The Journey To Excellence in Esthetic Dentistry, An Issue of
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Contributors
PHONG TRAN CAO, DDS
Lecturer, University of California, Los Angeles, Los Angeles, California; Cosmetic Dentist
and Private Practice, 5 Star Dental, Las Vegas, Nevada
DAVID WAGNER, DDS
Private Practice, West Hollywood, California, USA; Clinical Lecturer, Advanced
Restorative and Esthetic Dentistry, Division of Constitutive and Regenerative Science,
UCLA School of Dentistry, Los Angeles, California
YAIR Y. WHITEMAN, DMD
Associate Clinical Professor, Director of Advanced Restorative and Esthetic Dentistry,
Division of Constitutive and Regenerative Science, UCLA School of Dentistry, Los
Angeles, California
The Journey to Excellence in Esthetic Dentistry
Contents
Preface: The Journey to Excellence in Esthetic Dentistry ix
Yair Y. Whiteman and David J. Wagner
Science, Materials, and Technology Update
Science in the Practice of Clinical Dentistry 609
Todd R. Schoenbaum
This article informs dental clinicians on the essential workings of scientific
research and statistical analyses. It provides clinicians with the essential
knowledge necessary to understand and review scientific work.
Review of the Modern Dental Ceramic Restorative Materials for Esthetic Dentistry in
the Minimally Invasive Age 621
Alireza Moshaverinia
Material selection is one of the most important decisions to be made by
clinicians. Proper material selection can affect the long-term function,
longevity, and esthetics of restorations. There are a large number of
restorative materials available, which has increased the complexity of
the decision-making process. Improper material selection can lead to
failures in the outcome. This article is designed to provide the practi-
tioner with up-to-date practical information on ceramic restorative mate-
rials and techniques in a clear, evidence-based, and unbiased manner. It
also provides decision-making guides to help the practitioner determine
the best ceramic material for various clinical scenarios.
Adhesive Dentistry: Understanding the Science and Achieving Clinical Success 633
Marc Hayashi
Successful adhesive dentistry begins with correct placement and poly-
merization of the bonding agent. Although numerous agents exist, all abide
by certain key principles, including the newest group, the universal adhe-
sives. Fundamental steps also exist in the application process that require
the operator to understand the chemistry of the adhesive being used. Mo-
dalities exist that can help preserve the durability of the bond achieved,
thus slowing down the degradation process. However, no material or
agent can overcome poor technique. Thus, it is of the utmost importance
that the practitioner respects the technique sensitivity of adhesives, and
follows the manufacturer’s instructions.
Implementing Digital Dentistry into Your Esthetic Dental Practice 645
Lawrence Fung and Phil Brisebois
The use of digital dentistry is on the increase as costs to acquire digital
technology have gone down dramatically and allowed for more practi-
tioners to integrate digital equipment with reduced investment. One of
vi Contents
the most significant benefits of digital technology in dentistry is the
ability to streamline processes that can be cumbersome via the analog
way. In digital dentistry, it is important to understand the advantages
and disadvantages of each device or system available.
The Use of Botulinum Toxin and Dermal Fillers to Enhance Patients’ Perceived
Attractiveness: Implications for the Future of Aesthetic Dentistry 659
Phong Tran Cao
Physical appearance and attractiveness consciously and subconsciously,
affect patients’ quality of life. Traditionally, dentists were tasked with
improving a patient’s smile, a central aspect of facial aesthetics and phys-
ical appearance. More recently, as the scope of practice of the aesthetic
dentist has broadened to potentially include other components of facial
cosmesis that go hand-in-hand with a patient’s smile, new options have
emerged with which modern aesthetic dentists should familiarize them-
selves. As laws surrounding their use in dental offices continue to evolve,
Botox and dermal fillers represent natural next steps in aesthetic dentistry.
Team Collaboration and Communication
A Beginning Guide for Dental Photography: A Simplified Introduction for Esthetic
Dentistry 669
David J. Wagner
Photography is one of the most important skills dentists need to master in
order to perform esthetic dentistry at a high level. Today, digital single-lens
reflex cameras are commonplace. Young dentists have grown up with
Internet, smartphones, and online platforms exposing them, and their pa-
tients, to cases that other dentists have shared, increasing the awareness
and popularity of esthetic-focused treatment. This article provides readers
with a simplified and attainable approach to begin the dental photography
journey, as well as increase skill level, depending on practice style and
desired investment.
