I am a subscriber to the excellent online Endodontic resource www.rxroots.com. One of the advantages of belonging to this group is the RxROOTS "Guest Day". Guest Days offer us the unusual opportunity to interact with world class clinicians and researchers who have committed to being online for a few hours to interact with forum members. Over the internet, in real time we can ask questions and share answers with the hundreds of dentists monitoring the conversation.
I posed the three questions listed below to Dr. Buchanan:
1. How does one answer the "single vs. multi-appointment treatment success rate" argument?
2. How does Dr. Buchanan react when he is criticized for mostly publishing his material in non-peer reviewed journals that most serious researchers consider "bathroom reading"?
3. Is there any way for us to bridge the gap between the "Scandinavian Research Oriented - Show me the Studies - Your clinical impressions are meaningless" gang and "wet fingered - I do it everyday so I know it works" clinicians such as himself?
Here is a his response to my questions:
"I think all three of these questions can be answered with the same statement of my belief in evidence-based clinical knowledge. First off, I studied under Sam Seltzer and learned to have a healthy skepticism regarding baseless claims and opinions and to value peer-reviewed research published in scientifically respected journals. But I was also taught by Sam the limitations of published literature. Anyone who has gone to a decent post-grad program in Endo has spent hundreds of hours critiquing the literature, certainly not worshiping it. At the end of their training grad students should be able to read published articles, pick them apart and decide for themselves whether the author contributed to their understanding of what works and doesn't work in our procedures." (At this point Dr. Buchanan critiqued a paper that had recently published in the Journal of Endodontics. The researchers had used the files he designed but - according to Dr. Buchanan - in an unorthodox and improper manner. He felt this not only invalidated the paper but caused it to be misleading. ) "My point here is, what's so great about peer-reviewed literature when it is a poor model of clinical reality? The list of peer-reviewed research conclusions that later turned out to be either erroneous or seriously misguided is quite a long one, so I have a hard time praying at that alter. With that said, I am totally respectful of great research done by intellectually curious scientists who are looking for answers instead of those who "know all the answers" and are just trying to win a debate."
"I'll give you an example of a research study that I love, Sjogren, et al, 1997. These researchers were very smart, very careful, and very honest. They did a study, came up with surprising results, and while they seemed to be a bit non-plussed to see 100% success in overfilled canals, regardless of whether they had positive or negative culture results, they accurately deconstructed the etiology for the results. In their discussion, they attributed that success to technically excellent shaping and filling, as well as the probability that any remaining bacteria had been entombed within the canal by the fill, as opposed to the poor results achieved when infected canals were underfilled-allowing the bacteria a path of egress into the periradicular tissues. This paper accurately described clinical endodontic reality thereby furthering our specialty and I will worship at that alter."
Now, back to the claims of some that good articles published in Dentistry Today and sage conclusions drawn from clinical experience have no validity. What I most love about the philosophy of evidence-based clinical knowledge is it states that well observed clinical experience is more valid than in vitro research when no well-designed clinical studies are available. I think I would say the same about Dentistry Today. In the absence of a peer review article that accurately reflects what happens in a root canal during cone fitting and obturation (i.e., the example from the last JOE where the authors understood so little about the simple concept of preparation shape and conefit), I would prefer to read an article in Dentistry Today by Richard Mounce with a common sense technique description that works. What about the fact that I've published very little in peer review journals? Jeez, I'm sorry! Can we move on? In no way does my publishing history reflect a (sic) disrespect for those who do the harder thing-quite the contrary.
I think there are three significant reasons that I've published in Dentistry Today:
1. Articles are published within two or three months of submission-when JOE wait time was 18 months (no longer thanks to Ken Hargreaves), the rate of technologic advance in instruments and techniques by far outstripped the time lines of more prestigious journals,
2. The Journal of Endodontics is read by less than 10K dentists and DT is read by 100-140K dentists,
3. I have ADD and it is really hard for me to hang in there for the extended time necessary to get through more respected publications, mea culpa.
(Editor: Interestingly, these were virtually the identical answers that were given by Dr. Cliff Ruddle when I asked him why he too infrequently published in peer reviewed journals.)
With that said, it is my greatest professional ambition to submit myself and the research I am doing at the USC grad endo program to the peer review process. We are doing anatomic studies of root end anatomy and instrumentation studies comparing file function, both using MicroCT scanning as I've done since 1987. I would like to do a 20 year retrospective study of my cases as well, but don't hold your breath.
In terms of the seemingly huge distance between the "researchers" and the "clinicians", I would quote Rodney King and say, "can't we all just get along?" As most of us well-versed clinicians read and give respect to researchers for the knowledge they can share, I would only ask the same of them-could they look at what we do that works and explain it instead of saying that it can't work if it hasn't been published? The sun comes up every day whether or not somebody writes about it.
Single visit RCT literally wouldn't be done if it didn't work so predictably. It is really competitive out there in practice-if I had even a ten percent failure rate in Santa Barbara, I wouldn't have a practice in two years. I think the smartest researchers are curious, not opinionated; they are looking at procedural trends in the specialty and for ways to explain what works and doesn't work. It's the Craig Baumgartners, the Jim Simons, the Marcus Haapasalos, and the Mahmoud Torabinejads that I read with anticipation when my JOE gets delivered each month. Rather than disrespect any of my peers that fear sealer puffs, I would rather seek an understanding of why that is-and I'd probably find out that they use Grossman's Sealer or AH+, two sealers that are quite toxic for three days before setting. They are accurately describing their patient's post-op experiences. I'd be afraid of puffs too if all my patients wanked after I saw one on the post-op radiograph. When they see the calm demeanor that we "apical barbarians" exhibit when there is surplus filling material at the end of a case, I'd like them to ask themselves the question, do they use different sealer and do the tapered shapes they create have a more predictable potential to be sealed than the apical stop prep? When they are afraid to do single visit endodontics because (as we have all known) it is difficult to sterilize a complex root canal system still in a patient's head, I'd like them to read Sjogren's study again and think "Oh, those guys pull it off because they do their best to fill to the full apical and lateral extents of these root canal systems." END