ORIGINAL ARTICLE

Diagnostic paths for a mouth-breathing

patient
 Cummingsa and David W. Chambersb
Silke
Colorado Springs, Colo, and San Francisco, Calif

Introduction: The clinical choice of diagnostic tests or treatment options is determined by the probability that the
value of their execution (called the warrant for the test) exceeds their cost, and by their usefulness. The purpose
of this study was to determine the warrant and usefulness of STOP-Bang, an obstructive sleep apnea screening
questionnaire, and cone-beam computed tomography (CBCT) information about the minimal cross-sectional
area for referring a mouth-breathing patient to a sleep specialist and for modifying planned orthodontic
treatment. Methods: A branching survey was used to identify the prominence of paths between the presenting
situation, 2 diagnostic tests, and 2 referral and/or treatment options. A description was given of a hypothetical
patient: an overweight, mouth-breathing female teenager. Path analysis was used as a method for
quantifying diagnostic warrant and usefulness. Results: There was a wide variation among the 125
orthodontists who responded to the survey. All paths were chosen. The use of tests altered the referral
(c2 5 8.039; P 5 0.03) and/or treatment decisions (c2 5 12.636; P 5 0.005). Ownership of a CBCT system
significantly influenced the use of this diagnostic test, with owning a CBCT system resulting in greater use
in-office (c2 5 50.416; P \0.001) and greater use in the study (c2 5 22.959; P \0.001). The usefulness of
the diagnostic tests could not be determined directly because common values were used for each test, but
the variation in the use of this standard stimulus was very large, indicating personal differences in the
interpretation of actual data. Conclusions: Wide variation in the choice and interpretation of diagnostic tests
for referral and orthodontic treatment modification relative to airway condition exists among orthodontists.
Diagnostic path analysis is a potentially useful model for studying how practitioners make decisions independent
of research evidence. (Am J Orthod Dentofacial Orthop 2020;158:564-71)

C
linical decisions are the pivot between what is
known about a particular presenting patient and
patients of that type and specific interventions
undertaken to improve patient oral health.1 It is possible
to entertain, with varying degrees of confidence, several
plausible explanations for what might happen if one
chooses to intervene or not. However, once an action
is taken, it changes the situation. What orthodontists
do usually changes the circumstances and alters the
situation because this affects later decisions.
That is also the case for diagnostic decisions.
Information gathering, including tests, is undertaken
specifically to change what is known and useful for
a
Private practice, Colorado Springs, Colo.
b
Arthur A. Dugoni School of Dentistry, University of the Pacific, San Francisco,
Calif.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: David W. Chambers, Arthur A. Dugoni School of
Dentistry, University of the Pacific, 155 Fifth St, San Francisco, CA 94103;
e-mail, dchamber@pacific.edu.
Submitted, March 2019; revised and accepted, September 2019.
0889-5406/$36.00
Ó 2020.
https://doi.org/10.1016/j.ajodo.2019.09.019
guiding more high-stakes interventions. Gathering
information that is not used to guide treatment choice
is wasteful and may expose patients to unnecessary risks
or costs. Failing to use the tests with the highest
likelihood of revealing what is needed to treat patients
well is not the best practice.
Professional judgment is necessary in choosing which
diagnostic information to gather or ignore, and in what
order chosen tests should be undertaken. This is the
warrant decision: the authority under which it is
initiated. Professional judgment is also needed
regarding how the test results inform action. This is
the usefulness decision. Such basic diagnostic decision
units can be chained to form complex personal decision
protocols and professional guidelines. This model is
illustrated in Figure 1.
In this highly simplified model, the diagnostic test is
warranted by prior information and useful for initiating
future action. The term “screening” is generally used to
refer to justifications that are population- rather than
patient-specific.2 It is commonly recommended that all
males over a certain age should be screened with the
prostate-specific antigen test, and some practices use a

564
Cummings and Chambers
Fig 1. Basic model for a diagnostic test.
policy that cone-beam computed tomography (CBCT)
images should be taken on all new patients.3 By contrast,
“testing” means warranting gathering of information on
the basis of unique factors of the patient such as
complaints about thumb habits, signs such as open
bite, or risk factors such as parents with conspicuous
retrognathic profiles.
