Dr. Gregg Gilbert on the National Dental Practice-Based Research Network
In 2012, NIDCR awarded a $66.8 million, seven-year grant that consolidated its three regional dental practice-based research networks into one nationally coordinated effort. The consolidated initiative, renamed the National Dental Practice-Based Research Network is headquartered at the University of Alabama at Birmingham (UAB) School of Dentistry. UAB leads and oversees the six regional research sites of the network.
Dr. Gregg Gilbert
National Network Director and Chair of the UAB School of Dentistry's Department of Clinical & Community Sciences
Recently, Science Spotlight spoke with Gregg Gilbert D.D.S., M.B.A., the National Network Director and Chair of the UAB School of Dentistry’s Department of Clinical & Community Sciences, to ask how the work is going.
One of the keys for the network is to have practitioner-generated ideas for research. How are practitioners generating ideas that are clinically testable?
We do that in a lot of different ways. First, when practitioners enroll and complete their own questionnaire, we ask for study ideas there. I would say the most common and effective way to engage them directly is at our annual meetings, where we have breakout sessions or discussion groups about generating study ideas. We also have practitioners contact us directly, typically at one of the regional centers. Usually, I would say these ideas are really clinical topics rather than very specific research questions. We work with the practitioner and typically identify an investigative team to hone that topic into a research question, specific study design, and so on. It’s really a process instead of starting with a defined product at the outset.
But you need those ideas. They are the currency of the network.
Yes, definitely; we need to know which clinical issues practitioners think are important. We would never want to conduct a study that they aren’t interested in. Not only that, after the study has been completed we want them to look at the results and conclude that those results can actually make an immediate difference in their practices.
It took a little longer than expected to launch the first studies.
“Our studies focus on developing evidence based on the observations of clinical treatment in daily practice.”
That’s right. Part of it was we needed to have everything in place to conduct the studies efficiently. We also wanted to make sure to address clinical topics that practitioners think are important. So, we needed to engage them, hone the ideas, develop these into research questions, and then into research protocols. Then the study development process engages our network’s Executive Committee, the NIDCR Clinical Studies Group, and in some circumstances a Data and Safety Monitoring Board. We make a point of engaging a broad range of stakeholders. It takes time to get all of that input, but the final product is better because of it. We’re confident that our research studies will help to improve the profession and clinical care.
Our studies focus on developing evidence based on the observations of clinical treatment in daily practice and disseminating that evidence.
How many studies are in the works?
Well, we have a study that finished in July 2014, which assessed the isolation techniques used during root canal treatments. We have the Cracked Tooth Registry study that finished its pilot stage in July 2014 and now is enrolling patients in the full-scale baseline phase. We have two others that have recently been approved by the Data and Safety Monitoring Board. These are the Management of Dentin Hypersensitivity study and Decision Aids for the Management of Suspicious Occlusal Caries Lesions. Both are beginning initial enrollment and anticipate full launch in early 2015. A fifth study, called the Successful Crowns Study, has finished development of the research protocol and is under review by the network's Central Institutional Review Board. We also have ten other studies with approved study concepts that are in various stages of developing the full study protocols.
So things are going to get real busy real soon in a good way?
How did the Cracked Tooth Registry come about?
How best to diagnose and treat cracked teeth is certainly a topic of great interest amongst our practitioners. That study topic arose very early on when the national network was formed, as it transitioned from the three regional networks. We were fortunate in that one of the former regional PBRNs – the PRECEDENT network – had done a longitudinal study on cracked teeth, led by Drs. Tom Hilton and Jack Ferracane at Oregon Health and Science University. Their initial work allowed us to build on the evidence from that study as well as their experience in conducting a PBRN study. So they are leading the National Network’s Cracked Tooth Registry.
That will address the variables on whether to treat or not to treat?
Right. We’re interested in how the signs and symptoms of initially symptomatic or asymptomatic cracked teeth change over time. If the cracked teeth undergo treatment during the study, are there factors that contribute to treatment decisions, when is treatment done, and what are the outcomes of the treatment?
In the Isolation Techniques study you surveyed network dentists on those methods they use during root canal treatments. How was that survey delivered and presented?
All of the practitioners, when they enrolled in the network, were asked to provide a preferred email and postal address. First, practitioners received an email, inviting them to participate. If there was no response, we’d follow up by sending out a postal questionnaire to see if they’d respond that way. I think providing dual ways to respond was helpful. Next, our Regional Coordinators followed up by telephone or fax with those practitioners who did not respond to the survey. The Regional Coordinators are just a great group and conduct themselves in a very professional, effective manner. All of these factors contributed to a high survey response rate.
I also think the respondents were interested in the topic, which has immediate practical clinical impact.
How much time did it take to fill out the survey?
About 15 minutes. But, to be on the safe side, we told practitioners in the invitation that it could take up to 30 minutes. For those who took the online survey, the system tracked when they began and finished the survey; the average was about 15 minutes.