Dentist-Ceramist Communication: Protocols for an Effective Esthetic Team 697
Sivan Finkel and Peter Pizzi
No matter how skilled and well trained esthetic dentists or technicians may
be, they cannot deliver results without a proper partnership. Close
ceramist-clinician communication is a critical component of successful
esthetic dentistry. In order to design an esthetic vision, convey this vision
to the patient, and then execute the vision successfully, there must be
effective communication between the ceramist, the clinician, and (most
importantly) the patient. This article highlights some of the authors’ philos-
ophies, as well as an overview of the key communication protocols that
have proved effective for this team.
A Communication Guide for Orthodontic-Restorative Collaborations: An
Orthodontic Perspective on the Importance of Working in a Team 709
Kathryn Preston
As both restorative dentists and specialists have their respective realms of
expertise, it is important to develop a team of qualified providers to
Contents vii
improve treatment outcomes for patients. In many cases, this involves
collaboration between a restorative dentist and orthodontist. Effective
communication is critical, with the dentist’s understanding of basic ortho-
dontic terminology and case planning considerations. Recognizing the
context in which to apply normative occlusal and cephalometric values
often necessitates comprehensive specialty-level experience. All pro-
viders should recognize when to involve the indicated team members
when complex multidisciplinary treatment needs are present. The team
approach offers an opportunity to optimize excellent patient care.
A Communication Guide for Orthodontic-Restorative Collaborations: Digital Smile
Design Outline Tool 719
Yair Y. Whiteman
Ideally, Orthodontic-Restorative cases are planned alongside from the
beginning, however, in some instances the restorative dentist encounters
the patient for esthetic evaluation near the end of orthodontic phase. This
is a high-stakes evaluation because the decision to remove brackets im-
plies that refinement of tooth positioning cannot occur unless the patient
re-enters orthodontic treatment. One challenge in multidisciplinary treat-
ment is accommodating effective communication between providers
and employing Digital Smile Design outline tool as a visual aid can help
optimizing treatment outcome. This article discusses the importance and
steps utilizing digital outline tool to provide quick and effective communi-
cation on treatment progress and recommendations.
Business Professional Focus
Branding Dynamics for the Esthetic Dentist: Building Your Brand to Build Your
Practice 731
David J. Wagner and Julie Logan
The objective of this article is to introduce the concept of branding to den-
tists interested in implementing elective esthetic treatment into their prac-
tice. For many, this will serve as an introduction to begin; for others, it can
provide a road map for revising and reinforcing a branding program
already in place.
viii The Journey to Excellence in Esthetic Dentistry
DENTAL CLINICS OF NORTH AMERICA
FORTHCOMING ISSUES RECENT ISSUES
January 2021 July 2020
Implant Surgery Update for the General Controlled Substance Risk Mitigation in the
Practitioner Dental Setting
Harry Dym, Editor Ronald J. Kulich, David A. Keith,
Michael E. Schatman, Editors
April 2021
Geriatric Dental Medicine April 2020
Joseph M. Calabrese and Michelle Surgical and Medical Management of
Henshaw, Editors Common Oral Problems
Harry Dym, Editor
July 2021
Radiographic Interpretation for the Dentist January 2020
Mel Mupparapu, Editor Oral Diseases for the General Dentist
Arvind Babu Rajendra Santosh and
Orrett E. Ogle, Editors
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The Journey to Excellence in Esthetic Dentistry
Preface
The Journey to Excellence in
Esthetic Dentistry
Yair Y. Whiteman, DMD David J. Wagner, DDS
Editors
Our ability to provide patients with the most up-to-date treatment options, materials,
treatment modalities, and evidence-based decision making requires a culture of
continuous learning, collaborative teamwork, and exceptional focus. In his influential
work, Outliers, Malcolm Gladwell claims that an average of 10,000 hours is required
for a person to become an expert in a certain field. In dentistry, a considerable amount
of time outside of “normal work hours” is necessary in order to develop skills to
become an expert. This is not only where dentistry becomes a vocation, but also
how we can differentiate ourselves and how we can reach and maintain satisfying
and fulfilling careers.
