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A Recurring Problem: Research in Restorative Dentistry ...But There is a Light at the End of the Tunnel

College of Dentistry, University of Florida, Gainesville, FL 32610-0415; imjor{at}dental.ufl.edu

The guest editorial in J Dent Res 82:860–861 (2003)[Free Full Text] calls attention to the successful development of restorative dental science of more than 100 years ago. These major achievements were largely a result of clinical observations of success and failures of the treatment provided, i.e., practice-based research and clinical experience. The editorial then points to the meager research efforts at universities in the field during the last 30 years. It suggests that dental schools should let clinicians focus on clinical teaching, should give time to restorative scientists to do research, and should employ more "non-dental scientists" in restorative dentistry to help solve the problem. This approach, in my view, will require scientists to be trained in and practice restorative dentistry. Without roots in everyday dental practice, it is unlikely that "non-dental scientists" will increase the number of reports that have clinical relevance.

Another guest editorial some 10 years ago focused on the same problem ( Quintessence Int 23:3–4, 1992). The reasons listed in that editorial for the lack of research focused on basically the same problems as outlined in the J Dent Res editorial: The clinical faculty are (1) not trained in writing grant applications, (2) not trained to do research (including clinical research), (3) do not have the time to do research due to clinical teaching responsibilities, and (4) may not be interested in doing research. The 1992 editorial indicates that clinical faculty who primarily teach should not advance beyond the assistant professor level, and that they should not be tenured—a situation which obviously is hard for the clinical teacher to accept. After all, clinical teaching is a fundamental component of any dental curriculum, and without clinical teaching, there would be no dental schools from which basic scientists can apply for grant funding.

The need for research is evident, and it is easy to agree on the principle that treatment should be evidence-based and scientifically sound. The demand for evidence-based dentistry has become a "buzz term" in the dental literature and in educational materials. It has also led to the emergence of a new dental journal, Evidence-Based Dentistry (www.nature.com/ebd). In a recent editorial in this journal, it was noted that the search for simple, but clinically important, questions, like the longevity of different types of restorations, cannot be found in the literature ( Evidence-Based Dent 3:89–90, 2002).

In the strict sense, an evidence-based clinical procedure refers to a treatment based on scientifically sound evidence. If this requirement is a goal for dental education and dental practice, it will soon be realized that the evidence base for a large number of clinical procedures leaves much to be desired; in fact, it is missing for many clinical procedures in everyday clinical practice. As a renowned professor of dentistry once put it: "If the teaching of restorative dentistry shall be limited to procedures that are based on scientific evidence, very little teaching will be done."

Without a scientific basis for treatment, we are left with clinical experience and clinical evidence. Although these fundamentals are scientifically weak, restorative dentistry is largely successful; thus, the importance of clinical experience and clinical evidence must not be overlooked or minimized. However, clinical evidence can be of varied quality—anything from the testimonies based on a one-time treatment success to scientifically documented clinical data. Both these scenarios are flawed from a practice point of view. The enthusiastic clinician presenting his/her case with the final argument in a discussion of the case being that "...it works in my hands" is, and should be, easy to dismiss. Data from scientifically documented studies may appear convincing at first sight, but these studies often have significant limitations in their application to everyday clinical conditions. The inclusion and exclusion criteria used in the design of a scientific study are not applicable to clinical practice, where all patients and conditions must be treated. Compromises must be made whenever the ideal situation does not present itself, and it rarely does. You must simply do the best you can. Referral to specialized services may be feasible, but sending the patient away without treatment is unacceptable.

It must be recognized that clinical practice per se is not scientific, nor is it likely that it ever will be. Clinical practice should strive for scientific documentation to support the treatment provided, but the limitation of the scientific documentation must be acknowledged. The alternative must be to base the treatment on "confirmed clinical evidence". This term draws on documented clinical experience from a large number of dentists treating a large number of patients. The time has come to put this clinical experience base into a scientific context. Practice-based research must be the future of clinical dental research. It will provide an evidence base that is not only clinically relevant, but also scientifically documented to the extent possible at any given time. Practice-based research will initially be based on "confirmed clinical evidence" to provide scientific documentation. Practice-based research will also be a source from which clinically relevant problems can be identified. After the problems are defined, basic scientists can assist in solving the problems.

The National Institute of Dental and Craniofacial Research (NIDCR) has recently published a concept clearance related to a practice-based approach to dental research, including restorative dentistry. This concept clearance has led NIDCR to requests for development of a dental practice-based research network. It will focus on projects rooted in general dental practice. Clinicians will be invited to participate as practitioner-investigators. The time has finally come to establish a link between treatment outcomes in everyday dental practice with experienced clinical investigators. This is a major step in the right direction, and the future for restorative dentistry looks brighter than ever.

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