J Dent Educ. 69(11): 1251-1256 2005
© 2005 American Dental Education Association
Utilization of Evidence-Based Informational Resources for Clinical Decisions Related to Posterior Composite Restorations
Reem N. Haj-Ali, B.D.S., D.D.S., M.S.;
Mary P. Walker, D.D.S., Ph.D.;
Cynthia S. Petrie, D.D.S., M.S.;
Karen Williams, Ph.D.;
Tabitha Strain, B.S.
Key words: survey, evidence-based dentistry, dental education
Submitted for publication 03/30/05;
accepted 07/27/05
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Abstract
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The purpose of this study was to characterize evidence-based informational resources utilization patterns of a sample of general dentists with respect to clinical decisions regarding posterior composite restorations. A stratified random sample of general practitioners belonging to the Academy of General Dentistry (n=2880) was mailed a questionnaire that elicited information about practice characteristics and informational resources used for clinical decision making related to posterior composite restorations. Six hundred ninety-nine dentists responded (24 percent response rate). Use of evidence-based (EB) resources (journals and online data bases) was low for all respondents (14 percent) for all levels of experience; however, more experienced clinicians were more likely to use EB resources than recent graduates. AGD Master-level members were significantly more likely to use EB resources than their counterparts (p<.05). Within the limitation of this study, current patterns suggest a low reliance on evidence-based informational resources in the practice of clinical dentistry.
Dentists are faced daily with challenges of making treatment decisions regarding their patients. As health care providers, it is important that dentists offer the best possible care for their patients. One method that facilitates the decision-making process is a systematic approach that begins with identifying a question around an area of uncertainty regarding a patient treatment, locating the evidence that answers the question, assessing the evidence’s validity and relevance, making the decision based on the best available evidence, and finally evaluating the outcomes. In dentistry, this approach is described as evidence-based dentistry (EBD).1 It is a way of resolving clinical decisions based on evidence rather than empiricism.2
With a subject as complex and potentially controversial as the application of dental composite versus amalgam for posterior restorations,3–11 it is common that clinicians find themselves perplexed by the various factors involved in clinical decision making. Such controversies related to the use of amalgam include patients’ perceptions that there are hazardous effects from mercury release, the increased patient demand for esthetic dentistry, the limitless publications on this subject, and the various new products introduced to dentistry. There is a question as to how and whether practitioners are able to make appropriate decisions regarding the use of resin-based composites in posterior stress-bearing areas. Therefore, the purpose of this study was to characterize the informational resource utilization patterns of a national sample of general dentists with respect to clinical decisions associated with posterior composite restorations.
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Materials and Methods
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The target population was a stratified, random sample (n=2880) obtained from the latest Academy of General Dentistry membership list including different AGD levels (Members, Fellows, and Masters). Prior to selection, listed practitioners were stratified according to seven geographic regions, and a proportional, computer-generated, random sample was subsequently obtained. This strategy was used to prevent oversampling of members in more densely populated areas, while concomitantly ensuring geographical representation of members from across the United States. The sample size represented 10 percent of the accessible AGD members’ list in addition to a 2 percent oversampling strategy to compensate for the anticipated high nonresponse rate.
After obtaining approval of the University of Missouri-Kansas City Adult Health Sciences Institutional Review Board, a questionnaire was designed to elicit information from general practitioners regarding their dental practice characteristics, level of training, AGD member status, use of amalgam, and informational resources used in clinical decision making regarding posterior composites. The questionnaire was piloted among ten general dental practitioners and amended following receipt of their recommendations.
To achieve the highest possible response rate, a cover letter, the questionnaire, and a self-addressed, stamped return envelope were sent directly to each dentist. The cover letter requested that the dentist complete and return the questionnaire in the return envelope within a four-week period. No other dentist or practice identifiers were used. Four weeks after the initial mailing, follow-up reminder post cards were sent to the original list of subjects.
The data contained in the returned questionnaires was evaluated via SPSS statistical software (v. 12.0.2, SPSS Inc., Chicago, IL). Descriptive analysis was used to characterize the size of dental practice based on number of staff; type of practice (rural, small town, or large town); dentist’s experience (years since graduation); and AGD member status (AGD Member, Fellow, or Master). In addition, a weighted composite scale was computed to evaluate the degree to which individuals use evidence-based (EB) and non-evidence-based (non-EB) resources for clinical decision making. Monthly use of traditionally considered EB resources such as peer review journals and online databases were coded as positive, and use of resources traditionally considered to be non-EB (discussions with colleagues, study clubs/continuing education courses, and manufacturers’ information) were coded as negative. Survey respondents’ ratings of the use of EB and non-EB informational resources were then summed and ranked according to the following rubric: 
0 = Primary Use of Non-EB Resources, 1–2 = Some Use of Non-EB Along with EB Resources; and 
3 = Primary Use of EB Resources. This scale was used to evaluate whether use of evidence-based resources differed as a function of clinician experience. Experience was determined using two variables: years experience in ten-year intervals and AGD member status. Comparisons of groups were made with nonparametric chi square test statistics at an 
level of .05.
