Portal de Periódicos da CAPES

In the land of no evidence, is the salesman king?

2010; Elsevier BV; Volume: 138; Issue: 3 Linguagem: Inglês

10.1016/j.ajodo.2010.06.010

1097-6752

Kevin O’Brien, Jonathan Sandler,

Cleft Lip and Palate Research

Several years ago, while presenting the results of a randomized clinical trial about early Class II treatment at a national conference, we reported that that there was a limited effect of early functional appliance treatment on the skeletal relationship. When it came to question time, a delegate explained that we did not get skeletal changes in our Twin-block group because “we had clasped the lower first molars which reduced the orthopedic effect of the appliance on mandibular growth.” Our reply was that we found it hard to believe that a “little piece of wire” would change the genetically controlled growth pattern for the children in the study. We must confess to feeling a little disappointed that the question seemed to have missed the point of our presentation. This led us to the conclusion that a thorough understanding of contemporary orthodontic research and its interpretation was sadly lacking and that, as a specialty, we are not really adopting evidence-based orthodontic care. As a result, we wrote this editorial, which we hope is an account of “where we are now.” We have tried to adopt the viewpoint of people who have been involved in the transition from a specialty with a low evidence base to one that, we hope, is slowly improving.When we consider the changes in orthodontic research over the past 20 years, 2 notable milestones coincide with an acknowledgment that all was not well. The most well-known quote is that of David Sackett,1Sackett D. Nine years later: a commentary on revisiting the Moyers Symposium. Orthodontic treatment outcome and effectiveness. Craniofacial Growth Series. Center for Human Growth and Development; University of Michigan; 1995.Google Scholar an American-based medical researcher and a doyen of the “evidence-based care” movement. When asked to review the quality of orthodontic research at the Moyers Symposium of 1986, he stated that “orthodontics is reliant on an evidence base that is on a par with podiatry, chiropractitionary and aromatherapy.” This was soon followed by the conclusions of a review into the “functional” appliance literature by Tulloch et al,2Tulloch J.F. Medland W. Tuncay O.C. Methods used to evaluate growth modification in Class II malocclusion.Am J Orthod Dentofacial Orthop. 1990; 98: 340-347Abstract Full Text PDF PubMed Scopus (72) Google Scholar published in 1990. They concluded that “the literature was so weak, in terms of reliance on poorly controlled, restrospective studies, poor sample size calculations and inappropriate use of statistical tests, that it was not possible at that time to support or dismiss the growth modifying effects of functional appliances.”This then begs the question, “have we moved forward since then?” Many people would say that we have, since there has been general acceptance that most orthodontic interventions should be supported by the results of randomized controlled trials, when and if they are available. Many important studies have been published about a variety of treatments including early Class II treatment, bracket types, retainer regimens, management of displaced canines, and extraoral headgear.3Shawesh M. Bhatti B. Usmani T. Mandall N. Hawley retainers full- or part-time? A randomized clinical trial.Eur J Orthod. 2010; 32: 165-170Crossref PubMed Scopus (42) Google Scholar, 4Tulloch J.F. Proffit W.R. Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class II treatment.Am J Orthod Dentofacial Orthop. 2004; 125: 657-667Abstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar, 5Dolce C. McGorray S.P. Brazeau L. King G.J. Wheeler T.T. Timing of Class II treatment: skeletal changes comparing 1-phase and 2-phase treatment.Am J Orthod Dentofacial Orthop. 2007; 132: 481-489Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 6O'Brien K. Wright J. Conboy F. Appelbe P. Davies L. Connolly I. et al.Early treatment for Class II Division 1 malocclusion with the Twin-block appliance: a multi-center, randomized, controlled trial.Am J Orthod Dentofacial Orthop. 2009; 135: 573-579Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 7Baccetti T. Mucedero M. Leonardi M. Cozza P. Interceptive treatment of palatal impaction of maxillary canines with rapid maxillary expansion: a randomized clinical trial.Am J Orthod Dentofacial Orthop. 2009; 136: 657-661Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 8Silvola A.S. Arvonen P. Julku J. Lahdesmaki R. Kantomaa T. Pirttiniemi P. Early headgear effects on the eruption pattern of the maxillary canines.Angle Orthod. 