Utilization of Evidence-Based Informational

Resources for Clinical Decisions Related to

Posterior Composite Restorations
Reem N. Haj-Ali, B.D.S., D.D.S., M.S.; Mary P. Walker, D.D.S., Ph.D.; Cynthia S. Petrie,
D.D.S., M.S.; Karen Williams, Ph.D.; Tabitha Strain, B.S.
Abstract: The purpose of this study was to characterize evidence-based informational resources utilization patterns of a sample of
general dentists with respect to clinical decisions regarding posterior composite restorations. A stratified random sample of
general practitioners belonging to the Academy of General Dentistry (n=2880) was mailed a questionnaire that elicited informa-
tion about practice characteristics and informational resources used for clinical decision making related to posterior composite
restorations. Six hundred ninety-nine dentists responded (24 percent response rate). Use of evidence-based (EB) resources
(journals and online data bases) was low for all respondents (14 percent) for all levels of experience; however, more experienced
clinicians were more likely to use EB resources than recent graduates. AGD Master-level members were significantly more likely
to use EB resources than their counterparts (p<.05). Within the limitation of this study, current patterns suggest a low reliance on
evidence-based informational resources in the practice of clinical dentistry.
Dr. Haj-Ali is Assistant Professor, Department of Restorative Dentistry; Dr. Walker is Associate Professor and Director of Dental
Biomaterials, Department of Restorative Dentistry; Dr. Petrie is Assistant Professor, Department of Restorative Dentistry; Dr.
Williams is Professor and Director of Clinical Research Center, Department of Behavioral Sciences; and Ms. Strain is a dental
student and participant in the Dental Research Scholars Programall at the University of Missouri-Kansas City. Direct corre-
spondence and requests for reprints to Dr. Reem Haj-Ali, University of Missouri-Kansas City School of Dentistry, 650 E 25th St.,
Kansas City, MO 64108; 816-235-2012 phone; 816-235-2157 fax; haj-alir@umkc.edu.
This study was funded by the Rinehart Foundation, UMKC School of Dentistry.
Key words: survey, evidence-based dentistry, dental education
Submitted for publication 3/30/05; accepted 7/27/05

D
entists are faced daily with challenges of
making treatment decisions regarding their
patients. As health care providers, it is im-
portant that dentists offer the best possible care for
their patients. One method that facilitates the deci-
sion-making process is a systematic approach that
begins with identifying a question around an area of
uncertainty regarding a patient treatment, locating
the evidence that answers the question, assessing the
evidences validity and relevance, making the deci-
sion based on the best available evidence, and fi-
nally evaluating the outcomes. In dentistry, this ap-
proach is described as evidence-based dentistry
(EBD).1 It is a way of resolving clinical decisions
based on evidence rather than empiricism.2
With a subject as complex and potentially con-
troversial as the application of dental composite ver-
sus amalgam for posterior restorations,3-11 it is com-
mon that clinicians find themselves perplexed by the
various factors involved in clinical decision making.
Such controversies related to the use of amalgam
include patients perceptions that there are hazard-
ous effects from mercury release, the increased pa-
tient demand for esthetic dentistry, the limitless pub-
lications on this subject, and the various new prod-
ucts introduced to dentistry. There is a question as to
how and whether practitioners are able to make ap-
propriate decisions regarding the use of resin-based
composites in posterior stress-bearing areas. There-
fore, the purpose of this study was to characterize
the informational resource utilization patterns of a
national sample of general dentists with respect to
clinical decisions associated with posterior compos-
ite restorations.
Materials and Methods
The target population was a stratified, random
sample (n=2880) obtained from the latest Academy
of General Dentistry membership list including dif-
ferent AGD levels (Members, Fellows, and Masters).
Prior to selection, listed practitioners were stratified
according to seven geographic regions, and a pro-