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Results
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Replies were received from 699 currently practicing dentists, giving an overall response rate of 24.3 percent. Most of the responders were AGD Members (66.7 percent), 25.7 percent were AGD Fellows, and 7.6 percent were AGD Masters. The average years of clinical experience were 20.1 (±11.6). As for practice location and size, the majority of responders (73.4 percent) had their practices in large towns (>10,000) and were mostly (59.5 percent) involved in medium-sized practices with three to seven employees. Interestingly, 31.7 percent of respondents described their practices as amalgam/mercury-free practices, while the remaining 68.3 percent reported still using amalgam. Table 1
summarizes the demographic characteristics of responding AGD members.
Table 2 shows the responders’ general use of traditional EB and non-EB informational resources. Study clubs/CEC and discussions with colleagues were commonly used resources for making clinical decisions (69.2 percent and 69.2 percent, respectively). Online resources were used the least (24.9 percent). In addition, 59.6 percent of practitioners relied on peer-reviewed journals while 41.8 percent used manufacturers’ information as resources.
Table 3 shows the distribution of respondents’ use of resources for making clinical decisions. An overall review of the pattern of resource utilization indicated that the majority of practitioners used both the traditionally considered evidence-based resources (peer-reviewed journals and online data bases) as well as the traditionally considered non-evidence-based resources (discussions with colleagues, study clubs/ CEC, and manufacturers’ information) for making decisions regarding the use of posterior composites. However, a significant (p=.0001), smaller percentage of respondents used primarily EB resources (13.9 percent).
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Table 3. Distribution of respondents with regard to their collective use of resources for making clinical decisions by years of experience and AGD member status
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When looking at the resource utilization pattern in regard to the practitioners’ years of experience, the same pattern was observed, with the majority of respondents using a combination of EB and non-EB resources. However, even though there was no statistically significant difference (p>.05) between experience groups, it was evident, as demonstrated by the data presented in Table 3
, that the more experienced practitioners were more likely to use EB resources while the less experienced were more likely to use non-EB resources. When considering the respondents’ AGD status, a significantly higher (p<.05) percentage of AGD Masters used EB resources, while a lower percentage used non-EB resources for clinical decision making (28.3 percent and 20.8 percent, respectively).
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Discussion
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Patients are becoming much more informed via the widespread use of the Internet and other media resources; as a consequence, patients are demanding treatment options and explanations of the associated potential advantages and disadvantages. Thus, it is necessary for practitioners to base their treatment decisions not only on their experience and preference, but also on evidence-based resources such as the most recent and valid research data. An evidence-based approach to dental practice assists clinicians in making intelligent decisions regarding patient treatment.
With evidence-based practice being an emerging concept in dentistry, it is unknown whether it is being implemented in the general dental practice and what informational resources practitioners might be using when making clinical decisions. Therefore, in an attempt to answer that question, this survey targeted a sample population that represents the typical general dentist. While it was expected that newer graduates were more familiar with the concept of EBD and therefore possibly more likely to implement its principles into their practices, results from this survey suggest the opposite. Less experienced practitioners (i.e., newer graduates) were less likely to utilize what could be regarded as EB resources (peer-reviewed journals, online databases). Instead, one of their main resources for clinical decision making was discussions with colleagues. In contrast, more experienced practitioners were more likely to depend on EB resources. In addition, the pattern of informational resource utilization seemed to be also influenced by the practitioner’s AGD membership status. With AGD Masters attending additional training in various dental disciplines,12 they were more likely to use EB resources than AGD Fellows or Members.
This pattern may be explained by the fact that EB dentistry is not a rigid methodology that dictates what dentists should or should not do. Instead, a dentist using this approach to dental care must integrate the scientific evidence and the clinical and patient factors, in addition to the practitioner’s experience, in order to make the best possible decision regarding treatment for a specific clinical situation.13 Experienced practitioners hold the advantage of having seen the results of previous decisions, good or bad. This mental library of circumstances might act as a guide when other circumstances arise. Decision making in clinical practice thus is supported by pattern recognition when experience exists.14 Early in the dentist’s career, with little experience on which to draw, decision making may be the most difficult aspect of clinical dentistry. New practitioners may seek other experienced practitioners as a convenient source of guidance in their decision-making processes until they build their own.