2009; 79: 540-545PubMed Google Scholar These articles should not only have changed the orthodontic practice of more enlightened clinicians but should change the practice of everyone.Although the advantages of randomized controlled trials are undeniable, the findings of orthodontic trials are not always universally accepted, because they tend to challenge long-held beliefs that are often ingrained into our treatment approaches. This reluctance to change beliefs is not unexpected, but it demonstrates a poor understanding of statistics. This was concisely summarized by Meikle,9Meikle M.C. Guest editorial: what do prospective randomized clinical trials tell us about the treatment of Class II malocclusions? A personal viewpoint.Eur J Orthod. 2005; 27: 105-114Crossref PubMed Scopus (28) Google Scholar who pointed out that “clinical opinion is still strongly influenced by anecdotal evidence and the training and experience of the clinician, not always by the statistical artifact reported by the mean.” In other words, we remember our “good cases,” which are often “several standard deviations from the mean.” These are the cases we show at meetings and on which we try to base our training. We forget, however, that a scientific analysis of outcomes is not based on our collection of “precious things” but on the mean effect of treatment for the average child. Such a concept is admittedly not as attractive as an impressive case report but is a more rational, pragmatic, and valid basis on which to make treatment decisions. It can be argued that we all start a patient's treatment with the aim of achieving a fantastic response and an excellent outcome. The unfortunate truth, however, is that orthodontic therapy has a variable response, and we should acknowledge that the “miracle” or perfect treatment, despite our best intentions, sadly does not occur for all our patients.A common criticism is that the findings of clinical trials are not relevant to patients in private practice, because the operators in trials are working to such tight protocols that their treatment bears no resemblance to the real world.10Hayes J.L. Problems with RCT design.Am J Orthod Dentofacial Orthop. 2009; 136 (author's response, 144-5): 143-144Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Again, whereas on the surface this seems to be a reasoned criticism, it has been answered to a certain extent by multi-center trials that have bridged the gap between dental schools and more real-world settings.6O'Brien K. Wright J. Conboy F. Appelbe P. Davies L. Connolly I. et al.Early treatment for Class II Division 1 malocclusion with the Twin-block appliance: a multi-center, randomized, controlled trial.Am J Orthod Dentofacial Orthop. 2009; 135: 573-579Abstract Full Text Full Text PDF PubMed Scopus (85) Google ScholarOur specialty is often unwilling to accept the results of well-conducted, scientifically valid trials of common treatment methods but enthusiastically embraces treatment methods that have not been clinically tested to a level of evidence that withstands scientific scrutiny but are perhaps beautifully described and illustrated in marketing brochures.Current examples of this include the promotion and widespread adoption of noncompliance Class II correctors, temporary anchorage devices (TADs), and self-ligating brackets. As clinicians, we constantly aim to provide treatments that are quicker, easier, and more comfortable for our patients. This involves not only the search for effective methods of treatment as alternatives to headgear, but also appliances offering less friction in the bracket systems, and perhaps even the development of totally new philosophies, which do not necessarily stand up to scientific critique.11Damon D.H. The Damon low-friction bracket: a biologically compatible straight-wire system.J Clin Orthod. 1998; 32: 670-680PubMed Google ScholarIf we look at the use of TADs as an alternative to other forms of anchorage supplementation, it is clear that, despite their great potential, they are as yet unproven with respect to their effectiveness in anchorage reinforcement. Nevertheless, the advertising material suggests that TADs are not only a safe and effective alternative to headgear, but also comfortable; they reduce the need for extractions, speed up treatment, and lead to less orthognathic surgery. However, we must not confuse the cold, hard facts of science with the dreams and aspirations of the “pioneers” who are developing the latest techniques, particularly when their objectivity is somewhat opaque.When we critically review the literature on these devices, it unfortunately appears that, despite 3500 articles reporting on TADs, there are no randomized trials that scientifically evaluate these claims. The current state of knowledge is that we know that a microscrew can be placed easily and relatively painlessly and has approximately an 80% chance of staying where we place it, even after forces are applied to move nearby teeth. We know nothing about their effectiveness compared with other forms of anchorage. The use of TADs is now widespread but has been overshadowed by the wholesale acceptance of self-ligating brackets, often accompanied by a new treatment philosophy. What is the evidence for this clear change in treatment delivery? One source of