Evidence Based Science instead of Myths and Philosophy
Case in Point: 'Medical benefits of dental floss unproven, feds say', Headline in the San Francisco Chronicle 8/3/2016. So as it turns out, as investigated by the Associated Press:
' the federal government has recommended flossing since 1979, first in a surgeon' general's report and later in
the Dietary Guyidelines for Americans issued every five years. The guidelines must be based on scientific
evidence, under law. When the federal government issued its lates dietary guidelines this year, the flossing
recommendation had been removed
The existing studies on the subject, when looked at, did not scientifically prove benefits of flossing.
The evidence for flossing is "weak, very unreliable", of "very low" quality, and carries "a moderate to large
potential for bias."
' the federal government has recommended flossing since 1979, first in a surgeon' general's report and later in
the Dietary Guyidelines for Americans issued every five years. The guidelines must be based on scientific
evidence, under law. When the federal government issued its lates dietary guidelines this year, the flossing
recommendation had been removed
The existing studies on the subject, when looked at, did not scientifically prove benefits of flossing.
The evidence for flossing is "weak, very unreliable", of "very low" quality, and carries "a moderate to large
potential for bias."
I ended up on someones mailing list and got a letter announcing that the orthodontist in question was taking a partner to his practice and how it was good that they coming from the same school and had the same 'philosophy'.
That's is kind of the feeling you left with sometimes in orthodontics, it's more a personal way of thinking and handling thing rather than treatments solidly based on collected data resulting in evidence based science.
In talking to orthodontists explain treatment you may wonder how much is confidence and how much is competence. (Advice: Have your orthodontist explain exactly what and why he is doing to the teeth. If it doesn't
make sense to you, get more opinions!)
I came across this paper: 'Extraction of primary (baby) teeth for unerupted palatally displaced permanent canine teeth in children (Review)' by the Cochrane Collaboration. According to Wikipedia this is an "independent nonprofit organization consisting of a group of more that 31,000 volunteers in more than 120 countries...formed to organize medical research information in a systemic way to facilitate the choices that health professionals, patients, policy makers and others face in health interventions according to the principles of evidence-based medicine. The group conducts systemic reviews of randomized controlled trials of health-care interventions, which it publishes in the Cochrane Library." (For more on this group, see cochrane.org).
The article published in 2009 found that a lot of the published articles and studies on the subject of whether it helps the permanent canines if the baby canines are extracted at age 10-13, found that the studies available were flawed and could not confirm this. The practice is mainly based on a trial in 1988 where 'the major flaw...was the absence of a control group'. The Cochrane review team came to the same conclusion in 2012. An article on 'open versus closed surgical exposure of canine teeth that are displaced in the roof' 2008 said there was a lack of high quality studies to make any recommendations. It is up to the orthodontist/oral surgeon's judgement what technique is chosen.
When you are dealing with something like impacted canines, which occurs in about 1-2% of the population, you are dealing with something that is frequent enough that all orthodontists will encounter it, but it is not frequent enough that you will get good at it, unless you actually read about it and learn about it actively.
The article published in 2009 found that a lot of the published articles and studies on the subject of whether it helps the permanent canines if the baby canines are extracted at age 10-13, found that the studies available were flawed and could not confirm this. The practice is mainly based on a trial in 1988 where 'the major flaw...was the absence of a control group'. The Cochrane review team came to the same conclusion in 2012. An article on 'open versus closed surgical exposure of canine teeth that are displaced in the roof' 2008 said there was a lack of high quality studies to make any recommendations. It is up to the orthodontist/oral surgeon's judgement what technique is chosen.
When you are dealing with something like impacted canines, which occurs in about 1-2% of the population, you are dealing with something that is frequent enough that all orthodontists will encounter it, but it is not frequent enough that you will get good at it, unless you actually read about it and learn about it actively.
This is a frustrated article in 'The Angle Orthodontist' (4):
The scientific and professional literature today is packed with more reports than an active specialist in
orthodontics can possibly read. For each treatment approach, articles can probably be found that would
validate or invalidate the method, depending on one's point-of-vies. So where can one turn for sound
unbiased direction? The bad news is that good clinical advice is harder than ever to find. Even
presentations at meetings are becoming somewhat deceptive and exploitive.
Think again when you view the next polished PowerPoint presentation at an educational course or meeting.
Many of these shows are designed to persuade or entertain, rather than to educate....