This approach is known as a diagnostic path.
Situations, including sets of information, are
represented by ovals. Actions are represented by arrows
connecting situations. The path through the
information is sequential so that new actions are
warranted by previously obtained information. For
example, a practitioner may decide, on the basis of the
results of a diagnostic test, that treatment A or treatment
B is the best, or that the findings are negative and do not
affect treatment decisions. Test outcomes may even
warrant further tests, as when high prostate-specific
antigen scores warrant biopsies. For simplicity, this
model in Figure 1 does not show that presenting
population or initial personal factors might lead directly
to treatment or to doing nothing. Diagnostic decisions
may be chained in simple or complex patterns. This is
called the diagnostic protocol.
Path analysis is a formal statistical procedure that
permits estimates of the relative weight of each arrow.
Taken together, these represent the probability of
various paths through the diagnostic process. An
important feature of path analysis is that it is sequential.
American Journal of Orthodontics and Dentofacial Orthopedics
565
The probability of making a treatment decision with
information is different from the probability of making
the decision in the absence of that information. The
probability of ordering a test depends on what prior
information is known. Each practitioner has a personal
diagnostic protocol. Given identical presenting patients,
there is a variation in which diagnostic tests are chosen.
Given identical diagnostic findings, there is variation in
preferred treatment.
Path analysis has been used for decades in the social
sciences and medicine, to understand, for example,
residency performance,4 medical research priorities,5
fitness practices,6 drug use,7 and pro-health choices of
adolescents.8
This study aimed to demonstrate a model called path
analysis for characterizing the range of diagnostic
protocols that describe a specific presenting situation:
an overweight, female teenaged patient with signs of
mouth breathing. This research differs from the
evidence-based or clinical guidelines approach by being
entirely descriptive rather than normative. The goal
was to characterize how orthodontists use selected
information to make decisions regarding management
patients with specific occlusal conditions and the
potential for obstructive sleep apnea (OSA). It is not a
study of how experts interpret the best evidence or a
commentary on clinical guidelines.
It was hypothesized that there is wide individual
variation among orthodontics in terms of the warrant
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Fig 2. Diagnostic path for refer or watch regarding OSA.
of diagnostic tests and the usefulness assigned to
outcomes when orthodontists are presented with a
standardized case.
MATERIAL AND METHODS
Survey instrument
A simple diagnostic model was constructed.
Descriptions of presenting information and results of
diagnostic tests were made available in a branching
format, when requested, thus permitting respondents
to create their personal diagnostic protocols. The initial
information, common to all respondents, was a
teenaged female patient who was described as a mouth
breather. Two diagnostics tests were available: the
STOP-Bang survey for OSA and CBCT images with
reported minimal cross-sectional airway findings. Two
action outcomes were also available: respondents could
refer the patient to a medical doctor specializing in sleep
disorders or not, and additionally, they could either
modify the orthodontic treatment on the basis of the
found information or not. There were 10 paths through
this diagnosis model for OSA referral (various paths from
presentation to nonreferral, including direct referral
without diagnostic tests, presentation to STOP-Bang
to CBCT to nonreferral, etc.). There were also 10 paths
for the modification of orthodontic treatment. These
paths are shown by the arrows in Figures 2 and 3.
Initially, respondents were given the presenting
information and asked to indicate their preferred course
of action by assigning weights to the available options at
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Cummings and Chambers
that point and each subsequent decision node. When a
referral and modification action was selected, the exper-
iment ended. The STOP-Bang questionnaire9 is a widely
used 8-item survey that can be completed as part of
normal health provided by the patient or administered
verbally. All questions are yes or no and include snoring,
chronic tiredness, observed signs of stopped breathing or
chocking, high blood pressure, body mass index above
35 kg/m2, older than 50, enlarged neck circumference,
and being male. A score of 2 or less is considered “low
risk,” 3 or 4 is “intermediate risk,” and above 4 is “high
risk.” If the respondent requested this information,
they were told that the patient's score was 4, represent-
ing intermediate risk. Respondents could then choose
among the remaining options (CBCT, referral and/or
nonreferral, and modification and/or nonmodification).