information is the marketing literature available both directly from the manufacturing companies and indirectly from orthodontists' websites. Interestingly, this advertising is directed not only to the profession but also often to our patients and their parents. This is a worrisome trend.Where is the evidence behind these claims? The advertising material often quotes research that is at a low scientific level and published in journals that are not refereed; some of these are actually produced by the manufacturers. Paradoxically, several randomized clinical trials and a systematic review have shown that self-ligating brackets confer none of the claimed advantages over conventional brackets with regard to the speed of initial alignment or increased comfort for the patient.12Fleming P.S. DiBiase A.T. Sarri G. Lee R.T. Comparison of mandibular arch changes during alignment and leveling with 2 preadjusted edgewise appliances.Am J Orthod Dentofacial Orthop. 2009; 136: 340-347Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 13Fleming P.S. DiBiase A.T. Sarri G. Lee R.T. Efficiency of mandibular arch alignment with 2 preadjusted edgewise appliances.Am J Orthod Dentofacial Orthop. 2009; 135: 597-602Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 14Fleming P.S. DiBiase A.T. Sarri G. Lee R.T. Pain experience during initial alignment with a self-ligating and a conventional fixed orthodontic appliance system. A randomized controlled clinical trial.Angle Orthod. 2009; 79: 46-50Crossref PubMed Scopus (61) Google Scholar, 15Scott P. DiBiase A.T. Sherriff M. Cobourne M.T. Alignment efficiency of Damon3 self-ligating and conventional orthodontic bracket systems: a randomized clinical trial.Am J Orthod Dentofacial Orthop. 2008; 134 (470.e1-8)PubMed Google Scholar, 16Pandis N. Polychronopoulou A. Eliades T. Self-ligating vs conventional brackets in the treatment of mandibular crowding: a prospective clinical trial of treatment duration and dental effects.Am J Orthod Dentofacial Orthop. 2007; 132: 208-215Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, 17Miles P.G. Self-ligating vs conventional twin brackets during en-masse space closure with sliding mechanics.Am J Orthod Dentofacial Orthop. 2007; 132: 223-225Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 18Fleming P.S. Johal A. Self-ligating brackets in orthodontics.Angle Orthod. 2010; 80: 575-584Crossref PubMed Scopus (102) Google Scholar More importantly, no high-quality studies have followed a group of patients to the completion of treatment with self-ligating vs conventional brackets. This will be the ultimate test of the claims concerning self-ligating brackets, and we await the results of these studies with great interest.It may be that orthodontists who bought the new brackets and philosophy based on the promise that they reduce treatment time and discomfort with less need for extractions will come to believe that a compelling case of misselling has taken place. In retrospect, it is somewhat remarkable that manufacturers can make claims with no apparent checks on the validity or veracity of their statements, while at the same time we struggle for support for scientific research.In summary, it is clear that, over the last 20 years, orthodontics has begun to develop a strong scientific basis to support some of our treatment modalities. This evidence base is likely to have had its origins after the introduction of proper research methodology into our dental schools and curricula. Unfortunately, there is a tendency for our specialty to forget its research base when “new and better treatments” are developed. We fear that we are currently ignoring our scientific knowledge with the increasing pressure to provide treatment that is “faster, better, and more comfortable.”If we are to have the respect of our colleagues and our patients, we must very carefully consider the claims of sales representatives and interpret them with due consideration of our scientific knowledge. If we do not do this every time a new product hits the marketplace, we are in serious danger of letting down not only the general public but ultimately the entire profession. Several years ago, while presenting the results of a randomized clinical trial about early Class II treatment at a national conference, we reported that that there was a limited effect of early functional appliance treatment on the skeletal relationship. When it came to question time, a delegate explained that we did not get skeletal changes in our Twin-block group because “we had clasped the lower first molars which reduced the orthopedic effect of the appliance on mandibular growth.” Our reply was that we found it hard to believe that a “little piece of wire” would change the genetically controlled growth pattern for the children in the study. We must confess to feeling a little disappointed that the question seemed to have missed the point of our presentation. This led us to the conclusion that a thorough understanding of contemporary orthodontic research and