November 2005 Journal of Dental Education 1251

 portional, computer-generated, random sample was
subsequently obtained. This strategy was used to
prevent oversampling of members in more densely
populated areas, while concomitantly ensuring geo-
graphical representation of members from across the
United States. The sample size represented 10 per-
cent of the accessible AGD members list in addi-
tion to a 2 percent oversampling strategy to com-
pensate for the anticipated high nonresponse rate.
After obtaining approval of the University of
Missouri-Kansas City Adult Health Sciences Insti-
tutional Review Board, a questionnaire was designed
to elicit information from general practitioners re-
garding their dental practice characteristics, level of
training, AGD member status, use of amalgam, and
informational resources used in clinical decision
making regarding posterior composites. The ques-
tionnaire was piloted among ten general dental prac-
titioners and amended following receipt of their rec-
ommendations.
To achieve the highest possible response rate,
a cover letter, the questionnaire, and a self-addressed,
stamped return envelope were sent directly to each
dentist. The cover letter requested that the dentist
complete and return the questionnaire in the return
envelope within a four-week period. No other den-
tist or practice identifiers were used. Four weeks af-
ter the initial mailing, follow-up reminder post cards
were sent to the original list of subjects.
The data contained in the returned question-
naires was evaluated via SPSS statistical software
(v. 12.0.2, SPSS Inc., Chicago, IL). Descriptive
analysis was used to characterize the size of dental
practice based on number of staff; type of practice
(rural, small town, or large town); dentists experi-
ence (years since graduation); and AGD member
status (AGD Member, Fellow, or Master). In addi-
tion, a weighted composite scale was computed to
evaluate the degree to which individuals use evi-
dence-based (EB) and non-evidence-based (non-
EB) resources for clinical decision making. Monthly
use of traditionally considered EB resources such
as peer review journals and online databases were
coded as positive, and use of resources tradition-
ally considered to be non-EB (discussions with col-
leagues, study clubs/continuing education courses,
and manufacturers information) were coded as
negative. Survey respondents ratings of the use of
EB and non-EB informational resources were then
summed and ranked according to the following
rubric: <0 = Primary Use of Non-EB Resources,
1-2 = Some Use of Non-EB Along with EB Re-
1252
sources; and >3 = Primary Use of EB Resources.
This scale was used to evaluate whether use of evi-
dence-based resources differed as a function of cli-
nician experience. Experience was determined us-
ing two variables: years experience in ten-year
intervals and AGD member status. Comparisons of
groups were made with nonparametric chi square
test statistics at an level of .05.
Results
Replies were received from 699 currently prac-
ticing dentists, giving an overall response rate of 24.3
percent. Most of the responders were AGD Mem-
bers (66.7 percent), 25.7 percent were AGD Fellows,
and 7.6 percent were AGD Masters. The average
years of clinical experience were 20.1 (+11.6). As
for practice location and size, the majority of respond-
ers (73.4 percent) had their practices in large towns
(>10,000) and were mostly (59.5 percent) involved
in medium-sized practices with three to seven em-
ployees. Interestingly, 31.7 percent of respondents
described their practices as amalgam/mercury-free
practices, while the remaining 68.3 percent reported
still using amalgam. Table 1 summarizes the demo-
graphic characteristics of responding AGD members.
Table 2 shows the responders general use of
traditional EB and non-EB informational resources.
Study clubs/CEC and discussions with colleagues
were commonly used resources for making clinical
decisions (69.2 percent and 69.2 percent, respec-
tively). Online resources were used the least (24.9
percent). In addition, 59.6 percent of practitioners
relied on peer-reviewed journals while 41.8 percent
used manufacturers information as resources.
Table 3 shows the distribution of respondents
use of resources for making clinical decisions. An
overall review of the pattern of resource utilization
indicated that the majority of practitioners used both
the traditionally considered evidence-based resources
(peer-reviewed journals and online data bases) as well
as the traditionally considered non-evidence-based
resources (discussions with colleagues, study clubs/
CEC, and manufacturers information) for making
decisions regarding the use of posterior composites.
However, a significant (p=.0001), smaller percent-
age of respondents used primarily EB resources (13.9
percent).
When looking at the resource utilization pat-
tern in regard to the practitioners years of experi-
ence, the same pattern was observed, with the ma-
Journal of Dental Education Volume 69, Number 11
jority of respondents using a combination of EB and
non-EB resources. However, even though there was Table 1. Demographic characteristics of responding
no statistically significant difference (p>.05) between AGD members
experience groups, it was evident, as demonstrated Characteristic Summary Data
by the data presented in Table 3, that the more expe- Mean Years Experience (n=699) 20.6 (11.6)
rienced practitioners were more likely to use EB re- Experience Subgroups
sources while the less experienced were more likely 0-9 years 20.1 percent
to use non-EB resources. When considering the re- 10-19 years 26.1 percent
spondents AGD status, a significantly higher (p<.05) 20-29 years 33.9 percent
percentage of AGD Masters used EB resources, while >30 years 19.9 percent
a lower percentage used non-EB resources for clini- AGD Status
cal decision making (28.3 percent and 20.8 percent, Member 66.7 percent
respectively). Fellow 25.7 percent
Master 7.6 percent
Practice Setting