Nevertheless, regardless of years of experience or membership status, the survey suggests that practitioners generally utilize a combination of EB and non-EB resources. To encourage implementation of EBD in clinical practice, it is important to identify potential barriers that could hinder practitioners from incorporating the EBD approach into their practice. An important obstacle may be the inability of practitioners to discriminate good evidence from poor. It is important to note that finding the evidence is just the first step. Every informational resource has its advantages but more importantly its disadvantages that may mislead practitioners into making wrong decisions. While consultation with colleagues, which was the resource most commonly used, is an efficient and inexpensive approach to answering a clinical problem; this approach is not considered EB practice and has its drawbacks. Colleagues might not be up-to-date with newer materials and techniques, and even if they have read the most current evidence-based literature, they may not provide an unbiased interpretation of the associated information. Information from manufacturers is generally regarded as selective, at best, designed to put the product in the most favorable light and is not considered evidence-based. Yet, as the results indicate, approximately 40 percent of respondents rely on such resources.
Even when using peer-reviewed journals, one is assuming that the reviewers are skilled in the precepts of evidence-based dentistry and had applied those concepts when reviewing the manuscripts. CE courses or study clubs are only as good as the research presented in them, and CE presenters should clearly reveal their conflict of interest in a particular subject. Additionally, a high percentage of CE courses are given by representatives from manufacturers, which again provides information designed to support the product. While online data incorporates some non-EB resources such as personal and manufacturers’ websites, other EB resources such as Pub Med electronic databases and Cochrane reviews are valuable.15 This latest is intended to produce up-to-date, accurate information about the effects of health care readily available worldwide. It disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions.2,16 Nevertheless, if practitioners lack the appropriate skills for distinguishing good evidence from poor, inappropriate treatment decisions could still be made.17 To overcome this limitation, clinicians would likely need to participate in selective CE courses that review some basic literature assessment criteria that could be used to evaluate evidence-based resources. Although these courses have not been common, a comparable course, "Promoting Evidence-Based Decision Making," was part of the program at a recent American College of Prosthodontists national meeting.18 This topic could be similarly incorporated into programs for general dentists.
Last but not least, the attitude of the practitioner may be yet another barrier to changing practice.19,20 For example, as the current survey showed, approximately a third of the respondents described their practices as mercury/amalgam-free practices. Although there has not been any evidence to support this approach to dentistry,3,21 doing so deprives patients from a potentially viable treatment option that may be particularly appropriate in some posterior restorative situations. In fact, the National Council Against Health Care Fraud, which has no connection to organized dentistry, has taken the position that "mercury-free dentistry" should be considered substandard practice.22 As with practices that still provide amalgam as a treatment option, the dentist’s attitude related to meeting patient demands for esthetic dentistry may be an additional obstacle to evidence-based practice.23
This survey attempted to characterize the dental informational resource utilization patterns with respect to clinical decisions associated with posterior composite restorations; but as with any other survey, nonresponse bias seemed to be an associated limitation. The response rate to this survey was below the mean response rate (64 percent) to questionnaires completed by dentists as reported by Tan and Burke.24 Additionally, the questionnaire was sent to practitioners belonging to the AGD, who may be more motivated to seek information from evidence-based resources than other practitioners not seeking membership in this association and therefore it would be hard to generalize the results of this study to all general practitioners. However, the result may be an indication that evidence-based dentistry is still an emerging concept and, therefore, there still is a strong need for further teaching and implementation of evidence-based dentistry particularly in dental schools’ curricula.
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Conclusions
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It is likely that newer graduates have been exposed to the concept of evidence-based dentistry, but current patterns of information resource use elicited in this survey suggest a low reliance on evidence-based information in the practice of clinical dentistry. However, there was increased utilization of evidence-based resources by clinicians with more years of experience.
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Acknowledgments
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The authors want to express their sincere appreciation for the cooperation of the Academy of General Dentistry and more specifically want to acknowledge the AGD members who took time to respond to the survey.
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Footnotes
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Dr. Haj-Ali is Assistant Professor, Department of Restorative Dentistry; Dr. Walker is Associate Professor and Director of Dental Biomaterials, Department of Restorative Dentistry; Dr. Petrie is Assistant Professor, Department of Restorative Dentistry; Dr. Williams is Professor and Director of Clinical Research Center, Department of Behavioral Sciences; and Ms. Strain is a dental student and participant in the Dental Research Scholars Program—all at the University of Missouri-Kansas City. Direct correspondence and requests for reprints to Dr. Reem Haj-Ali, University of Missouri-Kansas City School of Dentistry, 650 E 25th St., Kansas City, MO 64108; 816-235-2012 phone; 816-235-2157 fax; haj-alir{at}umkc.edu.
This study was funded by the Rinehart Foundation, UMKC School of Dentistry.
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Abstract
Materials and Methods
