JADA 144(2) http://jada.ada.org February 2013 131

L E T T E R SC O M M E N T A R Y

and essentially nonexistent fordata in private practice.To change this situation for

the better, we need two things:first, practitioners who arewilling to use their electronicpatient data for research andquality assurance; and, second,methods to extract, validate andanalyze these data. In this man-ner, motivated practitionerscould contribute to advancingthe art of clinical care on a dailybasis. Plus, coming back to themain point of the editorial, itwould help forge a closer bondbetween practitioners andresearchers in dentistry.Titus Schleyer, DMD, PhD

Associate Professorand Director

Center for Dental InformaticsSchool of Dental MedicineUniversity of Pittsburgh

1. Institute of Medicine of the NationalAcademies. Best Care at Lower Cost: ThePath to Continuously Learning Health Carein America. www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx. Accessed Jan. 3, 2013.2. Schleyer T, Song M, Gilbert GH, et al.

Electronic dental record use and clinicalinformation management patterns amongpractitioner-investigators in The DentalPractice-Based Research Network. JADA2013;144(1):49-58.

MORE ABOUT RESEARCHI read with great interest theexcellent October guest edito-rial of Dr. Rena D’Souza andcolleagues, “How PracticingDentists Can Shape DentalResearch” (D’Souza RN, Eber-sole JL, Fox CH, Poverini PJ,Scannapieco RA. JADA 2012;143[10]:1069-1071) where, in aNational Institute of Dentaland Craniofacial Research(NIDCR) initiative, practicingdentists can contribute to clin-ical research.

Because high-level scien-tific clinical research, with ran-domized double-masked con-trolled trials, is difficult todesign and actuate and engen-ders significant expense, it hasbecome a minor part of pub-

lished evidence. Only about 3percent of published work indentistry is of high-level scien-tific design.1 The movement tohave a scientific basis for prac-tice rightfully has been broughtto the fore.While it may be that the

evidence-based movement wasinitiated by the 1993 U.S. Su-preme Court’s Daubert v. Mer-rill Dow Pharmaceuticals deci-sion, in which five tests weredelineated for admissibility ofscientific evidence in federalcourts, the concept has gainedpopularity.2Since high-level scientific

evidence is so difficult to ob-tain, we need to tap into thewealth of data that can be sup-plied by practicing clinicians.An accumulation of the infor-mation provided by individualand groups of clinicians abouttechniques and materials canbe analyzed and conclusionsderived. The National Instituteof Dental and Craniofacial Re-search truly has begun animportant, beneficial projectthat, hopefully, will besuccessful.Thus, evidence-based prac-

tice has developed practice-based evidence. This couldwork in a perpetual cycle forthe benefit of our beloved pro-fession and our patients so thatvirtually all of the professioncan be involved with the ad-vancement of the knowledgebase.

Dennis Flanagan, DDSWillimantic, Conn

1. Vere J, Joshi R. Quality assessment ofprospective case series of dental implant sur-gery and prosthodontics published between2004 and 2008: a systematic review. Int JOral Maxillofac Implants 2012;27(4):865-874.2. Daubert v. Merrill Dow Pharmaceuticals

(92-102) 509 U.S. 579 (1993). www.law.cornell.edu/supct/html/92-102.ZO.html.Accessed Jan. 3, 2013.

Authors’ response: Thethoughtful commentaries pro-vided by Dr. Titus Schleyer andDr. Dennis Flanagan furtherunderscore the need to engage

more practicing dentists inchairside-driven research.Clearly, dentistry is

equipped with the technologiesand expertise needed to facili-tate a better translation ofknowledge across traditionalbarriers. To best engage con-stituents in the private, aca-demic and corporate sectors,collaborative initiatives in-volving the American DentalAssociation, the AmericanDental Education Associationand the American Associationfor Dental Research (AADR)are needed to establish aninfrastructure that will make itfeasible for dental practitionersto contribute information frompatient dental records that canthen be processed, analyzedand validated.As the flagship organization

for dental research nationwide,AADR is well positioned toengage practicing dentists inestablishing links with aca-demic researchers as well asindustry. For example, theupcoming Joint AADR/Interna-tional Association for DentalResearch/Canadian Associationfor Dental Research GeneralSession meeting, to be held inSeattle March 20-23 offersmany forums for dentists tolearn about clinical researchmethodology, the progressmade by fellow dentists en-gaged in the National DentalPractice-Based Research Net-work and new research ad-vances in all of the disciplinesof dentistry.

Rena N. D’Souza, DDS,PhD

Professor, Biomedical SciencesBaylor College of Dentistry

Texas A&M HealthScience Center

Dallasand President

American Associationfor Dental Research

Alexandria, Va.

