Dear Readers:

As an educator, I am frequently approached by dentists asking my opinion on a particular technique or new material. The conversation usually involves a point of confusion about whether the technique or material is appropriate to use or should replace some approach the practitioner is using currently.

The answer to these dilemmas always involves the process of critical thought, which is to analytically evaluate the approach in question through a logical systematic process. Unfortunately, as a profession we aren’t always taught that process in dental school. That is not to say that the schools are at fault; they simply don’t have time or space in their curriculum to present the many alternatives necessary for critical evaluation. The outcome is that students are taught the techniques chosen by that school for a particular situation. Essentially, the student is given a recipe for the steps involved in treatment, and by the end of 4 years of dental school they have a recipe book of techniques for different problems they may encounter in clinical practice. When the patient arrives and a problem is recognized, the recipe for that problem is applied following the correct steps.

The challenge begins, however, when the dentist is now in practice and starts taking continuing education outside of a closed system, their dental school. Now they get exposed to very different recipes to treat the same problem. This is usually when the confusion begins. Now they attempt to decide who is right and often their confidence in knowing how to treat the patient is eroded.

This is when the weaknesses of having a recipe approach to treatment are exposed. What is required to feel confident and make good choices requires critical thinking. What I mean by that is having the ability to step back and evaluate the treatment approaches from a more global perspective rather than from merely a technique perspective. For me this starts by asking a very simple question: Is there clinical evidence to support that both approaches can be used successfully? When I say clinical evidence, I mean both literature evidence as well as clinicians whom you know and trust who are using one or the other successfully.

If the answer is yes, which it often is for both approaches, I ask myself why that might be. This usually involves looking for the similarities in the approaches. For example, compare a self-etching dentin adhesive to a conventional total-etch system. What they have in common is the development of a hybrid zone at the resin dentin interface, but they do it differently. And yet both do it successfully. After I have ascertained that the competing approaches are both successful, and attempted to identify what the similarities are that appear to make them successful, I then ask myself what the advocates of each approach say are the weaknesses in the competing techniques. I also ask myself whether there is evidence to support that position, or is there just emotion. Unfortunately, when a clinician has a vested interest in a recipe, they often have a difficult time accepting that there are alternatives that can be equally acceptable, and they tend to defend their point of view more from a position of emotion than logic.

Another example involves making centric relation bite records; specifically, the techniques used to find centric relation. One of my students, who also does some lecturing of his own, did a literature search to find evidence about how to make centric relation bite records. He and his partner have been using a leaf gauge in their practice for years to make records and perform equilibration, and have enjoyed great success using the technique. When he went to search the literature for support, however, he got more confused than supported. Using the process of critical thought, let’s work through the dilemma.

First, is there literature and clinical evidence to support his technique, the leaf gauge? The answer is yes; it has been used very successfully since 1968. Are there competing methods to achieve centric relation that also have been used successfully and with clinical evidence of success? Definitely. Bimanual manipulation, Lucia jigs, and appliance therapy all have a long history of being used successfully.

Second question, what are their similarities? They all promote deprogramming or releasing of the lateral pterygoid muscle with subsequent seating of the condyle, but do it differently, all with a history of success. Finally, what was confusing to the dentist was what some opponents of the leaf gauge said was its weakness; namely, that when using it to seat the condyles, surface electromyography showed it produced greater levels of muscle activity than using manipulation or a Lucia jig.

The final step in critical thought is to decide if the identified weakness interferes with the ability of the technique to achieve the treatment goal. In the case of the leaf gauge, the goal is to seat the condyle. The confusing literature finding concerned greater surface electromyographic levels of muscle activity when finding centric relation with a leaf guage when compared to other techniques. If one stops to take a more global approach to analyzing this finding rather than simply reacting to the finding, it makes perfect sense. When using a leaf gauge, the concept is that the patient will use their elevator muscles for condylar seating rather than the clinician’s hands loading the mandible. So, in fact, it’s perfectly logical that an article would show what it did concerning muscle activity, and also why that finding has nothing to do with this technique achieving the treatment goal.

The final challenge then becomes choosing what to use when multiple materials or techniques are successful. The answer really comes down to the clinician’s choice—what works in their hands predictably, and what they have confidence in. If one applies this thought process to many areas in dentistry today, from implants to bonding, you will see that there are multiple successful approaches to treating the same problem and achieving an excellent result. Unfortunately, the intense disagreements in approaches usually stem from a clinician or educator getting emotionally attached to their recipe or technique rather than using critical thought.

As a final comment, I am asked fairly often by young dentists who are interested in a specialty, what do you gain from a graduate program, assuming it must be an extension of the dental school process of learning recipes or techniques? My answer is that techniques can definitely be learned outside of a specialty program. Having spent 3 years in a Perio-Pros program, 5 to 6 days a week, 10 to 12 hours a day, I can say without hesitation that what you learn is the process of critical thought. You have the time and intensity to evaluate and dissect every approach in that specialty, and I am grateful to my mentors Ralph Yuodelis, Bill Ammons, Bob Faucher, and Roger Harper for helping me develop this thought process.

Sincerely,

Frank M. Spear, DDS, MSD