The emergence of evidence-based medicine (EBM) is more than a trend. It is a demand made upon surgeons in contemporary practice. The blossoming of EBM in oral and maxillofacial surgery is presented in the pages of JOMS and includes basic and patient-oriented research, randomized clinical trials, meta-analysis, and current therapy section contributions. These components of our specialty’s science are the elements of EBM in oral and maxillofacial surgery today. They are expressions of a universal trend in health care that supports the reasoned and contemplative path towards clinical decision-making.
The development of practice guidelines, care paths, and the JCAHO patient safety initiatives are systemic examples of this trend. These products are constructed upon evidence-based models. The path toward EBM in our practices depends upon rigorous research design presented in peer-reviewed surgical literature. Organizations including hospitals, government, and payers then filter such raw clinical evidence to create their own (sometimes conflicting) standards of practice. The content of such standards may go beyond simple scientific conclusion. The results of EBM attempts by organizations may be influenced by their organizational goals, political views, economic constraints, and business models among other factors extraneous to the surgeons’ world. As a result, these efforts may barely resemble the world of daily surgical practice.
The surgeon’s path toward EBM requires the continuous efforts of every individual clinician. Surgeons must continuously update their knowledge through continuing medical education and synthesize new knowledge into clinical practice. Surgeons learn from the daily experience of patient care in their unique community setting to guide their decisions. To develop their own EBM model, they must have a willingness to adjust practice decisions based upon new evidence. Increasingly, surgeons must also respond to the external forces outlined above that will attempt to influence (or even make) clinical decisions for them.
Thus is formed the essential question: How does EBM translate into oral and maxillofacial surgical practice today? How are clinical decisions really made? Actually they are made …
In the Blink of an Eye
Patient presents with 28 natural teeth and a painful mandibular left second molar:
Patient: “What do you recommend, doctor?”
Doctor: “I recommend we remove your molar and your best choice is to replace it with an implant today.”
Real decisions in clinical practice are made in the blink of an eye. While one might imagine it is better to carefully contemplate all options, the surgical mind is more impressive than that. Surgeons have the ability to synthesize vast amounts of information and formulate in their minds a host of competing issues to make clinical decisions. These instant clinical decisions take into account all the essential issues to provide maximum benefit to the patient. In the blink of an eye, clinical decisions are guided by:
•A synthesis of knowledge and personal experience
•An amalgamation of professional identity, patient care, and personal goals
•A continuously evolving assessment of one’s own ability and skills
•An assessment of patient goals and expectations
•A desire in every case for an achievable and successful outcome
A synthesis of knowledge and personal experience: In the above example, the surgeon recognized that the tooth was cracked and granulation tissue had filled the furcation, making the prognosis for root canal therapy poor. In fact, his endodontic colleague had recently counseled in a continuing education course that mandibular second molars were particularly vexing when cracked. The surgeon’s own observation of the loss of bone following extraction demonstrated to the surgeon the value of immediate implant placement. For the past 3 years, the surgeon had experienced good results with this technique. To confirm his impression, the surgeon had recently read a paper demonstrating good outcomes of immediate implant placement in molars utilizing wide body implants with the surgeon’s preferred system.
An amalgamation of professional identity, patient care, and personal goals: For too long, surgery was a destructive discipline: remove the damaged part and hope to pick up the pieces later. Mandibulectomy patients were left unreconstructed. Avulsed tissue was pexed and covered with dressings. Edentulous sites remained.
From free tissue transfer, tissue engineering, and dental implants, surgeons now always ablate disease with the end in mind being a functional and esthetic reconstruction. Ridge preservation and immediate implants are now part of the reconstructive professional identity of surgeons who now treat many diseases as a temporary entity.
A continuously evolving assessment of one’s own ability and skills: How many surgeons would have made the above recommendation a decade ago? Self-assessment of one’s own abilities is an essential survival skill for every surgeon.
An assessment of patient goals and expectations: The surgeon recognized (or perhaps anticipated) the patient’s desire to maintain their dentition as well as their dismay over the first loss of a functional tooth in their lifetime. While the surgeon assumed the desire that the patient likely had for a reconstruction, clearly the decision for care remained the patient’s autonomous choice.
A desire in every case for an achievable and successful outcome: Motivation for successful treatment is the most powerful factor in clinical decision-making. The nuanced understanding of what is achievable in a clinical case is so individualized to the patient, the setting, the surgeon, the team, etc that it can only be expressed as a summary decision.
The Surgeons’ Way
While it is often criticized, the surgeons’ “in the blink of an eye” surgical decision is unsurpassed as a method of providing quality care, provided that the surgeon is continuously incorporating new knowledge from the pages of JOMS, new experiences from practice, and new wisdom that is the synthesis of both. For example, our lead article in this month’s issue demonstrates Grant et al’s experience with implants placed in patients on bisphosphonates.1 Also, Susarla et al’s outcomes of immediated versus delayed loading of dental implants,2 Boronat et al’s assessment of bone loss about early loaded implants,3 and Nitzan et al’s experience with condylar hyperplasia4 are opportunities to compare these surgeons’ findings with your own clinical experiences.
If there were care paths for the above example of the extraction of the second molar, the surgeon might spend an hour entering critical information against which a clinical decision would emerge. After the software did its work and the result was displayed, the surgeon would find his/her blink of an eye decision confirmed or he/she would be dismayed by a ridiculous recommendation. The recommendation of an experienced doctor is rarely wrong.
So how would you compare the EBM contemplative approach with care paths to what is likely your current method of clinical decision-making? While there may be no evidence to support the superiority of either method, the surgeons’ actual approach to clinical decision-making is the one that works in their hands, the most important reason to support it.
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