When respondents selected the CBCT diagnostic test,
they were told that the minimal cross-sectional area
(MCA) was 50 mm2 and were asked what standard
they would use for MCA to trigger some sort of response
on their parts. At that point, respondents could select
any test or action they had not used. In pilot testing, it
was noticed that subjects tended to characterize the
airway in terms of MCA rather than volume and that
they expressed concern regarding the risk of OSA when
MCA values approached 55 mm2 or lower.10
The survey was administered electronically on
personal laptops or mobile phones, using the Qualtrics
system (Qualtrics, Seattle, Wash). In field tests, the survey
was completed at an average of 2.4 minutes.
Demographic information was also collected. The study
Cummings and Chambers
Fig 3. Diagnostic path for modified or not planned orthodontic treatment.
was approved by the institutional review board at the
University of the Pacific (no. 18-111). The survey is
shown in the Supplementary Text.
Sample
The survey was distributed via the American Associa-
tion of Orthodontists Partners in Research program. In
addition, email invitations to participate were sent to
faculty and alumni (2005-2017) at the University of
the Pacific, Arthur A. Dugoni School of Dentistry, mem-
bers of the Northern California Angle Society, and mem-
bers of the Schulman Study Group. A link to the survey
was also posted in the Orthodontic Pearls Facebook
group. The survey link was active from May 14, 2018,
to July 13, 2018.
Statistical analysis
The primary quantitative analysis used for these data
was path analysis, also known as causal modeling.11 The
strength of each path was determined by the proportion
of respondents selecting that path as an exit from the
previous diagnostic test. Weights given to each path
for individual respondents recorded in the survey were
also used for analysis, but are not reported here because
the averages very closely matched the proportion of
respondents. All path values were determined by
agreement between the 2 authors.
Demographic responses were analyzed by standard
descriptive statistics, and chi-square was used to test
American Journal of Orthodontics and Dentofacial Orthopedics
567
hypotheses. Actual test statistics and P values were
reported.
RESULTS
Sample characteristics
A total of 125 usable responses were returned. Of
these, 52% were from respondents who had been out
of residency for at least 20 years, 21% for 11-20 years,
15% for 5-10 years, and 12% had been out of residency
for fewer than 5 years. The number of years of practice
experience was unrelated to any other variable. Years
of experience with CBCT ranged from 0 to 10 years,
with an overall mean of 3.9 6 3.05 years. Nineteen
percent reported no CBCT experience.
Path diagrams
Figures 2 and 3 show the path diagrams for the action
options of refer and/or watch and modify orthodontic
treatment and/or same, respectively. Because such path
analyses contain a great deal of information and are un-
usual in the orthodontic literature, some interpretive com-
ments will be made. The numbers on the path arrows
exiting each diagnostic test represent percentages of re-
spondents selecting that path as his or her most likely
response given the cumulative data at that point. Because
the paths are mutually exclusive and exhaustive, the total
of the percentages exiting each diagnostic test always
equals 100%. That is true for each test, regardless of its
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Table I. Effect of diagnostic tests on decisions to refer
and modify treatment by the number of respondents
Diagnostic aid Watch* Refer* Same** Modify**
Examination only 32 28 32 28
STOP-Bang 14 38 20 30
CBCT 15 20 6 30
*c2 5 8.039; P 5 0.03; **c2 5 12.636; P 5 0.005.
sequence in the decision path. Irrespective of the number
of steps in the path, the probability of achieving an
endpoint (refer or watch, for example) always equals the
product of the probabilities along the path. So the proba-
bility of the initial examination directly producing a
referral equals 0.22. The probability of a referral passing
through the STOP-Bang questionnaire is 0.19 (0.34-
0.57). The probability of referral with the aid of a CBCT im-
age, alone or in connection with the questionnaire, is
small. Because the paths are assumed to be independent,
segments of different path diagrams can be pieced
together without altering the retained path segments.