Discussion Rural
Small Town (<10,000)
7.3 percent
19.0 percent
Large Town (>10,000) 73.4 percent
Patients are becoming much more informed via
the widespread use of the Internet and other media Practice Size (Number of Employees)
Small (<3 Employees) 22.9 percent
resources; as a consequence, patients are demand-
Medium (>3, <8) 59.5 percent
ing treatment options and explanations of the asso- Large (>8) 15.6 percent
ciated potential advantages and disadvantages. Thus,
it is necessary for practitioners to base their treat- CE Courses in Two Years
Average (SD) 3.1 (3.8)
ment decisions not only on their experience and pref-
Median (SI) 2.0 (1.5)
erence, but also on evidence-based resources such Range 0-50
as the most recent and valid research data. An evi- Proportion with No CE 13.3 percent
dence-based approach to dental practice assists cli-
Practice Philosophy
nicians in making intelligent decisions regarding Amalgam-Free Practice 31.7 percent
patient treatment. Amalgam-User Practice 68.3 percent
With evidence-based practice being an emerg-
ing concept in dentistry, it is unknown whether it is
being implemented in the general dental practice and
what informational resources practitioners might be
using when making clinical decisions. Therefore, in were more likely to depend on EB resources. In ad-
an attempt to answer that question, this survey tar- dition, the pattern of informational resource utiliza-
geted a sample population that represents the typical tion seemed to be also influenced by the practitioners
general dentist. While it was expected that newer AGD membership status. With AGD Masters attend-
graduates were more familiar with the concept of ing additional training in various dental disciplines,12
EBD and therefore possibly more likely to imple- they were more likely to use EB resources than AGD
ment its principles into their practices, results from Fellows or Members.
this survey suggest the oppo-
site. Less experienced practi-
tioners (i.e., newer graduates) Table 2. Respondents use of resources AT LEAST once a month for making
were less likely to utilize what clinical decisions
could be regarded as EB re-
Resource YES NO
sources (peer-reviewed jour-
nals, online databases). In- Read Peer-Reviewed Journals 59.6 percent 40.4 percent
stead, one of their main General Dentistry Journal 65.5 percent 34.5 percent
Online Resources 24.9 percent 75.1 percent
resources for clinical decision
Attend CE Courses/Study Clubs 69.2 percent 30.8 percent
making was discussions with Discussions w/ Colleagues 69.2 percent 30.8 percent
colleagues. In contrast, more Information from Product Manufacturers 41.8 percent 58.2 percent
experienced practitioners

