relevant literature is not, however, voluminous. Many clinical interventions in dentistry—as well as in medicine—have never been subjected to rigorous scientific investigation. Their effectiveness has been assumed on the basis of experience, indirect scientific evidence, and judgment.

Policymakers, insurers, and consumers are, however, demanding that more be done to document what works and what does not work in health care, and dentistry is not immune from these demands (Bader, 1992; Kantor, 1992; Pew Health Professions Commissions, 1992; Antczak-Bouckoms, 1993). Several dental organizations have developed practice guidelines, but the efforts of the American Dental Association to do so have been troubled by disagreements about purposes, procedures, and content (Berry, 1991; Spaeth, 1993). A new project to develop guidelines was approved in 1993 and began work in January 1994 (Spaeth, 1994). To the extent that better evidence of the effectiveness of dental interventions is accumulated and transformed into guidelines that, in turn, shape dental practice, the result should be further improvements in dental care and oral health status.

Practice guidelines are not, however, self-implementing. Some of the problems in implementation can be traced to deficiencies in the guidelines themselves including vagueness, bias, inconsistency, poor documentation of the evidence behind recommendations, unhelpful formats, and limited dissemination or availability (IOM, 1992). Other problems lie on the user side—organizational constraints, economic counter pressures, habit, psychological resistance to change, and failure to stay abreast of new knowledge (see, for example, Eisenberg, 1986; Lomas, 1991; Kibbe et al., 1994). Given the relatively cool reception of dentistry to initial guidelines development efforts, considerable persistence will likely be required before guidelines become a vehicle for change in dental practice. Nonetheless, as the pressures for accountability for both patient outcomes and costs increase in dentistry as they are elsewhere in health care, they will encourage clinicians to welcome guidelines that are clear, specific, and grounded in science. Researchers in dental schools have an important role to play in developing the clinical research base for guidelines and in assessing the factors that influence their acceptance and use by clinicians.

Improved Access to Calve

Access to dental care could be improved by reducing economic, geographic, cultural, and other obstacles to access. For example,



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