There were 2 checks on the validity of the
experimental design built into this study. First, all paths
for both action outcomes were well populated, meaning
that the full model contains viable diagnostic options for
orthodontics. If the model contained options that were
not considered viable, they would have tiny warrants
represented by small probability arrows leading into
them. In addition, there was a null option included in
the study. Respondents were given the option of
fabricating an appliance. Only 6 respondents selected
this option, none giving it more than 5 of 100 points
for weight. This node in the diagnostic path was
therefore dropped. Excluding it from the analysis did
not alter any of the reported results. Fabricating such
an appliance other than on the prescription of a
specialist in this discipline is not within the scope of
practice for orthodontists.
Table I compares the action choices of respondents
with and without using intermediate diagnostic tests.
It is more likely that a referral will be made and that
treatment will be modified if either diagnostic test was
used. With the initial examination only, the odds were
in favor of not referring to a sleep specialist and in
keeping the same treatment plan. Relative to the initial
examination alone, getting any diagnostic test increased
the likelihood of referring to a specialist (c2 5 8.039;
P 5 0.03) and the likelihood of modifying the treatment
plan (c2 5 12.636; P 5 0.005). Specifically, getting the
results of the screening questionnaire drove referral to
odds of a referral being 2.71. Similarly, getting the
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Table II. Effects of owning a CBCT system on the
proportion of own patients receiving CBCT scans
and propensity to use CBCT as a diagnostic test for
mouth-breathing patient
Own
Not Imaging CBCT
Diagnostic aid used center system c2 P
Proportion of 9.6 53.6 36.8
respondents
Own patient 10.3 12.5 74.8 50.416 \0.001
receiving
CBCT
Choice of CBCT 0.0 18.5 54.6 22.959 \0.001
in OSA study
results of the CBCT MCA drove modification of the
odds of treatment modification to 5.00.
Overall, 55% of respondents chose to change the
orthodontic treatment plan on the basis of the
examination alone, or on the basis of a STOP-Bang score
of 4 and/or an MCA score of 50 mm2. Of those favoring
modifications in orthodontic treatment based on
diagnostic information presented in the case, 74.6%
chose to incorporate expansion, 68.5% chose to
implement a nonextraction treatment plan, 41.8% chose
to incorporate a habit appliance, and 34.6% chose an
orthognathic surgery treatment plan.
Of those who selected a CBCT for the patient, they
indicated a personal threshold value for modifying
treatment or making a referral ranging from 50 mm2 to
154 mm2, with a mean of 103.4 mm2 (standard
deviation, 35.4). When these respondents were presented
with the 50 mm2 MCA, in this case, 54% chose to refer
to a sleep specialist, 79% chose to modify the treatment
plan, and 33.3% chose to do both. None of these 24 ortho-
dontists chose to keep the same orthodontic treatment
plan and not refer to a sleep specialist.
Respondent characteristics
Table II reports the effects of practitioners having
access to CBCT systems in their own practices. One third
of respondents had access to a CBCT machine in their
own office. In these orthodontic offices, on average,
74.2% of new patients received CBCT scans, 35% of these
practices have all of their new patients receiving a CBCT
scan. These practitioners have a mean of 4.9 years of
experience using CBCT-derived diagnostic information.
Half of the respondents had access to a CBCT machine
at a nearby imaging center. In these orthodontic offices,
on average, 12.6% of new patients had CBCT scans.
These practitioners have a mean of 3.4 years of
Cummings and Chambers
experience using CBCT-derived diagnostic information.
10% of respondents had no access to a CBCT machine.
The remaining 3% did not answer the question.
There was a positive relationship between the
percentage of patients receiving a CBCT scan and
proximity to and ownership of a CBCT machine. The
likelihood of requesting CBCT data in this survey
increased with the likelihood of the respondent's
personal patients receiving a CBCT scan. The
chi-square value was 50.416 (P \0.001). Similarly, the
likelihood of going through the survey without
additional diagnostic information decreased with the in-
crease in the percentage of new patients receiving a
CBCT scan (c2 5 22.959; P 5 0.001).