With minor discrepancies, almost anything works, including methods with serious biomechanics limitations,
such as the proprietary Invisalign system. If shallow treatment approach gains a sizable following, we risk
bringing down our high orthodontic outcome standards. Orthodontists know there are rarely shortcuts to
quality treatmen
The scientific and professional literature today is packed with more reports than an active specialist in
orthodontics can possibly read. For each treatment approach, articles can probably be found that would
validate or invalidate the method, depending on one's point-of-vies. So where can one turn for sound
unbiased direction? The bad news is that good clinical advice is harder than ever to find. Even
presentations at meetings are becoming somewhat deceptive and exploitive.
Think again when you view the next polished PowerPoint presentation at an educational course or meeting.
Many of these shows are designed to persuade or entertain, rather than to educate....
With minor discrepancies, almost anything works, including methods with serious biomechanics limitations,
such as the proprietary Invisalign system. If shallow treatment approach gains a sizable following, we risk
bringing down our high orthodontic outcome standards. Orthodontists know there are rarely shortcuts to
quality treatmen
...or Money talking?
It seems like every lecture that I am invited to now is sponsored by a company... They feed the
doctor "scientific" information about their product from published articles and seminars.
However, the information is coming from non-peered reviewed journals and from speakers that
are on their payroll...For example: self-ligating brackets were so en vogue over five years ago
and speakers touted it as the best way to treat cases without taking out teeth. Every time I met
the sales rep in my office, he would display CT scans that showed how passive self-ligating braces
expanded the arches without bone loss. He compared how efficiently the self-ligating system
treated cases versus standard edgewise appliances and active ligation. "Friction free" was the
buzz word he used and how superior their product was over other active clips. You can imagine
that I was shocked when during one visit the rep let me know that these years of lambasting an
active clip, he back-tracked and said that there was a greater demand from orthodontists to have
different options. This is the same company that I should trust when they sponsor a speaker?
More importantly, the literature is clearly showing that self-ligating braces do not cut down on
treatment times.(5)
It seems like every lecture that I am invited to now is sponsored by a company... They feed the
doctor "scientific" information about their product from published articles and seminars.
However, the information is coming from non-peered reviewed journals and from speakers that
are on their payroll...For example: self-ligating brackets were so en vogue over five years ago
and speakers touted it as the best way to treat cases without taking out teeth. Every time I met
the sales rep in my office, he would display CT scans that showed how passive self-ligating braces
expanded the arches without bone loss. He compared how efficiently the self-ligating system
treated cases versus standard edgewise appliances and active ligation. "Friction free" was the
buzz word he used and how superior their product was over other active clips. You can imagine
that I was shocked when during one visit the rep let me know that these years of lambasting an
active clip, he back-tracked and said that there was a greater demand from orthodontists to have
different options. This is the same company that I should trust when they sponsor a speaker?
More importantly, the literature is clearly showing that self-ligating braces do not cut down on
treatment times.(5)
The gold standard: Evidence-based Science
The science is obviously missing in a lot of instances. Data is not collected, there is no way to know the success rate of different strategies and individual professionals.
It would help to know the actual numbers of impacted canines and what happens to the ones that aren't referred for a second opinion and then actually end up in a study and thus get counted.
It would be good if the instances of radiolucency in teeth are noted and collected. It could then be confirmed how much of ICRR and PEIR and other resorption there actually is. It is bizarre that there is 8.1 % of PEIR in children's teeth in Jordan, while here it is an unknown, or it is called something else, like 'hidden caries'.
It seems that as long as the data is not collected you don't really know anything. How important are root dilacerations for impacted canines? Which ones move, which ones don't. In Brazil Dr Puricelli wants to do apicotomy even before attempting traction.
You need the data to get to the evidence based science and to actually 'know' things.
Why is it that you should wait 1-2 weeks before applying traction after expose & bond according to most oral surgery/orthodontist websites: while Dr. Becker says that being present at surgery and applying immediate traction gives him an advantage? Why does one orthodontist have 2 weeks in between visits and UCSF 5 weeks?
A continued education test (1) describes how after a palatal impacted canine has been exposed there should be 'light orthodontic force (not to exceed 60g or 2 oz)". Is that a fact that has been scientifically proven?