its interpretation was sadly lacking and that, as a specialty, we are not really adopting evidence-based orthodontic care. As a result, we wrote this editorial, which we hope is an account of “where we are now.” We have tried to adopt the viewpoint of people who have been involved in the transition from a specialty with a low evidence base to one that, we hope, is slowly improving. When we consider the changes in orthodontic research over the past 20 years, 2 notable milestones coincide with an acknowledgment that all was not well. The most well-known quote is that of David Sackett,1Sackett D. Nine years later: a commentary on revisiting the Moyers Symposium. Orthodontic treatment outcome and effectiveness. Craniofacial Growth Series. Center for Human Growth and Development; University of Michigan; 1995.Google Scholar an American-based medical researcher and a doyen of the “evidence-based care” movement. When asked to review the quality of orthodontic research at the Moyers Symposium of 1986, he stated that “orthodontics is reliant on an evidence base that is on a par with podiatry, chiropractitionary and aromatherapy.” This was soon followed by the conclusions of a review into the “functional” appliance literature by Tulloch et al,2Tulloch J.F. Medland W. Tuncay O.C. Methods used to evaluate growth modification in Class II malocclusion.Am J Orthod Dentofacial Orthop. 1990; 98: 340-347Abstract Full Text PDF PubMed Scopus (72) Google Scholar published in 1990. They concluded that “the literature was so weak, in terms of reliance on poorly controlled, restrospective studies, poor sample size calculations and inappropriate use of statistical tests, that it was not possible at that time to support or dismiss the growth modifying effects of functional appliances.” This then begs the question, “have we moved forward since then?” Many people would say that we have, since there has been general acceptance that most orthodontic interventions should be supported by the results of randomized controlled trials, when and if they are available. Many important studies have been published about a variety of treatments including early Class II treatment, bracket types, retainer regimens, management of displaced canines, and extraoral headgear.3Shawesh M. Bhatti B. Usmani T. Mandall N. Hawley retainers full- or part-time? A randomized clinical trial.Eur J Orthod. 2010; 32: 165-170Crossref PubMed Scopus (42) Google Scholar, 4Tulloch J.F. Proffit W.R. Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class II treatment.Am J Orthod Dentofacial Orthop. 2004; 125: 657-667Abstract Full Text Full Text PDF PubMed Scopus (187) Google Scholar, 5Dolce C. McGorray S.P. Brazeau L. King G.J. Wheeler T.T. Timing of Class II treatment: skeletal changes comparing 1-phase and 2-phase treatment.Am J Orthod Dentofacial Orthop. 2007; 132: 481-489Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 6O'Brien K. Wright J. Conboy F. Appelbe P. Davies L. Connolly I. et al.Early treatment for Class II Division 1 malocclusion with the Twin-block appliance: a multi-center, randomized, controlled trial.Am J Orthod Dentofacial Orthop. 2009; 135: 573-579Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 7Baccetti T. Mucedero M. Leonardi M. Cozza P. Interceptive treatment of palatal impaction of maxillary canines with rapid maxillary expansion: a randomized clinical trial.Am J Orthod Dentofacial Orthop. 2009; 136: 657-661Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 8Silvola A.S. Arvonen P. Julku J. Lahdesmaki R. Kantomaa T. Pirttiniemi P. Early headgear effects on the eruption pattern of the maxillary canines.Angle Orthod. 2009; 79: 540-545PubMed Google Scholar These articles should not only have changed the orthodontic practice of more enlightened clinicians but should change the practice of everyone. Although the advantages of randomized controlled trials are undeniable, the findings of orthodontic trials are not always universally accepted, because they tend to challenge long-held beliefs that are often ingrained into our treatment approaches. This reluctance to change beliefs is not unexpected, but it demonstrates a poor understanding of statistics. This was concisely summarized by Meikle,9Meikle M.C. Guest editorial: what do prospective randomized clinical trials tell us about the treatment of Class II malocclusions? A personal viewpoint.Eur J Orthod. 