DISCUSSION
A simple decision field involving an overweight fe-
male teen patient who appeared to be a mouth breather,
for 2 available diagnostic tests and 2 referral or treat-
ment decisions, revealed a wide variation of personal
diagnostic protocols in a sample of 125 orthodontists.
Fifty-seven percent of respondents chose to refer the pa-
tient to a sleep specialist, 47% of these doing so without
performing the offered screening questionnaire. All
diagnostic paths leading to this decision were chosen
by some respondents, with the range being 12%-69%.
Intent to modify orthodontic treatment was indicated
by 55% of respondents. Fifty-eight percent of orthodon-
tists indicating a preference for treatment modification
made this decision on the basis of the appearance of
mouth-breathing or the STOP-Bang instrument, and
42% based this decision on CBCT tests. All paths were
active, ranging from 8% to 92%.
STOP-Bang is a commonly used screening or diag-
nostic test for OSA has been proposed as a screening
test.12 It has been found to have high sensitivity for
further tests such as polysomnography.13 The position
of the American Academy of Sleep Medicine14 is that
screening tests are not definitive for diagnosing sleep
disorders caused by airway obstruction. The issue of their
usefulness then becomes one of demonstrating that
screened patients ultimately have better health out-
comes than patients who are not screened. The evidence
on this point is inconclusive.15-17
There are no clinical guidelines for the use of CBCT
images of the airway in orthodontic treatment manage-
ment decisions. The literature on the effects of airway
structure on orthodontic treatment is similarly inconclu-
sive.9,18-23 A draft white paper on sleep apnea has been
prepared by the American Association of Orthodontists,
which summarizes the best current evidence and makes
recommendations for various situations. The current
American Journal of Orthodontics and Dentofacial Orthopedics
569
research suggests that there is a divergence between
what is recommended and the diverse range of
practice behaviors of orthodontists.
Guidelines and variation in diagnostic testing
protocols
Warrant is the set of active reasons that justify a diag-
nostic test or treatment decision before activating that
choice. It is what is considered important to learn about
without knowing yet what the test result or treatment
outcome will be. It is represented graphically as the
path arrows leading into a test or treatment in the
path diagram. In this study, warrant was found to be
personally variable and influenced by factors other
than patient characteristics. Usefulness is the value
added by a diagnostic test or treatment once the results
are known. It is measured as the difference in dentist
behavior or patient health with the test or treatment
compared with the results without the test or treatment.
In the path diagram, this is represented by the arrows ex-
iting each test. In this study, it was found that there is
considerable variation in test usefulness across practi-
tioners. Given identical information, respondents chose
to make a different decision. This finding is consistent
with previously reported results. Lee et al24 found that
the kappa scores for agreement among 10 orthodontists
viewing 60 patients were “modest” when comparing a
practitioner's choices across 2 times and “very weak”
when comparing orthodontists against each other. At
the same time, the aggregate paths in this study with
and without tests were different. Testing warrants ac-
tion, even when the nature of the action is uncertain.
This finding is consistent with the classical work on
cognitive dissonance, showing that voluntarily choosing
an action (ordering a test) increases commitment to the
decision even in the face of evidence that costs outweigh
benefits for the person making the decision.25
Evidence-based clinical guidelines sponsored by
professional organizations are an attempt to smooth
out the diagnostic paths. If there were well-establish
and consistently followed clinical guidelines for
screening mouth-breathing patients for referral to sleep
specialists and for modifying orthodontic treatment on
the basis of findings of constricted airways, the path
diagram in this study would have been collapsed, with
some paths having very high response rates and others
being ischemic. Path diagrams differ even further from
the proposed expert opinion schema that presents a
single, idealized flow through decision nodes.
Research in medicine finds that about half of
practitioners follow relevant guidelines.25-28 The most
prominent barriers include: (1) not knowing that
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guidelines exist,27,29,30 (2) inconvenience or reluctance
to change personal practice patterns,31 (3) belief that
guidelines are for students and patients,32 and (4) the
presence of comorbidities.33 The latter point is impor-
tant as guidelines often address single conditions,
whereas patients present with multiple and sometimes
conflicting needs. For example, in this study,
orthodontists may focus on the airway with CBCT
imaging to guide their orthodontic treatment rather
than to support decisions regarding referral for OSA.