Jeffrey L. Ebersole, PhD

Copyright © 2013 American Dental Association. All rights reserved.

132 JADA 144(2) http://jada.ada.org February 2013

L E T T E R SC O M M E N T A R Y

Professor and AssociateDean for Research

The Centerfor Oral Health ResearchUniversity of Kentucky

Lexington

Christopher H. Fox,DMD, DMSc

Executive DirectorInternational and American

Associations for Dental ResearchAlexandria, Va.

Peter J. Polverini, DMD,DMSc

Professor and DeanSchool of Dentistry

University of MichiganAnn Arbor

and President-ElectAmerican Associationfor Dental Research

Frank A. Scannapieco,DMD, PhD

Professor and ChairDepartment of Oral

BiologyUniversity at BuffaloThe State University

of New Yorkand Treasurer

American Associationfor Dental Research

UNDERSTANDINGOCCLUSIONAfter reading Dr. VladimirLeon-Salazar and colleagues’September JADA article, “Painand Persistent Occlusal Aware-ness: What Should DentistsDo?” (Leon-Salazar V, MorrowL, Schiffman EL. JADA 2012;143[9]:989-991), we are con-cerned about the diagnosticbasis used to ascribe a neuro-logical cause for the patientthey diagnosed as havingmyofascial pain (MP), temporo-mandibular arthralgia andocclusal hyperawareness. Thispatient had orthodontics, mul-tiple equilibrations, severeabrasion and self-appliedcoronoplasty. Despite this, hisocclusion was assessed as non-

contributory to his problem dueto bilateral stable contacts inmaximum intercuspation (MI).Assessing the bite relation-

ship in MI is inadequate for oc-clusal analysis and cannot dis-count a structural cause for thepatient’s symptoms.1,2 Three-dimensional models mounted ona semiadjustable articulatorwith the condyles in centric rela-tion are required for precisereplication and analysis of thepatient’s occlusion. We recom-mend verifying this positionwith bimanual guidance and amarked anterior deprogrammeras a predictable technique.3Accurate mounted models con-sistently show arc-of-closureinterferences in patients afterorthodontics, restorative den-tistry or improper equilibrationthat are not apparent in MI.Dentists cannot assume that

a history of bite problems withsplint therapy, equilibration ororthodontics that did not re-solve the patient’s pain indi-cates a nonphysical explana-tion. In our practices, it is rareto see a patient with a splintthat is stable with zero mobil-ity, has multiple bilateral pos-terior teeth contact to 2–micron-thick ribbon andsmooth anterior guidance withimmediate posterior teeth dis-clusion. If these criteria are notmet, the splint has introduced anew malocclusion to thepatient.The patient described in the

article may have an arc-of-closure interference on hisanterior teeth from orthodon-tics or overreduction of pos-terior teeth. This could havebeen determined from properocclusal analysis. It is the den-tist’s responsibility to assess allfactors that may cause or con-tribute to the problem andavoid treating pain of unknownorigin. This is especially truewhen multiple dentists andtreatments have been involved

without a specific diagnosis.The association of psychiatricproblems with temporoman-dibular problems requires thatboth structural and psycholog-ical factors be evaluated andtreated. Splint therapy isuseful in this situation, as itprovides the patient protectionfrom attrition with a preview ofhow an optimal occlusion af-fects the masticatory musclesand orofacial pain.The scientific literature for

occlusal correction with ortho-dontics, splint therapy, equili-bration and comprehensive res-toration is extensive.4-7 All ofthese modalities share thesame goal of increased comfortand function via benign redis-tribution of force to the teethand periodontium to eliminatemasticatory muscle hyperac-tivity. Multiple clinical studieswith computerized occlusalanalysis objectively documentocclusal correction and MP res-olution from dramatic reduc-tion in masticatory musclehyperactivity.8,9Equilibration is a predictable

and highly conservative treat-ment modality when done prop-erly.10 The amount of reshapingshould be quantified with trialequilibration on mountedmodels. Reduction into dentinis not acceptable without initialcomprehensive planning forpostequilibration restoration.Irreversible procedures is

not a derogatory term. Most ofthe procedures in dentistry—crowns, endodontics and third-molar removal—are irre-versible. All disciplines of den-tistry base their standard ofcare on comprehensive diag-nosis and predictable pro-cedures. All dentists need tounderstand the role of occlusionin their daily practice and learnhow to diagnose, prevent andtreat occlusal problems. Weencourage dentists to takehands-on continuing education

Copyright © 2013 American Dental Association. All rights reserved.