Journal of Oral Implantology April 2013 - (Page 121)
Evidence-Based Practice or Practice-Based Evidence?
Dennis Flanagan, DDS*
he evidence-based practice movement
was begun in 1972 by the Scottish
epidemiologist Archie Cochrane,1 and
the term was first used in 1990. In
1992, a group at the Oxford University
in England defined five steps for evidence-based
practice. The second step asks for the ‘‘best
evidence available,’’ irrespective of the level of
credibility. This implies that any evidence is better
than none. In 1993, the US Supreme Court decision
of Daubert v Dow Merrill Pharmaceuticals, Inc ruled
on the admissibility of evidence in federal court
cases.2 With this decision, federal court evidence
must meet standards for admissibility, that is, there
must be test-proven and expert-accepted, informational support for all scientific-related testimony.
There must be evidence that supports the evidence.
We implant dentists strive to have our treatments supported by basic science and clinical
research. The reality is that only about 5% of the
published work is true science—randomized double-blinded, controlled trials, the highest-rated level
of evidence. The large majority of implant research
consists of case reports, case series, and metaanalyses of these. Thus, we basically may have
anecdotes and series of anecdotes and analyses of
collected anecdotes as our basis for treatment.
Obtaining true scientifically based evidence is
time-consuming, expensive, and many times humanely impossible. Animal studies are done but
cannot be extrapolated to human application.
Studies with a high credibility level are difficult to
design and equip and expensive to perform.
Equipment, medications, and patients must be
collected. The study must be scientifically well
founded and answer a proposed question. Any
patients must be informed and not harmed by the
process. Human and animal subjects must be
treated humanely. All this entails a major commitment of time and financial resources. Consequently,
much research is done by the larger implant
manufacturers, which have the financial resources
to fund research.3 When their research results are
published there is a financial disclosure statement
placed at the end of the article. This may incur
doubts as to the veracity for the reader.
As a result, although not science, published case
reports from practitioners are an important resource
by default. At this point in the advancement of
clinical implant dentistry, case reports are the main
source of evidence for how we operate. Thus, rather
than looking to manufacturers to elucidate and
edify our discipline, we should publish our particular clinical experiences, both successful and
unsuccessful. Complications and unsuccessful treatment outcomes are very useful clinical caveats.
In the end our published case reports and case
series may be the most underrated level of evidence
we have. Our evidence is ultimately practice based.
1. Cochrane A. Effectiveness and Efficiency: Reflections on Health
Services. London, UK: Royal Society of Medicine Press, Nuffield
Hospital Trust; 1972.
2. Flanagan DF. US Supreme Court decisions, expert testimony
and implant dentistry. J Oral Implantol. 2002;28:97–98.
3. Fugh-Berman A. The corporate coauthor. J Gen Int Med.
Private practice, Willimantic, Conn.
* Corresponding author, e-mail: firstname.lastname@example.org
Journal of Oral Implantology
Table of Contents for the Digital Edition of Journal of Oral Implantology April 2013
Evidence-Based Practice or Practice-Based Evidence?
Evaluation of Optimal Taper of Immediately Loaded Wide-Diameter Implants: A Finite Element Analysis
A Prospective, Randomized Controlled Preclinical Trial to Evaluate Different Formulations of Biphasic Calcium Phosphate in Combination With a Hydroxyapatite Collagen Membrane to Reconstruct Deficient Alveolar Ridges
Retention of Implant-Supported Overdenture With Bar/Clip and Stud Attachment Designs
The Clinical and Histologic Outcome of Dental Implant in Large Ridge Defect Regenerated With Alloplast: A Randomized Controlled Preclinical Trial
Fluoride-Treated Bio-Resorbable Synthetic Hydroxyapatite Promotes Proliferation and Differentiation of Human Osteoblastic MG-63 Cells
Resonance Frequency Analysis of 208 Straumann Dental Implants During the Healing Period
A Simplified Technique for Solving the Transfer Problem of Implant-Supported Fixed Partial Dentures for Patients With Microstomia
Esthetic Evaluation of Single-Tooth Morse Taper Connection Implants Placed in Fresh Extraction Sockets or Healed Sites
A Technique for Improving the Retention of Dentures Retained by Ramus Frame Implants
Treatment of Congenitally Missing Maxillary Lateral Incisors: An Interdisciplinary Approach
Use of Titanium Mesh in Lieu of a Fixation Screw to Stabilize an Autogenous Block Graft: A Case Report
A Novel Approach to Preserve the Buccal Wall in Immediate Implant Cases: A Clinical Report
Implant Failure Associated With Actinomycosis in a Medically Compromised Patient
Replacement of Mandibular Posterior Teeth With Implants in a Postmandibular Resection Case: A Case Report
Zygomatic Implants/Fixture: A Systematic Review
An Overview of Immediate Root Analogue Zirconia Implants
Letter to the Editor
Reviews of Current Literature
Journal of Oral Implantology April 2013