2005; 27: 105-114Crossref PubMed Scopus (28) Google Scholar who pointed out that “clinical opinion is still strongly influenced by anecdotal evidence and the training and experience of the clinician, not always by the statistical artifact reported by the mean.” In other words, we remember our “good cases,” which are often “several standard deviations from the mean.” These are the cases we show at meetings and on which we try to base our training. We forget, however, that a scientific analysis of outcomes is not based on our collection of “precious things” but on the mean effect of treatment for the average child. Such a concept is admittedly not as attractive as an impressive case report but is a more rational, pragmatic, and valid basis on which to make treatment decisions. It can be argued that we all start a patient's treatment with the aim of achieving a fantastic response and an excellent outcome. The unfortunate truth, however, is that orthodontic therapy has a variable response, and we should acknowledge that the “miracle” or perfect treatment, despite our best intentions, sadly does not occur for all our patients. A common criticism is that the findings of clinical trials are not relevant to patients in private practice, because the operators in trials are working to such tight protocols that their treatment bears no resemblance to the real world.10Hayes J.L. Problems with RCT design.Am J Orthod Dentofacial Orthop. 2009; 136 (author's response, 144-5): 143-144Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Again, whereas on the surface this seems to be a reasoned criticism, it has been answered to a certain extent by multi-center trials that have bridged the gap between dental schools and more real-world settings.6O'Brien K. Wright J. Conboy F. Appelbe P. Davies L. Connolly I. et al.Early treatment for Class II Division 1 malocclusion with the Twin-block appliance: a multi-center, randomized, controlled trial.Am J Orthod Dentofacial Orthop. 2009; 135: 573-579Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Our specialty is often unwilling to accept the results of well-conducted, scientifically valid trials of common treatment methods but enthusiastically embraces treatment methods that have not been clinically tested to a level of evidence that withstands scientific scrutiny but are perhaps beautifully described and illustrated in marketing brochures. Current examples of this include the promotion and widespread adoption of noncompliance Class II correctors, temporary anchorage devices (TADs), and self-ligating brackets. As clinicians, we constantly aim to provide treatments that are quicker, easier, and more comfortable for our patients. This involves not only the search for effective methods of treatment as alternatives to headgear, but also appliances offering less friction in the bracket systems, and perhaps even the development of totally new philosophies, which do not necessarily stand up to scientific critique.11Damon D.H. The Damon low-friction bracket: a biologically compatible straight-wire system.J Clin Orthod. 1998; 32: 670-680PubMed Google Scholar If we look at the use of TADs as an alternative to other forms of anchorage supplementation, it is clear that, despite their great potential, they are as yet unproven with respect to their effectiveness in anchorage reinforcement. Nevertheless, the advertising material suggests that TADs are not only a safe and effective alternative to headgear, but also comfortable; they reduce the need for extractions, speed up treatment, and lead to less orthognathic surgery. However, we must not confuse the cold, hard facts of science with the dreams and aspirations of the “pioneers” who are developing the latest techniques, particularly when their objectivity is somewhat opaque. When we critically review the literature on these devices, it unfortunately appears that, despite 3500 articles reporting on TADs, there are no randomized trials that scientifically evaluate these claims. The current state of knowledge is that we know that a microscrew can be placed easily and relatively painlessly and has approximately an 80% chance of staying where we place it, even after forces are applied to move nearby teeth. We know nothing about their effectiveness compared with other forms of anchorage. The use of TADs is now widespread but has been overshadowed by the wholesale acceptance of self-ligating brackets, often accompanied by a new treatment philosophy. What is the evidence for this clear change in treatment delivery? One source of information is the marketing literature available both directly from the manufacturing companies and indirectly from orthodontists' websites. Interestingly, this advertising is directed not only to the profession but also often to our patients and their parents. This is a worrisome trend. Where is the evidence behind these claims? The advertising material often quotes research that is at a low scientific level and published in journals that are not refereed; some of these are actually produced by the manufacturers. Paradoxically, several randomized clinical trials and a systematic review have shown that self-ligating brackets confer none of the claimed advantages over conventional brackets with regard to the speed of initial alignment or increased comfort for the patient.12Fleming P.S. DiBiase A.T. Sarri G. Lee R.T. Comparison of mandibular arch changes during alignment and leveling with 2 preadjusted edgewise appliances.Am J Orthod Dentofacial Orthop. 2009; 136: 340-347Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 13Fleming P.S. DiBiase A.T. Sarri G. Lee R.T. Efficiency of mandibular arch alignment with 2 preadjusted edgewise appliances.Am J Orthod Dentofacial Orthop. 