Decision Making Using the Evidence-Based Approach
Michael G. Newman*
Angeles, California; Medical Science Systems, Newport Beach, California; and private practice, Los Angeles, California
Abstract Clinical experience, technical ability, and intuition are indispensable but no longer sufficient as the sole skills necessary to providethe best outcomes from periodontal and implant treatment. This article describes the evidence-based approach, a comprehensive and rigorous literature evaluation process applied by scientists and clinicians. The methodology was used by the participants in The American Academy of Periodontology World Workshop to assess the evidentiary status ofperiodontal and implant treatment. The major goal ofusing the evidence-based approach was to improve treatment decisions by increasing the strength of the inference that practitioners can derive from the base of knowledge contained within the literature.
improves the opportunity for successful outcomes.1
diagnosis, performing optimum treatment, and monitoring the patient. Keeping up to date with current information, having a system for properlyevaluating it, and using the knowledge to help make treatment decisions
Providing the most appropriate periodontal treatment requires making an accurate
Ann Periodontol 1996;l:i-ix.
tal treatment. In the absence of the evidencebased approach, one must be cautious about interpreting information primarily derived from clinical experience and intuition or poorly designed studies because itcan be (and often is) misleading and/or harmful. Since the 1989 World Workshop in Clinical Periodontics, there have been many clinical, technological, and biological advances that have greatly improved the quality of periodontal diagnosis and treatment.2 The basis, or evidence, that periodontal treatments are effective comes from a vast, extensive, and high-quality database. The systematicincorporation of new high-quality information (evidence) together with clinical judgment and personal experience has improved treatment results, reduced the variation in outcomes, and given patients more satisfying options. Improvements in "traditional" clinical decision making can improve the opportunity for achieving successful results.36
The evidence-based (EB) approach is a straightforward,systematic process which helps the clinician and researcher evaluate the relevant information regarding diagnostic, treatment, prognosis, and experimental decisions. Applying the EB process to the periodontal literature will improve periodon-
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Patient decision making is also enhanced when clear choices and realistic estimates of treatment predictabilityare provided.7'8 One of the key principles associated with making good clinical decisions is the need to be scientifically accurate so that unintentional and or hidden sources of bias are not inadvertently allowed to influence the decision process. The process of inductive reasoning, which is the most common approach used by clinicians, has great potential for erroneous conclusions because it doesnot normally include the explicit determination of harm.910 Clinicians naturally use their personal experience and the results they have achieved from their own practices to formulate their unique practice philosophy and modus operandi. However, most clinicians make observations without the benefit of controlled and blinded observations. In clinical practice there are usually no "control" patients.Without the benefit of controls, the practitioner is not in the best position to determine the potential harmful effects of administered therapy. For example, a dentist might conclude that patients taking an antibiotic to arrest Periodontitis get better because probing depths become shallower, bleeding on probing diminishes, and the color and tone of the gingiva become more healthy looking....