In an interview article in the Journal of Clinical Orthodontics (2) from 1979, Dr Mulick, talks of how he, when putting traction on impacted canines will use 50-60 grams, and maybe more, but "This an area that could be studied to really come up with more meaningful information." He talks of ankylosis and inostosis**and whether
you can luxate the tooth free concluding, "Again, longitudinal study of these problems is not available. Therefore, I must say that when dealing with ankylosis, we are dealing at best with a guess"
Unfortunately, I don't think there has been an overwhelming advancement in actual scientific orthodontic facts since 1979, that the Cochrane Collaboratioin would approve of. As long as there is no scientifically substantiation
patients will hear opinions from clinicians, you would hope it is based on a long experience and someone uptodate on current
The science is obviously missing in a lot of instances. Data is not collected, there is no way to know the success rate of different strategies and individual professionals.
It would help to know the actual numbers of impacted canines and what happens to the ones that aren't referred for a second opinion and then actually end up in a study and thus get counted.
It would be good if the instances of radiolucency in teeth are noted and collected. It could then be confirmed how much of ICRR and PEIR and other resorption there actually is. It is bizarre that there is 8.1 % of PEIR in children's teeth in Jordan, while here it is an unknown, or it is called something else, like 'hidden caries'.
It seems that as long as the data is not collected you don't really know anything. How important are root dilacerations for impacted canines? Which ones move, which ones don't. In Brazil Dr Puricelli wants to do apicotomy even before attempting traction.
You need the data to get to the evidence based science and to actually 'know' things.
Why is it that you should wait 1-2 weeks before applying traction after expose & bond according to most oral surgery/orthodontist websites: while Dr. Becker says that being present at surgery and applying immediate traction gives him an advantage? Why does one orthodontist have 2 weeks in between visits and UCSF 5 weeks?
A continued education test (1) describes how after a palatal impacted canine has been exposed there should be 'light orthodontic force (not to exceed 60g or 2 oz)". Is that a fact that has been scientifically proven?
In an interview article in the Journal of Clinical Orthodontics (2) from 1979, Dr Mulick, talks of how he, when putting traction on impacted canines will use 50-60 grams, and maybe more, but "This an area that could be studied to really come up with more meaningful information." He talks of ankylosis and inostosis**and whether
you can luxate the tooth free concluding, "Again, longitudinal study of these problems is not available. Therefore, I must say that when dealing with ankylosis, we are dealing at best with a guess"
Unfortunately, I don't think there has been an overwhelming advancement in actual scientific orthodontic facts since 1979, that the Cochrane Collaboratioin would approve of. As long as there is no scientifically substantiation
patients will hear opinions from clinicians, you would hope it is based on a long experience and someone uptodate on current
This is Dr Charles Burnstone, professor emeritus of orthodontics at the University of Connecticut, writing on 'Common Myths in Orthodontics' (3)
Why is evidenced-based treatment not practiced?
1. Traditions, emotions, beliefs, commercialism, gurus, easy-learning, appliance worship all contribute to the
lack of evidenced-based treatment in our specialty.
2. In research, evidence is clouded by sampling methods, traditions, and tendencies to follow authority
figures.
3. Epidemiologic data has limits with regard to understanding the mechanism of response to treatment.
Scientific understanding of the mechanism is essential to solid evidence-based treatment. (3)
Why is evidenced-based treatment not practiced?
1. Traditions, emotions, beliefs, commercialism, gurus, easy-learning, appliance worship all contribute to the
lack of evidenced-based treatment in our specialty.
2. In research, evidence is clouded by sampling methods, traditions, and tendencies to follow authority
figures.
3. Epidemiologic data has limits with regard to understanding the mechanism of response to treatment.
Scientific understanding of the mechanism is essential to solid evidence-based treatment. (3)
Bad science
Atlantic magazine article in 2010 entitled 'Lies, damned lies and medical science' talks of Dr John Ioannidis, a meta researcher, and the prevailing flaws of medical research and evidence based science, who wrote a paer in 2005 entitled Why Most Published Research Findings Are False'.
In the Atlantic article
In pouring over medical journals he was struck by how many findings of all types were refuted by later
findings. Of course, medical science "never minds" are hardly a secret. And they sometimes make headlines.
as when in recent years large studies or growing consensuses of researchers concluded that mammograms,
colonoscopies, and PSA tests are far less useful cancer-detection tools than we had been told; or when widely
prescribed anti-deressants such as Prozac, Zoloft, and Paxil were revealed to be no more effective than a
placebo for most cases of depression...
Peer-reviewd studies have come to opposite conclusions on whether using a cell-phone can cause brain
cancer, whether sleeping more than eight hours a night is healthful or dangerous, whether taking aspirin
every day is more likely to save your life or cut it short, and whether routine angioplasty works better than
pils to unclog heart arteries...