You had an 80 percent-plus response rate in the Isolation Techniques study. That’s phenomenal.
The final percentage ended up being 87%, or 1,490 eligible practitioners. To be eligible, practitioners had to be general dentists and report that they do at least one root canal treatment each month.
Do you have any dissemination studies in the pipeline?
Yes, we have one that was recently approved and is about to begin development of the full protocol. It looks at how evidence and clinical information gets diffused throughout the profession and may provide ideas for how we might best disseminate evidence to dental practitioners.
If the network weren’t looking at dissemination, who would?
Well, dental organizations certainly have an interest in the topic. But it would be difficult for them to fund the research, so I am not sure that it would ever get done even though it is very important to actually move recent scientific evidence into routine practice.
You often talk about the progression of oral health research from the laboratory to the community. Can you elaborate on that and tell us where the network fits in?
I have a slide that I often use that really nails down this point. Specifically, research exists along a continuum. At one end is basic science. This is the best context when the research isn’t ready for humans. Next up is clinical trials in academic settings. This is the best place to do research that is not ready for patients. It is efficacy research, so seeing if it can work under ideal conditions. The next step up is practice-based research. That’s where the network sits. This is the best context to determine whether an intervention is effective in real-world settings with its constraints and limitations. It’s not efficacy research. It’s effectiveness research. Then, the next step up is community-based research. That allows us to evaluate interventions outside the healthcare system or to study the natural history of disease that is not intervened upon by health care. Of course, community-based research can evaluate interventions that are integrated in some way with the healthcare system, too.
Do you see the network collaborating across all those levels of research?
So, in that continuum, network research borders clinical and community-based research. Two steps down the continuum is basic research. I would say that we’ve been very effective in bidirectionally engaging researchers in clinical trials in academic settings. We’ve reached out to academics, and they’ve integrated well into the activities of the network. We’ve also had some success for that one step in the other direction, community-based research. But I can’t really point to any successes, yet, for engagement between the network and laboratory researchers.
I think engaging with basic science is particularly challenging because, in the network context, we’re not evaluating interventions that haven’t been demonstrated to be at least efficacious under ideal conditions. That’s two steps away from us. So, it’s going to continue to be a real challenge. We’re open to exploring the possibility. But it’s going to be a challenging one to solve.
What about a bidirectional exchange of information across the entire continuum?
An information exchange would be great, and I think we are getting some of that via the academic health centers. But, quite frankly, it’s not coming from the basic sciences. Now, we may be getting input from the basic sciences indirectly through the clinical sciences.
I pulled up the article you published on the network in 2013 in the Journal of Dentistry. I noticed that one of the tables shows the
characteristics of practitioners in the network. That was for 2,000 practitioners. You’re up to 5,000 members now, correct?
Right. There are about 5,600 total enrollees as of November 2014. That consists of dentists, hygienists, and non-practitioners. We have 3,617 dentists. 1,438 are hygienists, and then about 500 are non-practitioners. Non-practitioners are people who are interested in the network, but they aren’t in active clinical-practice dentistry. So, these might be retired dentists, dentists who are between positions, dental students, and non-dentists, such as university faculty who have an interest in oral health research.
How did you meet your recruitment goals so quickly?
I think the key to our success is we’ve always tried to identify a win-win zone. Any time we engage in collaboration with other people - and that includes practitioners - I would say there are some recurring themes, or benefits, from engaging in the network. That’s certainly important when we try to identify where this win-win zone lies for them. I would say these themes include the notion that network engagement increases the stature of their practice. It conveys to their patients that they are working to stay current. Patients often say that it must be a good thing that my dentist is in a research network, and it must mean that he or she is trying to stay current. The practitioners also tell us that network engagement is professionally rewarding. It improves the quality of care that they deliver to their patients. They also tell us that all of the studies that we do have immediate clinical impact.
We hope that one day the profession will actively engage on a routine basis in research and quality improvement just because that’s what we do as a profession. I would love for a dentist to be out one night at a social gathering, and somebody there says, “Oh, you’re a dentist. Do you happen to do research studies in your office to improve the quality of care?” Surprised by the question, the dentist answers, “Well, of course, I’m a dentist. That’s just what we do as a profession.” I would say that our network practitioners already embrace that vision. They are helping to transform the profession into a truly evidence-based profession. Our long-range goal is all of the profession will be doing it. Not just the practitioners in our network. And that starts with awareness.
Your 2013 article also showed participants to be practicing in a diverse array of locations and have a mean age of 50. Are those characteristics still holding up now that the network has grown?
Yes. It’s pretty consistent. I don’t think that we can make the claim that the practitioners in the network are necessarily representative of practitioners at large, because there may be unmeasured characteristics, such as their interest in research and willingness to participate in research. But what we do is compare these results to the 2010 American Dental Association (ADA) Survey of Dental Practice. We can say that the characteristics of the dentists in the network have a lot in common with those who participated in the ADA survey, which is not limited to ADA members. It's just done by the ADA. We can also point to the fact that findings from several network studies document that network dentists report patterns of diagnosis and treatment that are similar to patterns determined from studies done by non-network dentists.