November 2005 Journal of Dental Education 1253


Table 3. Distribution of respondents with regard to their collective use of resources for
making clinical decisions by years of experience and AGD member status
Factor Use Primarily Use Both EB and
EB Resources Non-EB Resources
Years Experience
0-9 9.3 percent 49.6 percent
10-19 12.7 percent 55.4 percent
20-29 17.0 percent 47.7 percent
>30 15.6 percent 58.8 percent
AGD Member Status
Member 12.1 percent 51.3 percent
Fellow 14.0 percent 54.7 percent
Master 28.3 percent* 50.9 percent
Overall 13.9 percent* 52.0 percent
*Statistically significant p<.05
This pattern may be explained by the fact that
EB dentistry is not a rigid methodology that dictates
what dentists should or should not do. Instead, a den-
tist using this approach to dental care must integrate
the scientific evidence and the clinical and patient
factors, in addition to the practitioners experience,
in order to make the best possible decision regard-
ing treatment for a specific clinical situation.13 Ex-
perienced practitioners hold the advantage of hav-
ing seen the results of previous decisions, good or
bad. This mental library of circumstances might act
as a guide when other circumstances arise. Decision
making in clinical practice thus is supported by pat-
tern recognition when experience exists.14 Early in
the dentists career, with little experience on which
to draw, decision making may be the most difficult
aspect of clinical dentistry. New practitioners may
seek other experienced practitioners as a convenient
source of guidance in their decision-making pro-
cesses until they build their own.
Nevertheless, regardless of years of experience
or membership status, the survey suggests that prac-
titioners generally utilize a combination of EB and
non-EB resources. To encourage implementation of
EBD in clinical practice, it is important to identify
potential barriers that could hinder practitioners from
incorporating the EBD approach into their practice.
An important obstacle may be the inability of practi-
tioners to discriminate good evidence from poor. It
is important to note that finding the evidence is just
the first step. Every informational resource has its
advantages but more importantly its disadvantages
that may mislead practitioners into making wrong
1254 Journal of Dental Education Volume 69, Number 11
decisions. While consul-
tation with colleagues,
which was the resource
Use Primarily most commonly used, is
Non-EB Resources
an efficient and inexpen-
sive approach to answer-
41.1 percent ing a clinical problem;
31.9 percent this approach is not con-
35.3 percent
sidered EB practice and
25.8 percent
has its drawbacks. Col-
leagues might not be up-
36.6 percent to-date with newer mate-
31.3 percent
rials and techniques, and
20.8 percent*
even if they have read the
34.1 percent most current evidence-
based literature, they
may not provide an un-
biased interpretation of
the associated information. Information from manu-
facturers is generally regarded as selective, at best,
designed to put the product in the most favorable
light and is not considered evidence-based. Yet, as
the results indicate, approximately 40 percent of re-
spondents rely on such resources.
Even when using peer-reviewed journals, one
is assuming that the reviewers are skilled in the pre-
cepts of evidence-based dentistry and had applied
those concepts when reviewing the manuscripts. CE
courses or study clubs are only as good as the research
presented in them, and CE presenters should clearly
reveal their conflict of interest in a particular subject.
Additionally, a high percentage of CE courses are
given by representatives from manufacturers, which
again provides information designed to support the
product. While online data incorporates some non-EB
resources such as personal and manufacturers
websites, other EB resources such as Pub Med elec-
tronic databases and Cochrane reviews are valuable.15
This latest is intended to produce up-to-date, accurate
information about the effects of health care readily
available worldwide. It disseminates systematic re-
views of health care interventions and promotes the
search for evidence in the form of clinical trials and
other studies of interventions.2,16 Nevertheless, if prac-
titioners lack the appropriate skills for distinguishing
good evidence from poor, inappropriate treatment
decisions could still be made.17 To overcome this limi-
tation, clinicians would likely need to participate in
selective CE courses that review some basic literature
assessment criteria that could be used to evaluate evi-
dence-based resources. Although these courses have
not been common, a comparable course, Promoting
Evidence-Based Decision Making, was part of the
program at a recent American College of Prostho-
dontists national meeting.18 This topic could be simi-
larly incorporated into programs for general dentists.
Last but not least, the attitude of the practitio-
ner may be yet another barrier to changing prac-
tice.19,20 For example, as the current survey showed,
approximately a third of the respondents described
their practices as mercury/amalgam-free practices.
Although there has not been any evidence to support
this approach to dentistry,3,21 doing so deprives pa-
tients from a potentially viable treatment option that
may be particularly appropriate in some posterior
restorative situations. In fact, the National Council
Against Health Care Fraud, which has no connec-
tion to organized dentistry, has taken the position that
mercury-free dentistry should be considered sub-
standard practice.22 As with practices that still pro-
vide amalgam as a treatment option, the dentists at-
titude related to meeting patient demands for esthetic
dentistry may be an additional obstacle to evidence-
based practice.23
This survey attempted to characterize the den-
tal informational resource utilization patterns with
respect to clinical decisions associated with poste-
rior composite restorations; but as with any other
survey, nonresponse bias seemed to be an associated
limitation. The response rate to this survey was be-
low the mean response rate (64 percent) to question-
naires completed by dentists as reported by Tan and
Burke.24 Additionally, the questionnaire was sent to
practitioners belonging to the AGD, who may be
more motivated to seek information from evidence-
based resources than other practitioners not seeking
membership in this association and therefore it would
be hard to generalize the results of this study to all
general practitioners. However, the result may be an
indication that evidence-based dentistry is still an
emerging concept and, therefore, there still is a strong
need for further teaching and implementation of evi-
dence-based dentistry particularly in dental schools
curricula.
Conclusions
It is likely that newer graduates have been ex-
posed to the concept of evidence-based dentistry, but
current patterns of information resource use elicited
in this survey suggest a low reliance on evidence-
November 2005 Journal of Dental Education
based information in the practice of clinical dentistry.
However, there was increased utilization of evidence-
based resources by clinicians with more years of
experience.
Acknowledgments
The authors want to express their sincere ap-
preciation for the cooperation of the Academy of
General Dentistry and more specifically want to ac-
knowledge the AGD members who took time to re-
spond to the survey.
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Journal of Dental Education Volume 69, Number 11