He zoomed in on 49 of the most highly regarded research findings in medicine over the previous 13 years...
these were articles that had helped lead to the widespread popularity of treatments such as the use of
hormone replacement therapy for menopausal women, vitamin E to reduce the risk of heart disease, coronary
stents to ward off heart attacks and strokes... of the 49 articles, 45 claimed to have uncovered effective
interventions. Thirty-four of theses claims had been retested, and 14 of these, or 41 percent, had been
convincingly shown to be wrong or significantly exagerrated.
Dr Ioannides is now a Professor of Health Research and Policy at Stanford.
Atlantic magazine article in 2010 entitled 'Lies, damned lies and medical science' talks of Dr John Ioannidis, a meta researcher, and the prevailing flaws of medical research and evidence based science, who wrote a paer in 2005 entitled Why Most Published Research Findings Are False'.
In the Atlantic article
In pouring over medical journals he was struck by how many findings of all types were refuted by later
findings. Of course, medical science "never minds" are hardly a secret. And they sometimes make headlines.
as when in recent years large studies or growing consensuses of researchers concluded that mammograms,
colonoscopies, and PSA tests are far less useful cancer-detection tools than we had been told; or when widely
prescribed anti-deressants such as Prozac, Zoloft, and Paxil were revealed to be no more effective than a
placebo for most cases of depression...
Peer-reviewd studies have come to opposite conclusions on whether using a cell-phone can cause brain
cancer, whether sleeping more than eight hours a night is healthful or dangerous, whether taking aspirin
every day is more likely to save your life or cut it short, and whether routine angioplasty works better than
pils to unclog heart arteries...
He zoomed in on 49 of the most highly regarded research findings in medicine over the previous 13 years...
these were articles that had helped lead to the widespread popularity of treatments such as the use of
hormone replacement therapy for menopausal women, vitamin E to reduce the risk of heart disease, coronary
stents to ward off heart attacks and strokes... of the 49 articles, 45 claimed to have uncovered effective
interventions. Thirty-four of theses claims had been retested, and 14 of these, or 41 percent, had been
convincingly shown to be wrong or significantly exagerrated.
Dr Ioannides is now a Professor of Health Research and Policy at Stanford.
Working for the advancement of the art and science of orthodontics, you wish.
Orthodontic Societies
The Pacific Coast Society of Orthodontics
'Harvard Society for the Advancement of Orthodontics' (http://www.hsao-online.org)
I tried contacting them, but didn't hear back.
'The Angle Society' (7 different sections in the US), there is one for northern California (anglenortherncalifornia.org)
The Angle Society of Europe (angle-society.com)
Orthodontic Societies
The Pacific Coast Society of Orthodontics
'Harvard Society for the Advancement of Orthodontics' (http://www.hsao-online.org)
I tried contacting them, but didn't hear back.
'The Angle Society' (7 different sections in the US), there is one for northern California (anglenortherncalifornia.org)
The Angle Society of Europe (angle-society.com)
(1) Park JH, Srisurapol T, Kiyoshi T. Impacted maxillary Canines: Diagnosis and
Management.dentalcetoday.com, sep 2012. dentalCEtoday.com
(2) http://www.jco-online.com/archive/article-view.aspx?year=1979&month=12&articlenum=824
(3) http://www.cdabo.org/burstone.pdf
(4) Sheldon Speck. The State of Our Speciality. The Angle Orthodontist:August 2004, Vol. 74, No. 4, pp iv-iv.
(5) Dr Blaine Langberg. Editoral in 'Veritas' (The Harvard Society for the Advancement of Orthodontics).
Summer 2014. (www.hsao-online.org)
Management.dentalcetoday.com, sep 2012. dentalCEtoday.com
(2) http://www.jco-online.com/archive/article-view.aspx?year=1979&month=12&articlenum=824
(3) http://www.cdabo.org/burstone.pdf
(4) Sheldon Speck. The State of Our Speciality. The Angle Orthodontist:August 2004, Vol. 74, No. 4, pp iv-iv.
(5) Dr Blaine Langberg. Editoral in 'Veritas' (The Harvard Society for the Advancement of Orthodontics).
Summer 2014. (www.hsao-online.org)
* Interesting npr story on Koch, Pasteur, Arthur Conan Doyle and tb in "The Remedy" by Thomas Goetz.
At the time, around 1875, 'medical science' started getting used as a term as opposed to 'plain' medicine.
The term of our time and age is evidently 'evidence-based' science, as opposed to 'plain' science.
** a defect in the periodontal membrane has permitted ingrowth of alveolar bone into the cementum (2)