimen, Kuiipers, and colleagues provide a systematic review of the literature related to CBCT applications in orthodontics.  550 articles are reviewed and assessed in relation to 13 established criteria related to study design measurements and statistical analysis.  Only 50 articles met their inclusion criteria, demonstrating the sad state of the science to date.  And of these, the methodological quality averaged only 53 percent (range 15-77 percent).  While the results of some of the studies suggested that CBCT allowed for improved diagnosis and better treatment planning, it was not found to be better than that provided by conventional imaging modalities.  However, they did find that the area in which CBCT excelled was in relation to airway diagnostics.

This information, based on systematic review of the research literature,  should be helpful to the clinician thinking of using CBCT in the evaluation of orthodontic patients.  Hence, inceDental (incedental.com) recognizes the importance of evidence based clinical decision making and encourages its readers to review the available literature that has been accumulated to support their ‘best practices’.  We also suggest that there be an International group similar to the Canadian group be established to broaden the reach of the developed evidence based clinical guidelines.

Warm Regards,
Jeff Burgess
DDS MSD, Editor in Chief

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