The Intersection of Science and Belief in Dentistry
In the practice of dentistry, as in all fields of medicine, our primary commitment is to the health and well-being of our patients. “Do no harm.” This commitment necessitates that we base our treatment recommendations on the most reliable and valid information available. To fulfill this duty, it is crucial to understand the distinction between science and belief, and how these concepts impact the delivery of care. Over my last 3 decades of practice, it is disheartening to see that this distinction has become muddied, and may be poorly understood.
Science vs. Belief: A Crucial Distinction
Science is a systematic approach to acquiring knowledge. It relies on empirical evidence, rigorous testing, and logical reasoning. It is characterized by the use of controlled experiments, peer review, and reproducibility of results. In contrast, a belief is a conviction or acceptance that something is true, typically without the need for empirical evidence or scientific validation.
In our profession, beliefs can be adopted through tradition, through influential opinions of respected colleagues and through personal experiences or success stories. In essence, beliefs are based on anecdotal evidence. I have personally witnessed that beliefs shape the delivery of care to patients, sometimes leading to sub-optimal patient outcomes. For us to provide sound, predictable treatments to our patients, it is essential to recognize that beliefs, regardless of their origin, do not equate to scientific evidence.
The Influence of Belief on Clinical Practices (Delivery of Care)
Certain treatment philosophies persist not because they are supported by robust scientific evidence, but because they are rooted in long-held beliefs. Clinicians adhere to these specific treatments simply because they observed positive outcomes in their own practice or because these methods were taught by self-professed experts. However, this is anecdotal evidence and requires confirmation or refutation through the use of rigorous scientific method. As an example, it is not long ago when a common belief in our field was that temporomandibular joint disorders were predominantly occlusal in origin and were treated as such. Only through scientific method was this notion disproven. Recently, the medical profession believed that Oxycontin was a panacea for chronic, intractable pain. It was promoted as a wonder drug that had no addiction potential. We all know that this sparked an opioid addiction crisis that had a profound negative impact on our population. It is essential to understand that while anecdotal evidence can be compelling, it is inherently subjective and lacks the rigour necessary to be considered scientific. This can lead to the perpetuation of practices that are not the most effective or safe for our patients, while sometimes also increasing their financial burden.
Currently, in our profession, there is significant focus on “airway-centric dentistry.” Sleep Disordered Breathing is a real problem in our society and dentists have an important role to play in its treatment. Let’s look at a concept within this discipline. There is a belief that expansion of the maxilla or dentition “cures” obstructive sleep apnea by allowing the tongue to be housed in a proper sized maxilla/arch, hence preventing its obstruction of the airway. I don’t discount the possibility that this theory may be validated with thorough scientific scrutiny, but we’re not there yet.
With that in mind, let’s talk about a maxillary expansion appliance that was pioneered by an “expert.” This “specially designed and patented” appliance provides forces to the maxillary complex that are different than any other type of orthodontic appliance due to its spring design. This statement in itself should cause one to pause and think: does it make sense that our biology is engineered to discern between forces applied using a spring, screw, elastic or other means? At any rate, the appliances’ promise is that it significantly improves obstructive sleep apnea (OSA), permanently. In reviewing a published article about this technique, it is seriously lacking. Firstly, it is retrospective and based on a data set that allowed various clinicians (or a task force) to input data from their own clinical experience. Secondly, the improvements in OSA were varied, and certainly did not offer a cure. Thirdly, the successful outcomes may be due to other “adjunctive treatments” that were provided concurrently while utilizing the appliance, one of them being the use of a CPAP machine! Furthermore, there is not one mention of controlling variables such as weight loss or sleeping position. This is not scientific evidence and we should not base the delivery of care on this level of evidence.
Let’s look another example – min-screw-assisted rapid palatal expansion (MARPE). This is an excellent, relatively new, treatment modality to skeletally expand a maxilla. When used in the proper situation, it has brought significant benefits to patients that were previously only available through orthognathic surgery. And yes, MARPE procedures do appear to increase the size of the airway. However, the use of this technique is promoted to be a cure for OSA. At a recent conference, a well-known and respected lecturer demonstrated this belief by showcasing a 55-year-old woman whose “life was changed forever” due to the success of a MARPE treatment. But is this true and predictable? If we look at the data, it is clear that the success rate of MARPE (sutural/skeletal expansion) is 83.3% in ages 15-19, 81.8 % in ages 20-29, and drops to 20% in ages 30-37. It is likely worse in 50-year-olds. Even if MARPE was the panacea we are looking for, to have success in one patient in their fifties (when OSA is most prevalent), you would have to treat 5. That is simply not predictable treatment.
Defining Scientific Evidence and Proper Clinical Studies
Scientific evidence in dentistry is derived from well-designed clinical studies that follow strict methodological guidelines. A proper clinical study should include:
1. Randomized Controlled Trials (RCTs): These are considered the gold standard in clinical research. Participants are randomly assigned to either the treatment group or the control group, minimizing bias and ensuring that the outcomes are attributable to the intervention. Variables are controlled.
2. Prospective and Blinding: Ideally, the treatment group and control group should be assembled prior to the delivery of the treatment being investigated. Both the participants and the researchers should be unaware of which group participants are in (double-blind) to prevent bias.
3. Large Sample Sizes: Studies with larger sample sizes are more likely to produce statistically significant results that can be generalized to the broader population.
4. Peer Review and Reproducibility: Research findings should be published in peer-reviewed journals and be reproducible by other researchers to validate the results.
Our Duty to Practice Evidence-Based Dentistry
As dental professionals, we have a moral and ethical obligation to provide care based on the best available evidence. This means continuously updating our knowledge and practices in light of new scientific research. By doing so, we ensure that our patients receive the most effective, safe, and up-to-date treatments.
While beliefs may have a place in our personal and professional lives, they should not dictate our clinical practices. It is our duty to our patients to distinguish between belief and scientific evidence, and to practice evidence-based dentistry. This commitment not only enhances patient outcomes but also advances the field of dentistry as a whole.
About the Editor
Bruno Vendittelli is a Toronto based orthodontist whose practice is Forest Hill Orthodontics. He is a Staff Orthodontist at the Hospital for Sick Children and an Associate at the University of Toronto, Faculty of Dentistry.