Asking the right questions

I was pleased to have been asked recently to speak at the 10^th anniversary celebrations of the Cochrane Oral Health Group in Manchester. The Group is part of the Cochrane Collaboration which is an international organisation that aims to help people make well-informed decisions about healthcare by preparing, maintaining and promoting the accessibility of systematic reviews of the effects of healthcare interventions. As a consequence the Oral Health Group aims to produce systematic reviews which primarily include all randomised controlled trials (RCTs) in oral health and has, during the past decade, published a long list of such reviews on a wide variety of subjects within the field of dentistry.

The organisers asked me to speak under the title of 'A View from the Chair', the erstwhile heading of the tongue-in-cheek series that I used to write for this journal, which I took to be an invitation to take a wry, sideways look at the work that they did and the outcomes they produced. I therefore described how many of the reports that I read seemed to follow a similar pattern. They began with a description of searching the literature for RCTs on the relevant subject area. This usually threw up a number of promising papers, let's say 235. However, once scrutinised further, a much smaller number actually met the strict criteria which made them comparable. This whittled the number available down to about 17. Further weeding in order to match the even stricter criteria of Cochrane itself left just a handful of appropriate references, let us say eight. Then, after careful reading, cross-referencing and statistical analysis, the conclusion was reached. Somewhat disappointingly the upshot was that there was too little evidence available to be able to provide guidance or a definitive answer either way, on whatever the subject under investigation was. Oh yes, and one further, very important observation – that more research was needed!

The audience chuckled politely before the rest of the conference continued, during which a succession of erudite speakers mounted the podium and repeatedly proved my point – not enough evidence to be conclusive and the only certainty was that more research was needed. Indeed it is a scenario not unknown to readers of many an evidence-based paper or article. Now please do not misunderstand me, I am not criticising the Cochrane Oral Health Group, as I believe that the principles under which they operate and indeed the extensive work that they do, are extremely laudable and point the way forwards. However, the most important signpost they have erected is that somewhere along the line the 'right questions' are not being addressed, or if they are being addressed they are not being answered.

...what on earth do dental researchers do all day that is of relevance to the real world?

Given this situation, would it be unreasonable for dentists, and other dental care professionals, working on a daily basis to solve the oral health problems of their patients to ask what on earth dental researchers do all day that is of relevance to the real world? For how many years have we had dental research? For as many as we have had dental check-ups surely. Yet there seems to be scant if any evidence as to their effectiveness one way or another. What about the benefits of scaling and polishing, another fairly basic, routine intervention – the jury it seems is still out on this one too until we have 'more evidence'. The list continues.

In her article entitled 'Research in primary dental care' in the Oral Health Report distributed with the previous issue of the BDJ, Professor Liz Kay wrote the following, addressed to readers: “Take five minutes to think of three issues which, if indisputably resolved, would make practice life easier. Just imagine the useful and applicable research which would get done if it were real questions like yours that were being answered.” So what is the answer? Who does drive the research agenda to be undertaken by our academics and researchers? How do they decide which paths to follow and which not?

What would be very exciting when the Cochrane Oral Health Group reaches its 20^th or 25^th anniversary, which I am sure it will, would be for it have started to find that the body of available research and evidence enabled it to be rather more definite in the robustness of its conclusions and therefore of direct and beneficial help to ourselves and those for whom we care.