Though dental school strives to provide students with as much in-depth knowledge
and experience as possible, due to lack of time, only a foundational level of education
can be achieved. As a result of continuous advancements in material science, tech-
niques, dental research, and integration of digital technology, there has been a tremen-
dous increase in teaching requirements and need for curriculum transformation in
recent years. Consequently, dental schools may only have the bandwidth to concen-
trate on procedural-teaching and single-tooth dentistry. Therefore, upon graduation,
when a dentist aims to practice at the highest level, they must continuously elevate
their skills not only to match the latest standards of care but also to improve their ability
to provide exceptional dental care beyond what is normally expected.
In this series of articles, we focus on a journey to excellence in esthetic restorative
dentistry and aim to provide a roadmap for clinicians who wish to develop clinical skills
and elevate the scope and status of their dental practices. We emphasize not only that
at the core of this area of dental care is one’s ability to technically perform treatment
but also it is equally as important to attract patients, build relationships, and commu-
nicate the value of treatment. Finally, the series of articles is designed to include
Dent Clin N Am 64 (2020) ix–xi
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x Preface
checklists and practical reference guides that can be used while working clinically or
when developing the business and team of one’s practice.
To achieve a higher level of competence, dentists must pursue continuing education
that is taught by ethically responsible experts rooted in sound, unbiased information.
Dentists should seek out upper-echelon dental academy meetings and surround
themselves with like-minded people, building lasting professional relationships with
mentorship dynamics. Evidence-based scientific data must be critically evaluated
and assessed when making decisions. To start, Dr Todd R. Schoenbaum provides
a detailed guide for reading and evaluating scientific literature.
Materials and bonding techniques must be thoroughly understood in order to
execute a minimally invasive modern style of dentistry. An update of current materials
and bonding techniques is reviewed by Dr Alireza Moshaverinia and Dr Marc Hayashi.
In today’s dental landscape, digital technology is increasingly becoming a viable and
alternative method to traditional analog workflows. Dr Lawrence Fung and digital lab
innovator Mr Phil Brisebois discuss digital technology and its place and integration in
the dental practice. Adjunctive services, such as injectables, have been a complemen-
tary component of the esthetic dental landscape for some time. There is a major po-
sition for their place within the scope of treatment, and patient’s outcomes can be
enhanced, creating an even greater value and awareness for the life-changing treat-
ment that esthetic dentists can provide, as outlined by Dr Phong Tran Cao.
Team collaboration and communication are imperative to a dentist’s success when
performing restorative esthetic treatment. Photography is a tool used to help achieve
seamless communication among the dental team as well as with patients. A begin-
ner’s guide to dental photography along with a clinical reference manual is provided
by Dr David J. Wagner. It is known that dental esthetic treatment results hinge on
the skill set of both restorative dentist and ceramist. Developing a world-class
dentist-ceramist partnership is discussed by Dr Sivan Finkel and master ceramist
Mr Peter Pizzi.
The role that specialists play is invaluable when properly executing minimally inva-
sive esthetic treatment. The goal should always be to preserve as much natural tooth
structure in order to accomplish the best outcome for the patient. An understanding of
what is possible with various specialty points of view is therefore necessary for restor-
ative dentists. Proper communication with all specialist types is imperative.
Specifically, orthodontists play a significant role within the scope of minimally invasive
treatment. Getting teeth in the proper position results in the need to reduce less tooth
structure to obtain beautiful, lasting outcomes. The paired articles by orthodontist Dr
Kathryn Preston and prosthodontist Dr Yair Y. Whiteman help to introduce these con-
cepts and display a high-level communication style to allow seamless treatment inte-
gration among patient, restorative, and specialist.