Thirdly, we can also say the dentists in the network have diverse characteristics. It's not as though we’re selecting from one segment of the dental profession. It's clear we're getting participation from a very broad range of practice types, dentist types, patient populations, etc.
What about dental specialties? It looks like you're headed in that direction.
We are, even though we have not made a concerted effort yet to do so. We’ve been waiting to develop studies that a specialist would be particularly interested to participate in. We already have studies that pediatric dentists would want to join. We’ve had a study that orthodontists would be interested in participating in, as well as now endodontists. We are developing a study that may be of interest to periodontists. So, we find that when we have a study that a particular specialty would be eligible and interested to participate in, that’s when our enrollment goes up. That certainly happened with pediatric dentists. It’s beginning to happen with orthodontists. I want to commend the national specialty organizations with which we’ve collaborated. They’ve been excellent collaborators in trying to get the word out. We’ve presented at their meetings. They’ve put announcements in their newsletters. The specialty organizations have also participated in developing study ideas, study concepts, and full protocols. That’s all worked very well. I think that they would say that collaboration with the network has been a ‘win-win’ for them as well as us.
How high will the recruitment numbers rise? Do you have a cut-off number in mind? Or is it the more the merrier as long as the practice-based research infrastructure will bear the increased participation?
I would say the latter. Now the number that can participate in questionnaires or surveys is basically unlimited. It’s really the participation in clinical studies where we begin to bottleneck.
What about engaging military and public health dentists?
We really haven’t made good inroads with the military. We’ve looked into it; they’re open to participating. It just hasn’t worked out so far.
I think it’s more a matter of mission. They’re focused more on non-research aspects of their mission, that is, treating patients. Participation has been good by public health and other community dentists who are not in private practice. They comprise about 10 percent of our enrolled practitioners, depending on how you define them. We’re certainly glad to have them in the network. They bring a fresh perspective to the discussion table, and that’s important.
We’re also grateful for our collaboration with the National Network for Oral Health Access. It is an organization of public health and community dentists, for example, dentists in federally qualified health centers. They’ve been very engaged and participated in study development.
They’ve been excellent in distributing news items that we’ve presented at their conferences. We truly appreciate that.
It sounds like there are a lot of great organizations out there. The key is to make a connection with them and engage in the win-win zone you mentioned.
Exactly. We try to be intentional at the outset about discussing with them where they see the win-win zone is. So, there seems to be a pretty broad win-win zone. The national organizations have participated in the dissemination of news, encouraging enrollment, participating in study development, and, in several cases, actually proposing study ideas that now have come to fruition. For example, the American Association of Orthodontists just collaborated with us on a study concept that has been approved. The same is true with the American Association of Endodontists. The American Academy of Pediatric Dentists has developed some concepts. None have been approved yet, but they continue to work on them. So, that’s gone very well.
Given this is a national network, how are you working to enhance communication and collaboration across so many miles and regions of the country?
It’s been pretty easy to accomplish actually. We have frequent email communications across the regions and throughout the network to engage practitioners as well as administrative personnel. With regard to practitioners, we have annual face-to-face meetings. Our regional coordinators are in regular communication with practitioners, particularly as they are involved in clinical studies. We have Practitioner Advisory Committees in each of our regions, open to practitioners who are engaged and interested in contributing to the Network. We have an Executive Committee, which is the main decision-making body for the network, and the majority voting authority there is practitioners. We have monthly conference calls of the various administrative committees and study teams. We have regular traffic on email distribution
systems across these committees. Further, a communications plan has been developed. It was designed to foster active engagement and increase communication among practitioners across all of the regions. We’re developing a discussion forum on the public web site. It will be available to members. That’s not ready for release yet, but it will have topics related to current studies in the field, study ideas, and a quarterly journal club. Practitioners will be able to start up their own discussion topics.
What about practitioners in remote areas? Has it been a challenge keeping them engaged?
Yes, I would say so. I think our most effective engagement is face to face, and that would happen predominantly at our regional meetings. The farther away the practitioner is from these regional hubs, the more challenging it is to attend the annual meetings.
It’s a challenge, but doable?
Yes. Of course, practitioners in remote areas can easily participate in questionnaires. They receive regular email communication, and we are setting up an online discussion forum. They can participate in clinical studies, but it depends on how intensive the training aspect is. For some of the clinical studies, we can actually do the clinical protocol training via conference call after sending them the materials in advance. But we’re experimenting with that to some degree.
It sounds like a lot of good work is in progress from the network. Where can practitioners go to learn more about the network, how to participate, and what’s coming next?
Well, as part of our duties as the national administrator of the network, we maintain and update a website with all of that information. It’s at www.nationaldentalpbrn.org. The site has information on joining the network, study results, publications, and more.
Thanks for providing the overview.