2009; 135: 597-602Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 14Fleming P.S. DiBiase A.T. Sarri G. Lee R.T. Pain experience during initial alignment with a self-ligating and a conventional fixed orthodontic appliance system. A randomized controlled clinical trial.Angle Orthod. 2009; 79: 46-50Crossref PubMed Scopus (61) Google Scholar, 15Scott P. DiBiase A.T. Sherriff M. Cobourne M.T. Alignment efficiency of Damon3 self-ligating and conventional orthodontic bracket systems: a randomized clinical trial.Am J Orthod Dentofacial Orthop. 2008; 134 (470.e1-8)PubMed Google Scholar, 16Pandis N. Polychronopoulou A. Eliades T. Self-ligating vs conventional brackets in the treatment of mandibular crowding: a prospective clinical trial of treatment duration and dental effects.Am J Orthod Dentofacial Orthop. 2007; 132: 208-215Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, 17Miles P.G. Self-ligating vs conventional twin brackets during en-masse space closure with sliding mechanics.Am J Orthod Dentofacial Orthop. 2007; 132: 223-225Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar, 18Fleming P.S. Johal A. Self-ligating brackets in orthodontics.Angle Orthod. 2010; 80: 575-584Crossref PubMed Scopus (102) Google Scholar More importantly, no high-quality studies have followed a group of patients to the completion of treatment with self-ligating vs conventional brackets. This will be the ultimate test of the claims concerning self-ligating brackets, and we await the results of these studies with great interest. It may be that orthodontists who bought the new brackets and philosophy based on the promise that they reduce treatment time and discomfort with less need for extractions will come to believe that a compelling case of misselling has taken place. In retrospect, it is somewhat remarkable that manufacturers can make claims with no apparent checks on the validity or veracity of their statements, while at the same time we struggle for support for scientific research. In summary, it is clear that, over the last 20 years, orthodontics has begun to develop a strong scientific basis to support some of our treatment modalities. This evidence base is likely to have had its origins after the introduction of proper research methodology into our dental schools and curricula. Unfortunately, there is a tendency for our specialty to forget its research base when “new and better treatments” are developed. We fear that we are currently ignoring our scientific knowledge with the increasing pressure to provide treatment that is “faster, better, and more comfortable.” If we are to have the respect of our colleagues and our patients, we must very carefully consider the claims of sales representatives and interpret them with due consideration of our scientific knowledge. If we do not do this every time a new product hits the marketplace, we are in serious danger of letting down not only the general public but ultimately the entire profession. We would like to thank Steve Chadwick, Consultant Orthodontist, for his thoughtful comments on this paper. Don’t throw the scientific self-ligation baby out with the commercial bathwaterAmerican Journal of Orthodontics and Dentofacial OrthopedicsVol. 141Issue 1PreviewAs an orthodontic researcher, it behooves me to address certain omissions of fact along with the growing errors emanating from the Guest Editorial in the September 2010 issue, “In the land of no evidence, is the salesman king?”1 Drs O’Brien and Sandler raised a valid issue, that unsubstantiated claims of growing buccal bone in 1 philosophy have been used by a team of evangelistic-styled promulgators to propel sales for a particular manufacturer, especially because these claims do not stand up to the evaluation of peer-reviewed journals. Full-Text PDF Lack of evidence forces practitioners to make clinically based decisionsAmerican Journal of Orthodontics and Dentofacial OrthopedicsVol. 139Issue 1PreviewIn their recent guest editorial (O’Brien K, Sandler J. In the land of no evidence, is the saleman king? Am J Orthod Dentofacial Orthop 2010;138:247-9), Drs O’Brien and Sandler leveled unfair criticism against a great number of practicing orthodontists who use TADs, self-ligating brackets, and certain functional appliances. I will give them the benefit of the doubt that this criticism is not intended to insult but, rather, to initiate an important discussion about the scientific basis of orthodontic treatment using newer, less-examined appliances. Full-Text PDF Conflicts of interestAmerican Journal of Orthodontics and Dentofacial OrthopedicsVol. 138Issue 6PreviewI wish to compliment you for 2 fine articles in the September issue: “Financial conflicts of interest policies: From confusion to clarity” (Turpin DL. Am J Orthod Dentofacial Orthop 2010;138:245-6), and “In the land of no evidence, is the salesman king?” (O'Brien K, Sandler J. Am J Orthod Dentofacial Orthop 2010;138:247-9). Full-Text PDF