Last, it is within the private practice sector that a dentist tends to find his or her pro-
fessional life butterflied most, wearing multiple hats as a health care provider, a small
business owner, a manager of people and the lead decision maker influencing the suc-
cess of a dental practice enterprise. As we become clinicians choosing to elevate our
practices, skills, patient experience, and ultimately help to change the lives of our pa-
tients by providing the highest level of dentistry that is possible, we need to be able to
communicate to patients what this means. Branding is a mechanism that allows this
communication to occur on many levels. To develop a brand for a dental practice in
parallel with an elevated set of clinical skills can catapult a dental practice and patient
experience to new heights and help to create a legacy of excellence in a world of
average. Branding for the esthetic dentist is outlined by Dr David J. Wagner and Ms
Julie Logan, a branding specialist based in Los Angeles, California.
Preface xi
We hope you find this series of articles helpful at whatever point you are in the
journey to esthetic excellence. We too are on this lifelong journey and continue to
seek advancement, always aiming to improve, acquire new skills and perspective,
build professional relationships, and learn something new every day.
Yair Y. Whiteman, DMD
Division of Constitutive and
Regenerative Science
UCLA School of Dentistry
10833 Le-Conte Avenue
Room 33-064A CHS
Los Angeles, CA 90095-1668, USA
David J. Wagner, DDS
8733 Beverly Boulevard
Suite 202
West Hollywood, CA 90048, USA
E-mail addresses:
[email protected] (Y.Y. Whiteman)
[email protected] (D.J. Wagner)
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Science in the Practice of
Clinical Dentistry
Todd R. Schoenbaum, DDS, MS
KEYWORDS
Biostatistics Clinical dentistry Science
KEY POINTS
Comprehend study design and its impact on research quality and meaning.
Learn essential biostatistical tests and analyses.
Understand what is meant by statistical significance and its relation to clinical
significance.
THE RATIONALE AND CHALLENGES OF IMPLEMENTING SCIENTIFIC DATA INTO
CLINICAL PRACTICE
Extensive amounts of time and energy are spent by clinicians learning how to be the
most proficient operators they can be, learning how to execute treatment at increas-
ingly exceptional levels. They know that their skills, materials, techniques, diagnostic
abilities, and treatment planning abilities ultimately determine how successful they are
in addressing the needs and desires of their patients.
Clinical decision making is a complex skill. It requires the synthesis of hundreds of
questions for every decision: material selection, preparation design, implant locations,
and so forth. Some of these complex decisions are made out of habit or tradition,
where clinicians rely (not necessarily incorrectly) on their mentors, previous suc-
cesses, and training. Ultimately, clinicians must continue to evaluate and adapt and
learn and move forward in producing improved results. Clinicians must strive to be
perpetual students, to continually endeavor to improve their skills and knowledge.
These improvements might be in longevity, aesthetics, ease of use, patient comfort,
patient health, duration of treatment, economics, or consistency.
When making any clinical decision, there are 4 areas to take into consideration:
1. Patient desires (ie, finances, time constraints, aesthetics)
2. Clinical evaluation (ie, bone volume, American Society of Anesthesiologists classi-
fication, functional loads)
3. Unique clinical experience (eg, “We have been very successful immediately loading
implants in our practice”)
UCLA, 10833 Le Conte Avenue, CHS, Room B3-034, Los Angeles, CA 90095, USA
E-mail address: [email protected]
Dent Clin N Am 64 (2020) 609–619
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0011-8532/20/ª 2020 Elsevier Inc. All rights reserved.
610 Schoenbaum
4. Scientific evidence (ie, most systematic reviews show little increase in risk for im-
mediate load implant protocols when carefully selected and skillfully executed)
None of these 4 areas should be neglected, although at times clinicians may find
that the strength of one outweighs another. Their patients will be best served, and their
outcomes improved, when clinicians successfully incorporate as much information as
possible from each area. Scientific studies are not the be-all and end-all of clinical de-
cision making. It represents only a piece. Clinicians’ anecdotal experiences should
carry weight in the decision-making process. Conflicts arise between what clinicians
have seen to be true, in their hands, and the scientific literature. The potential reasons
for this may include differences in patient populations, differences in surgical
approach, differences in implant systems, and differences in the skill of technicians.
Individual clinicians develop standard operating procedures based on the unique sit-
uation but efforts should be made to increase the understanding of when alternative
materials and techniques should be implemented for a given clinical scenario. Exper-
tise is built on accurate answers to hundreds of questions from all 4 areas in every clin-
ical decision that clinicians make.
