I see EBD as a snowball running downhill, gainingmomentum unchecked. We need someone who will stand upand shout to the world (to quote Darth Vader), “Don’t be tooproud of this technological terror you have created.” I don’tsee that happening anywhere right now, so I guess this is myshout out.

I suggest the following.

1. Ignore negative findings. It is too easy to make somethingNOT work. In our specialty, there are many immea-surables, such as technique, clinical experience, andintuition. Science might never be able to validate somepractices, but that doesn’t necessarily mean that theydon’t have great value. The problem is with the science,not the practice.

2. Be patient. EBD likely has much to offer, but in myhumble opinion it will take a generation or 2 of dedicatedwork to make it truly useful.

3. Be on your guard. Some would make EBD a standard ofcare. Legislators love nothing more than well-definedregulations that they can impose on a profession. Are youprepared to practice according to someone else’s defini-tions? If you hear of movements in this regard, movequickly to quash them because, once it’s legislated, you’llnever have things reversed.

4. Remember that you are treating people, not averages.5. Don’t let the era of evidence diminish the importance of

the era of expertise; they need to work hand-in-hand.

Mark AntoszCalgary, Alberta, Canada

Am J Orthod Dentofacial Orthop 2007;131:573-40889-5406/$32.00Copyright © 2007 by the American Association of Orthodontists.doi:10.1016/j.ajodo.2007.03.006

REFERENCES

1. Martinson BC, Anderson MS, deVries R. Scientists behavingbadly. Nature 2005;435:737-8.

2. Easterbrook PJ, Berlin JA, Gopalan R, Matthews DR. Publicationbias in clinical research. Lancet 1991;337:867-82.

3. Dickersin K, Chan S, Chalmers TC, Sacks HS, Smith H Jr.Publication bias and clinical trials. Control Clin Trials 1987;8:343-53.

4. Panel on Scientific Responsibility and the Conduct of Research.National Academy of Science, Washington DC, 1992.

EDB Editor’s responseI strongly advocate being a critical thinker, but critical

thinking is a 2-edged sword and should be applied no matterwhat the source of the claim; we should not assume that an“expert’s” teachings can be believed as the gospel. This is acommon stance among some “experts”—that they know howto perform techniques successfully, and those who are con-ducting research don’t.

The case of TMD is an interesting example. A recentarticle in the Journal of the American Dental Association1

reported that soft splints, hard splints, and palliative therapy

were equally effective for treating TMD. The first author, EdTruelove, is chair of Oral Medicine at the University ofWashington, and he has been treating TMD patients for 3decades. Is he one of those academicians who does not knowhow to adjust a splint? Likewise, Bill Proffit was involvedwith the Class II randomized trials at the University of NorthCarolina. Is he another clinically unskilled academician? Isuggest another possibility—that the expert clinicians havenot presented convincing evidence that was conducted withrigorous and well-accepted research methods.

Regarding EBD speakers at meetings, they should knowand be able to present the evidence for their positions. That isnot to say that development should be stifled and that newideas are not appropriate at meetings. Clinicians are oftenahead of researchers when it comes to innovation, but, astechniques become more widespread, they should withstandthe rigors of scientific evaluation to determine their value. Iagree 100% that our specialty is a blend of many elements, ofwhich science is one. The ADA’s definition is also consistentwith this, stating that: Evidence-based dentistry (EBD) is anapproach to oral health care that requires the judiciousintegration of systematic assessments of clinically relevantscientific evidence, relating to the patient’s oral and medicalcondition and history, with the dentist’s clinical expertise andthe patient’s treatment needs and preferences.2

Simply ignoring negative findings sounds a little tooconvenient to me. Can we really afford to simply ignore whatwe don’t like? EBD is not perfect, and we all must be criticalin our assessment of all literature to make it work.

Regarding standards of care, there probably should be abalance between an old-west attitude of anything goes and aprofession that is so tightly regulated that it can never evolveand improve. At this time, should we be proud to say that ourspecialty does not have a single treatment guideline for itsmembers (except maybe the one for prophylactic antibioticsfor subacute bacterial endocarditis)?

It is certainly true that we treat people, not averages. TheADA definition states that practitioners should consider eachpatient’s needs and preferences: [T]he ADA recognizes thattreatment recommendations should be determined for eachpatient by his or her dentist, and that patient preferencesshould be considered in all decisions. Dentist experience andother circumstances, such as patients’ characteristics, shouldalso be considered in treatment planning.2

I agree that the importance of evidence should notdiminish the importance of expertise; they do need to workhand-in-hand, and that means don’t ignore the evidence. It isan important component to providing our patients with thebest, most appropriate care, and that is the correct motivationfor incorporating an evidence-based approach to patient care.

Greg HuangAssociate Editor for Evidence-based Dentistry

Seattle, WashAm J Orthod Dentofacial Orthop 2007;131:574-50889-5406/$32.00Copyright © 2007 by the American Association of Orthodontists.doi:10.1016/j.ajodo.2007.03.007

American Journal of Orthodontics and Dentofacial OrthopedicsMay 2007

574 Readers’ forum

REFERENCES

1. Truelove E, Huggins KH, Mancl L, Dworkin SF. The efficacy oftraditional, low-cost and nonsplint therapies for temporomandib-ular disorder: a randomized controlled trial. J Am Dent Assoc2006;137:1099-107.2.