The expectation that better evidence alone will reduce
variance in clinical practice fails to take into account
the complexity of decisions faced by practitioners,
including factors not studied by traditional research.
An American Association of Orthodontists study in
201134 found poor understanding of the concept of
literature-informed practice and mixed attitudes toward
their use, generally related to the fact that the literature
in most areas is inconsistent. A British study of guide-
lines in orthodontic care in the government health care
system35 reported no effect from programs teaching
the guidelines on reducing inappropriate referrals.
However, there are clinical guidelines for the use of
invasive diagnostic technology, such as CBCT. Horner
et al36 identified 3 such sets of guidelines in Europe and
1 in the United States. There is uncertainty regarding the
evidence for establishing such guidelines.37-39 Safety and
Efficacy of a New and Emerging Dental X-ray Modality
guidelines of the European Union are more specific in
requiring that the use of CBCT in orthodontics must be a
test based on prior risk assessment of individual patients
and cannot be a screening policy: “All CBCT
examinations must be justified on an individual basis by
demonstrating that the potential benefits to the patients
outweigh the potential risks. . Routine or screening
imaging is unacceptable.”40,41
Part of the variance in the current study may come
from a thin description of the presenting case. In a
Brazilian study,42 it was found that 97% of interviewed
orthodontists base their determination of mouth
breathing on observation alone, eschewing the use of
lip seal and water retention tests.
Limitations
The study design used an abbreviated description of
the presenting patient, only 2 diagnostic tests, and forced
dichotomous decisions on 2 referral or treatment options.
Orthodontic practice is more complex than this. However,
this research design follows the traditional model of tightly
defined research that explores a small number of variables
at a time. It is necessary for research to present a somewhat
standardized stimulus situation. A significant range of
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Cummings and Chambers
choices emerged, given a common and exact reading for
the STOP-Bang questionnaire and for the MCA finding.
Further research is necessary to elucidate the usefulness
of the diagnostic tests by varying the reported outcomes
and observing the effects of these changes on practi-
tioners' action choices. Further studies are needed as
well to clarify which factors contribute to the warrant for
choosing tests whose outcomes are not yet known. The
exploration of warranting factors that drive the selection
of diagnostic tests should not be limited to the damage
caused by disease conditions. They should include sensi-
tivity, selectivity, and cost in the broadest sense for both
practitioners and patients.
This study is a proof of concept. No claim is made
about how patients should be screened using a survey
for potential referral to a sleep specialist or what airway
values obtained from CBCT images should be linked with
various modifications of orthodontic treatment. Howev-
er, the diagnostic path model does offer a new research
paradigm for the investigation of how orthodontists
made clinical decisions.
CONCLUSIONS
A wide range of decisions regarding referral and
treatment of patients with potential airway issues is
observed among practicing orthodontists when given
standardized information about a teenaged female
mouth-breathing patient. Part of the personal variation
is attributable to dentist practice characteristics, such as
owning a CBCT system. The capacity of path analysis as a
rigorous quantitative method for characterizing how a
sample of orthodontists actually make clinical decisions
was tested in this research, and it was found to be a use-
ful research and analytic model for studying how practi-
tioners choose diagnostic tests (warrant) and how they
modify their decisions on the basis of the information
received (usefulness).
SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version, at https://doi.org/10.
1016/j.ajodo.2019.09.019.
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SUPPLEMENTARY TEXT
Path analysis as a process theory of clinical
judgment
Path analysis is descriptive rather than normative.
Under the assumption that practitioners always optimize
the expected value of their choices, any inconsistency in
theory and research between actual and predicted deci-
sions signals that the model is incomplete.