However, this article is about the science part of this process. The other 3 areas are
not addressed here but should in no way be neglected. Properly interpreted and un-
derstood, scientific evidence can significantly improve results. Scientific studies give
insight into the expected success rates of a new material, complications that can be
expected with a particular treatment protocol, or which patients might be at increased
risk for failures.
There are a few requirements, though: the science must be sound, the analysis
appropriate, the question answered relevant, and the interpretation cautious. The
job of clinicians is not to determine whether the science was sound or whether the sta-
tistical analysis was appropriate. That is the job of biostatisticians, editors, and re-
viewers. The job of clinicians is to determine whether the study question being
answered is relevant to the current bigger clinical question. Clinicians must also deter-
mine whether the interpretation of the study is correct. It is all too common in the sci-
entific literature to see conclusion statements woefully undersupported or even
countered by the data in the study.
A Hypothetical Vignette
Imagine that a new 1-piece implant has come to market with US Food and Drug
Administration (FDA) approval. Clinicians are interested in switching over to it for
most of their implants and the patients are asking for it, but will it work? This is not
a binary question, and perhaps there will be indications where it will and will not prove
sufficiently successful. There is no objective threshold for success. What one clinician
might classify as successful might be intolerable to another. At any rate, clinicians are
considering surgically implanting this new device into a vast number of their patients
and results matter.
The clinicians ask a manufacturer representative to come by the office. They are
shown a bar graph from an osseointegration study published in a reputable journal,
and the new implant’s bar is the tallest. It has superior bone to implant contact
compared with the control, and in another study, this one testing dry static axial
load to failure, the new implant’s number is the biggest and there is a P value of
.02. Then there is a quote from a supposedly famous dentist: she loves the new
implant and so do her patients.
So far, everything looks promising and the clinicians decide to switch over to the
new implant. For 12 months, many of the implants placed in the practice are the
Science in the Practice of Clinical Dentistry 611
new implant; hundreds of them. The patients are happy, and the referrals are flowing
in, but then the failures begin to show up. Slowly at first, then en masse. Peri-
implantitis, prostheses repeatedly debonding, abutments fracturing. It seems that
osseointegration and dry static axial load to failure are not the only factors that the cli-
nicians should have considered before aggressively incorporating this material.
Looking back, the clinicians wonder how this implant got through the FDA clearance
process. Without going into the granular details of the process, suffice to say that
dental devices are generally FDA approved without need for extensive testing of safety
and efficacy. In general, it is done by claiming (to the FDA) that the new device or ma-
terial is largely similar to previously approved devices. So what did the clinicians miss
in their cursory evaluation of this implant and what should they have done differently?
Assuming the 2 studies they flipped through were properly performed and analyzed,
the osseointegration and dry static axial load of the implant are as good as or superior
to the current implants. However, those are only 2 of the hundreds of questions clini-
cians should be asking about whether or not this implant is viable. This implant is 1
piece, so why are none of the other implants clinicians use of this design? What are
the clinical challenges of this design? Are the results of a dry static axial load test really
correlated with how implants are treated in the oral environment? Is there a better way
clinicians should test load to failure? Was the famous dentist raving about this implant
vested in the manufacturer?
I am proposing that, in this scenario and hundreds of others like it, clinicians will be
better able to identify and avoid potential problems if they have an understanding of
the literature. Science cannot avoid all problems in clinical dentistry, but I hope that
this article helps provide a start on a journey of better understanding of the scientific
literature that clinicians rely on (directly or indirectly) to make clinical judgements. A
proficient understanding of the science and literature will not occur immediately. It
takes time and effort. As a starting point, I suggest that clinicians make a habit of
finding a reputable, scientifically based, clinically oriented journal in their area of focus
and read through it on a regular basis. This habit will increase familiarity and comfort
with how studies are performed, analyzed, and interpreted. The learning curve may be
steep at first. Ignore studies that are of no interest. Read through the others with the
understanding that it is not necessary to grasp every aspect of what is presented. With
time, a greater level of comfort and confidence will develop and I believe the reader will
become significantly more empowered to make strong, science-backed decisions.