2. The ADA Policy on Evidence-based Dentistry. http://www.ada.org/prof/resources/positions/statements/evidencebased.asp.Accessed April 11, 2007. Am J Orthod Dentofacial Orthop2007;131:00

Temporary anchorage devicesI commend the ingenuity of the authors of the February

2007 case report (Öncag G, Akyalçın S, Arıkan F. The effec-tiveness of a single osteointegrated implant combined withpendulum springs for molar distalization. Am J Orthod Dento-facial Orthop 2007;131:277-84). Temporary anchorage deviceapplications are seen growing with every orthodontic journalissue and lecture. The overall treatment result in the case reportwas excellent, with one exception: although implants mightallow previously impossible tooth movements, I think we shouldquestion whether “the means justify the ends.”

Although significant molar distalization was acheived,the maxillary right second and first molars have poor mar-ginal ridge relationships. The distal of #3 contacts the mesialof #2 at the cementoenamel junction. If caries were to developon the mesial of #2, it would be root caries, which would bedifficult to restore. Perhaps extraction of the third molarswould have allowed uprighting the roots of the second molars(if enough bone remained in the tuberosity).

Whereas the treatment alternatives listed (4 bicuspidextractions, upper bicuspid extractions) are all possibilities, Itake exception with the authors’ opinion that extraction of theupper bicuspids would cause maxillary incisor retraction.Ultimately, the final position of the mandibular incisorsdictates the final position of the maxillary incisors. The profilewas preserved because the mandibular incisors tipped for-ward, causing the incisal edges to have relative intrusion (inthe effort to level the curve of Spee and reduce the overbite).Whether the maxillary bicuspids were extracted or the buccalsegments were distalized, the maxillary incisors were re-quired to come forward to couple with the already advancedmandibular incisors. Extraction of the maxillary bicuspids(with proper anchorage preparation, perhaps with an im-plant?) would have provided an equivalent result in theanterior and would have made it possible to match themarginal ridges of the molars without distal tipping.

Richard SchechtmanJefferson Valley, NY

Am J Orthod Dentofacial Orthop 2007;131:5750889-5406/$32.00Copyright © 2007 by the American Association of Orthodontists.doi:10.1016/j.ajodo.2007.03.002

Author’s responseI want to thank Dr Schechtman for commenting on our case

report. Understanding the long-term effects of temporary an-

chorage device(s) (TADs) is a continuous learning process; casereports and long-term follow-ups can help us better understandthe indications and the contraindications for TAD use.

Although we bonded the maxillary second molars, distalroot tipping was limited to the erupting third molars. The nexttime I attempt to use this kind of molar distalization, I willmake sure that the patient is congenitally missing third molarsor is at least willing to have the germs extracted. In myopinion, third molars aggravate the situation and might,therefore, be considered a contraindication. Nevertheless, inthis patient, clinical follow-up showed no increased probingdepth or clinical attachment loss between the first and secondmolars until recently. The patient is highly motivated tomaintain excellent oral hygiene in addition to professionaltreatment. She is being followed for her erupting third molarsand knows that third-molar extractions might be required.

Extractions of maxillary premolars were avoided dueto the forward mandibular growth tendency, which mightlater become an issue of stability. Dr Schechtman sug-gested that extraction of maxillary premolars with properimplant anchorage was a viable treatment option. Thismight aid in tipping the maxillary incisors and provide anequivalent result in the anterior region. However, ifimplant-supported anchorage is to be used, I would ratherextract third molar germs and apply the same technique fordistalization procedures. This would also aid in preservingthe broadness of the maxillary arch for an optimal estheticoutcome in a patient with apparently wide soft-tissueextensions during smiling.

Sercan AkyalçinIzmir, Turkey

Am J Orthod Dentofacial Orthop 2007;131:5750889-5406/$32.00Copyright © 2007 by the American Association of Orthodontists.doi:10.1016/j.ajodo.2007.03.003

TMJ disorders and facial morphologyThe evidence for an association between altered

craniofacial morphology and TMJ disorders is supportedby two recent articles (Flores-Mir C, Nebbe B, Heo G,Major PW. Longitudinal study of temporomandibular jointdisc status and craniofacial growth. Am J Orthod Dento-facial Orthop 2006;130:324-30; Ahn SJ, Baek SH, KimTW, Nahm DS. Discrimination of internal derangement oftemporomandibular joint by lateral cephalometric analysis.Am J Orthod Dentofacial Orthop 2006;130:331-9). How-ever, readers need to appreciate how difficult it can be toactually determine which occurred first—the altered mor-phology or the TMJ disorder—and whether one variableinfluenced the occurrence of the other.

The article by Ahn et al describes a cross-sectional studyin which cephalometric radiographs and MRIs were obtainedfor each woman who participated. These images were used tomeasure the facial skeleton and classify the severity of anyTMJ disorders. The authors state that “these results stronglysuggest that disc displacement is a potential risk factor that

American Journal of Orthodontics and Dentofacial OrthopedicsVolume 131, Number 5

Readers’ forum 575