The Knowing-Doing GAP in Dentistry. Part I

Research has shown that removing amalgam without rubber dam (RD) results in a significant increase in mercury levels in plasma and urine. A Cochrane study in 1989 showed that RD also reduces the transmission of infectious material. Do you use RD as often as possible? I know I am guilty of failing to do so and I blame time and convenience. However, there is extensive research that, once you overcome the short learning curve, utilizing RD is actually quicker than not using it. Research has shown that it takes about 2 minutes for a dentist to place RD and the remainder of the appointment can be faster and more efficient. Moreover, we assume patients hate RD even though literature shows that 77% of patients believed it to be comfortable. One study even found that dentist stress levels were lower when working with RD. Even though the benefits are ample and evidence is unequivocal we fail to comply 100% of the time. Why?


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In business management there is a recognized concept called the knowing-doing gap. The knowing-doing gap is the idea that, in spite of education, training and research evidence, it is difficult for us to truly change our ways. We suffer from various biases that preclude us from succeeding. Firstly, confirmation bias – we tend to recall the information that confirms our perception more than experiences that contradict them. For example, if I have 10 patients for whom the RD experience was uneventful and 1 who had a really difficult time I am more likely to remember the 1 that confirms my bias that patients hate RD.



Secondly, evaluation bias means people tend to value the information they have more than information they gain from other sources. This means that people are slow to “trust” new ways of thinking and many dentists may be guilty of this. My first boss is someone I regard highly and he advised me “Never be the first dentist to adapt a new technology but never be the last either.” This is “bandwagon effect” or “herd mentality” where people do something or believe something because many others already do. I valued my boss’ advice and acceded his mantra until recently – why not be the first to adapt something new?

Patients suffer from the knowing-doing gap too. Though we advise them to floss once per day, brush twice per day, control their snacking and limit their consumption of pop they do the very opposite. Creditability bias is the concept that people consider information to be more creditable when they share that viewpoint. But this inhibits learning new information from your healthcare provider and promotes re-confirming perspectives you already have. For example, dentists frequently diagnose bruxism with severe attrition, cheek biting and abfractions in multiple teeth. However, patients find it hard to process this new information because they are not aware of their habit and have difficulty accepting an alternate viewpoint. It’s easier for them to believe that the dentist is just trying to make more money by advocating for a costly therapy.



Similarly, self-serving bias helps us maintain our self-esteem by attributing failure to uncontrollable outside factors and attributing success to ourselves. Hence, patients complain that their oral health status was inevitable for them because a parent had “soft teeth.” But failing to take ownership of an issue will inhibit resolution of that issue.

Finally, status quo bias affects dentists and their patients. It is a fact that people have an emotional preference for their current state and any change represents discomfort and stress (in spite of potential benefits gained). For example, a dentist may ask their new patient “did you receive antibiotic prophylaxis when you last went to the dentist?” This, however, is an irrelevant question that serves to maintain the status quo – we should not ask the patient about the past but use our expertise to make a judgment on what is needed for the patient today. Dental Association antibiotic guidelines update frequently, a patient’s health status can change and their last dentist may have been overprescribing or under-prescribing.

How do you overcome the Knowing-Doing GAP??? Wait for the next post…

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