TYPES OF STUDIES AND THEIR VALUE IN CLINICAL PRACTICE
Most clinicians have seen something like the hierarchy of evidence pyramid (Fig. 1). A
few things about this: it is not universally agreed on and various disciplines in medicine
and dentistry have variations they lean on (more than 80 such hierarchies have been
published). Epidemiology uses a vry different hierarchy than orthopedic surgery for
example. Nor does the pyramid mean that any conclusion from an upper level is al-
ways more correct than a conclusion from a lower level. Table 1 provides a brief
explanation of the various types of studies and their use in clinical dentistry.
The hierarchy is not a strict ranking of what study is right or wrong when conflicting
information arises. There are poorly done (and published) systematic reviews, and
there are well-informed experts. Experts are often right (that is why they are experts),
but the potential for bias is high. Objective and forthright experts are easily identified
and develop a reputation for minimizing and acknowledging their biases. For busy cli-
nicians, these unbiased experts are immensely valuable resources. In contrast, sys-
tematic reviews and randomized controlled trials (RCTs) can be wrong, or poorly
612 Schoenbaum
Fig. 1. A hierarchy of evidence for clinical dental research. This hierarchy is best understood
as a risk for bias pyramid, not a hierarchy of truth. The higher levels of evidence are more
likely to be correct, but they are not implicitly superior. Sys, systematic.
done, or grossly overinterpreted, although they are less likely to be wrong because of
biases. The hierarchy is best understood to represent the potential for biases affecting
the resulting recommendations, so perhaps a reliability pyramid is a better term for
them. Every study has inherent biases. The best studies recognize this, apply analyt-
ical and study design techniques to mitigate them, and acknowledge how they may
have affected the results and conclusions.
In brief, a systematic review (preferably with a meta-analysis) attempts to answer a
question (eg, do screw-retained implant crowns survive longer than cemented implant
crowns?) by aggregating, synthesizing, and analyzing all relevant published studies.
Clinicians might consider it an expert-level book report. It is an attempt to analyze
the existing data in a meaningful way. This approach only works if there are sufficient
studies on a given topic, and its resultant quality depends on the quality of the included
studies. The systematic review is a report on the current preponderance of evidence,
which is the metric by which clinical decisions are best made.
Anecdotally, it seems there has been a strong trend in clinical dentistry to publish
and cite (formally or casually) systematic reviews. Although I appreciate the enthu-
siasm for increased levels of evidence, clinicians need to think about systematic re-
views for a moment.
Systematic reviews should be performed by a group of experts knowledgeable in the
field. Such undertakings require deep understanding of the problem at hand, which
questions need to be asked, which studies should be included, and how to properly
interpret the results. Such tasks are not best performed in the early stages of a career.
Not all systematic reviews are created equal, and in clinical dentistry this is espe-
cially true. Table 1 shows that the position of systematic reviews in the hierarchy de-
pends on the types (and quality) of the studies analyzed. Systematic reviews built on
less rigorous studies are not at the top of the pyramid.
Science in the Practice of Clinical Dentistry 613
Table 1
Levels of evidence for clinical treatment disciplines
Study Design What It Is Relevance to Clinical Dentistry
Systematic reviews An expert synthesis of the best This is the highest level of
of homogenous available interventions on a evidence. However, rarely seen
RCTs particular topic in clinical disciplines because of
the sparsity of strong RCTs
Strong RCTs A random, controlled, blinded Rare in any surgical discipline
trial. The only way to (especially clinical dentistry).
