Early Class II treatment. Part 2; Are we clinician scientists or barber surgeons?
This is the second part of my post from last week. This is concerned with our presentation at the early treatment point/counterpoint discussion at the AAO conference 2015.
Jonathan Sandler started our session by discussing further data from the systematic review. He also pointed out that while the data suggested that routine early treatment is not effective; it does not mean that early treatment is not indicated for any patient. There always will be patients whose problem is so severe and/or they are being teased so badly that treatment is clearly indicated. In these instances, clinical experience needs to combine with evidence and patient opinion. This led to my final sections which I shall outline below. He also raised the question that if we ignore the evidence then we need to consider if we are clinician scientists or simply barber surgeons?
The evidence-based care movement in dentistry has become firmly established. Nevertheless, there is a common misinterpretation that treatment decisions should be based solely on scientific evidence. This is not the case and I have discussed this previously in this post.
Figure 1: the components of Evidence Based Care
We need to remember that evidence based care has three main components and I have illustrated these in Figure 1. The best way to interpret this interaction is to consider that the initial stage of developing a treatment decision is based around a combination of evidence and clinical experience. This is then followed by the essential step of outlining the possible treatments to our patients, along with any available evidence. As a result, they are in a position to take an informed decision on their care. In a situation where there is substantial evidence, it is likely that the evidence will outweigh clinical experience, because uncertainty is reduced. However, when there is limited evidence clinical experience then carries more weight.
It is then clear to me that the most important component of this relationship is the information that we provide to our patients. If the evidence is high and uncertainty is low, we can provide evidence-based recommendations. We certainly cannot ignore the evidence and we should not be saying to them “there is substantial evidence that we should treat you in a certain way, but I’m going to ignore it completely because of my clinical experience”.
I would also like to point out that when evidence is lacking, there is nothing wrong with explaining to our patients that there is limited evidence, but our experience suggests that they should be treated in a certain way. Our patients will then have all the evidence required to make an informed decision as part of consent to treatment.
In the case of early class II treatment, the evidence is clear and we cannot ignore it if we are to ethically consent our patients to treatment.
In my final comments, in our counterpoint, I expressed disappointment that we were having this debate. In this respect it is worth mentioning the comments of Dr David Sackett one of the founders of evidence-based medicine. In 1985 he spoke at the Moyers symposium and stated
“Orthodontics is behind such treatment modalities as acupuncture, hypnosis, homoeopathy and on a par with Scientology”.
He then attended the Moyers symposium again in 1994 when the early results of the class II studies were being presented He responded by saying.
“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”.
At this point the United States was leading in clinical trials. But since then I wonder if there has been a lack of momentum and researchers from other countries are beginning to lead the way?
Finally, at the end of our presentation, my overall feeling was disappointment that in the face of so much evidence we were still debating early class II treatment. Indeed, Drs Dugoni and Oh suggested that this was a controversial area! I propose that it is not; we have the evidence on this clinical question. It is time to move on… or indeed, are we clinician scientists or barber surgeons?