Given its current attention, one would think that Evidence-Based Practice was a new concept that burst forth upon the health care scene like Archimedes’ “Eureka!” One would expect that the rising tide of evidence would submerge practices proved ineffective, which is, after all, the standard that preceded EBP. Hasn’t effectiveness always been the hallmark of good practice? Is there any difference between effectiveness and EBP? Well, yes, there is. EBP is concerned with the effect of evidence on practice, whereas effectiveness is in the province of evidence.

To be sure, evidence has had some effect in dentistry. There has been some technical tinkering. Composites supplanted silicates. Gutta percha conquered silver points. This implant plants better than that one. Better materials but not necessarily better practicing.

What of patterns of practice? Following are some examples of Non-Evidence-Based Practice:

• Routine full-mouth radiographs on all “new” patients.
• Routine six-month recall examination. 
• Routine six-month and/or annual bitewing radiographs.
• Routine six-month and/or annual prophylaxis, regardless of demonstrable need.
• Coronal polishing in the absence of otherwise unremovable stains.
• Prophylactic removal of wisdom teeth.
• I-V sedation/general anesthesia for simple procedures, including M3 extractions.
• Routine cephalographs for routine orthodontic cases ― always before, frequently after completion.

Others could name other examples, but I am out of practice.

Actually, there has been some progress. Some, perhaps many, but probably not all state Medicaid programs pay only for annual examinations and prophylaxes, even when prophylaxis is, for most children, merely coronal polishing. Medicaid, like some dental insurance plans, also have stated policies excluding prophylactic removal of third molars and I-V sedation and GA for routine procedures. But one wonders how effective they are, particularly against the aggressive demands of oral surgeons or patients.

These are interesting clinical issues, but isn’t there a major category that may in fact override Evidence-Based Practice, namely, Economic-Based Practice? Is it realistic to expect that GPs, much less pediatric dentists, would stop doing and charging for worthless coronal scalings, aka child prophylaxis, or place a caries-free kid on 18-month recall, which is what EBD calls for, when examinations and prophylaxis represent a major source of their income? Would oral surgeons provide prophylactic third molar extractions as an altruist service to prevent all the pathology they believe is out there? Would GPs stop removing and replacing long-standing, serviceable amalgam fillings with disposable composites, if it didn’t represent a quick buck?

In short, can Evidence-Based Practice that does not take into account Economic-Based Practice be practiced?

Jay W. Friedman