establish cause and effect Best available new evidence
Systematic review An expert synthesis of the best Good for summarizing risk factors
of cohort studies available observational associated with an outcome
studies
Individual cohort A high-level observational In general, a tool used less in
studies study. No treatment is clinical dentistry and more in the
performed on patients as public health disciplines and
part of the study epidemiology
Systematic review An expert synthesis of the best Not common in clinical dentistry
of case control available research for risk
studies factors for rare outcomes
Case control A cross-sectional study used to An efficient way to identify risks
studies identify risk factors for rare for diseases not often seen
outcomes
Case series A series of cases showing Useful in seeing what might be
proof of concept. Not proof possible by experts. Useful for
of expected results or exploring new techniques or
expected complications materials. Interpret cautiously
Expert opinion A well-regarded individual’s or Efficient and practical method for
group’s opinion on a topic. finding information. High risk
Reliability and accuracy potential for bias
depend on the veracity and
knowledge of the expert
However, in clinical dentistry (and in surgical medical fields), clinicians have a prob-
lem: the best novel evidence is a sufficiently powered RCT (Fig. 2) with narrow varia-
tion in the results. High-quality RCTs are expensive to execute and require strong
management, oversight, and analysis. Randomizing patients into control or placebo
groups in clinical treatment produces ethical and practical challenges (is anyone inter-
ested in a placebo surgery?). Blinding of patients, operators, and evaluators is nearly
impossible for obvious reasons. In addition, even when such challenges are
addressed, recruitment of sufficient numbers of participants commonly proves prob-
lematic. As a result, there are not enough RCTs of any quality in clinical dentistry,
Fig. 2. Randomized clinical trial design.
614 Schoenbaum
let alone high-quality RCTs. Much of what is commonly published in the dental litera-
ture as RCTs are often better classified as clinical trials because of a lack of true
randomization, controls, and blinding. A clinical trial is essentially a large, more
rigorous case series with quantified analysis.
There are various methodological approaches to creating a systematic review.
Among the most well regarded is the Cochrane Review. The rigor of the Cochrane
approach synthesizes the appropriate studies into concise and reliable results. Only
high-quality studies are included in such reviews. However, clinical dental research
is not well funded, and clinicians do not see many high-quality clinical studies for
any given question. As a result, a highly rigorous Cochrane Review for a given clinical
dental technique or device often produces conclusions such as, “The quality of the ev-
idence is assessed as very low due to high and unclear risk of bias of primary studies
and there is some evidence of reporting bias so clinicians should treat these findings
with caution.”1 Although honest, this is not very useful when clinicians are looking for
scientific guidance to treat their patients. The high rigor of the Cochrane Reviews often
leaves practitioners in clinical dentistry without much guidance.
As such, many systematic reviews published in clinical dentistry do not adhere to
the Cochrane guidelines and use other, less restrictive frameworks in order to find
something useful to say about the evidence. This approach produces more clinically
relevant information but with a higher risk for errors and bias. Imagine a systematic re-
view with strong conclusion and recommendation statements finding that immediate
loading of implants is highly successful. On the surface, this seems to be a high-level
recommendation about what success rates can be expected with this procedure.
However, what if the systematic review was built on 4 small case series, 2 of which
were from 1 author, and all of which were performed by experts? It is easy to see
how such conclusions might be biased toward results that will not prove generalizable.
Cohort studies are nonintervention studies; they are observational exclusively. This
term is commonly misused in published titles in dentistry. They are not useful for deter-
mining what techniques or materials perform better. They are used to see how risk fac-
tors affect an outcome. For example, Raes and colleagues2 studied 2 groups of
implant patients over time: smokers and nonsmokers. The primary outcome being
evaluated was papilla regeneration, for which the smoking group was at significantly
greater risk to not regenerate papilla.
Case control studies are also strictly observational. They are designed to find asso-
ciated risk factors for a rare outcome. The resulting odds ratio indicates the odds of a
patient with the risk factor developing the disease outcome. For example, Becker and
colleagues3 studied the effect of osteoporosis on the odds of having an implant failure.
This exploratory study was unable to find any association between osteoporosis and
implant failure. This finding does not mean that there is no real association. There may
be, but perhaps it is too small to see with this sample size, or perhaps there is too
much variation. These issues are discussed later. The results of observational studies
are correlation only and do not prove causation, but they may hint at it.
The case series and case study mostly commonly reside near the bottom of every
hierarchy of evidence, but why then are they so frequently published in many high-
level clinical dental journals? As a procedural discipline, clinical dentistry relies heavily
on advancement in techniques and protocols to improve outcomes. Such develop-
ments are difficult or impossible to test in RCTs and observational studies. Case series
and case studies come in various levels of rigor and reliability. At the most rigorous
end, the case series is designed with a primary outcome measurement (eg, number
of prosthetic complications with angled screw channels). The next (n) number of par-
ticipants (n) is determined in advance, along with strict inclusion/exclusion criteria. The