Elements in the path are evaluated from the
practitioner's perspective. Patient health outcomes
should be understood as a reputation for serviceable,
accessible, long-lasting outcomes, and the absence of
adverse side effects. Other values practitioners optimize
are their time and hassle and their financial return. It is
an illusion to believe that dentists optimize patient
health: the optimization is over the practitioner's
interpretation of oral health practice. All systems that
imply that “X is better in some objective sense,” found
in research papers to clinical guidelines, are incomplete
because they imply that the perspective of their
proposers is identical to the more diverse perspectives
of the practitioners.
Warrant is justification for taking specific action in a
given situation. In the following, example A stands for
action and D for description. The action may be treat-
ment, testing, or nothing. The expected value of the
warrant is the probability of a specific outcome multi-
plied by the value to the dentist if that outcome were
to occur. Warrant is a conditional probability: EV (A j
D). This is a subjective estimate. Of the actions that are
plausible to consider, the practitioner always takes the
1 with the greatest EV. Seeing a case that does not
A1
a b
D EV (A1 | D)
C d
~D EV (A1 | ~D)
A1 A2
D D
~D ~D
Supplementary Fig 1. Decision making in the 2 3 2 context.
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Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Cummings and Chambers
appear to follow the “always” part of this rule only
means that the observer has miscast the decision.
Usefulness is a measure of the advance in EV for
choosing an action compared without diagnostic data.
EV (D j B) . EV (D), in which B is baseline information.
All of the clinical dental research is a series of tests, as
confirmed by statistical tests, for whether various Bs
increase EV. Both screening logic and research projects
undervalue baseline or handle it without reference to
individual practitioners.
A, D, and B are arrays as defined in practice. Research
variables in controlled studies tend to be scalars, fixed
factor variables rather than random ones.
The measurement units in the warrant and usefulness
calculations should be ordered sets or binary values, not
numerals. Actions are always dichotomous, with the
differences between descriptive values that lead to the
same actions not amounting to actual differences. There
are “zones of indifference” in all clinical decisions, with
personal thresholds serving as the boundaries of these
zones. The thresholds are personal and variable; often,
the “zone of indifference” becomes the “zone of noncom-
mitment.” It is a plausible hypothesis to be explored that
clinical behavior functions on a default setting in which D
is monitored in the background and warrant or usefulness
only become issues if observations fall outside the
threshold boundaries of the default action pattern.
Rational approaches to modifying A on the basis of D
take a 2 3 2 structure. The active components in the
matrix are B (baseline), T (threshold), R (accuracy of
the test), and C (cost and benefits to the decision maker).
Such 2 3 2 matrices can be chained. See Supplementary
Figure 1.
A2
EV (A2 | D) Warrant: EV (A1 | D) > EV (A1)
EV (A2 | ~D) Acon: EV (A1 | D) > EV (A2 | D)
A1 A2
Cummings and Chambers
Clinical decisions are complex. They have multiple
dimensions and cannot be understood completely by
piecing together isolated studies. They are also beyond
the capacity of clinicians to solve rationally and
comprehensively and of researchers to describe
completely. As a result, we “satisfice,” using monitored
approximations.1
Clinical decisions are unstable and not intransitive.
They depend on a multitude of factors, many of
which are situational. As a consequence, R2 values
will never exceed 0.600 or 0.800 for any meaningful
decision in full context, and the specialty will resist
algorithms.2
Clinical decisions are indeterminate. Given the fixed
(presumed accurate) determinations of EV, optimization
remains impossible if there are more than 2 alternative
actions and more than 3 decision makers. This issue is
American Journal of Orthodontics and Dentofacial Orthopedics
571.e2
known as the social welfare problem. It does not affect
individual practitioners (1 decision maker is
always king in his or her domain), but it presents
insurmountable obstacles in which multiple professional
groups seek to establish standards, or literature-
informed practice (evidence-based design) advocates
imply that their findings are universally applicable.3
SUPPLEMENTARY REFERENCES
1. Simon HA. Rational choice and the structure of the environment.
Psychol Rev 1956;63:129-38.
2. Meehl PE. Clinical versus statistical prediction: a theoretical analysis
and a review of the evidence. Minneapolis: University of Minnesota
Press; 1954.
3. Arrow KJ. Social choice and individual values. New York: John Wiley
& Sons; 1951.
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