The scientific literature disorient the Orthodontist

For some years, I use and recommend an App named Pub Med on Tap to study in deep: PubMed on Tap. We can search by key word and/or author, choose the type of article, limit search to a certain period, read the abstracts and often download PDFs of journal that allow it. Using literature for my work, being accustomed to do for my thesis and as to publish something with a bit of bibliography. It happens that with our patients we act on hearsay, for college memories, as they told us at the last congress or during the most recent course: but rarely , after reading the results of a recent systematic review that suggests that we do in a certain way. It is fair to say that for a clinician is already sufficient to read the abstract and we can say that the recent revolution EBM outlines a pyramid whose summit there are systematic reviews. And so we should look for the abstracts of these, knowing that what we learn in a study group, by the advice of fellow, or that we see in a case report has scientific value almost nothing.

But meta-analysis and systematic reviews often provide surprising results in the negative, or conclude that there is no evidence, that it would take the most appropriate scientific works. In other words, the academies suggest to be more scientific in what we do, but when we use science to improve the quality of treatments, we do not get good informations.

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Do not believe us? I will do some examples. Having searched the PubMed on Tap items with the word Orthodontics in Title/abstract and confined the choice to the meta-analysis .

Exemple No 1. The effects of the chin , which lately he speaks well again.

Article: Prog Orthod, 2014 vol. 15 pp. 62
Clinical effectiveness of chin cup treatment for the management of Class III malocclusion in pre-pubertal patients: a systematic review and meta-analysis
Chatzoudi, MI; Ioannidou-Marathiotou, I; Papadopoulos, MA
Conclusions: Although the occipital chin cup affects significantly a number of skeletal and dentoalveolar cephalometric variables, indicating an overall positive effect for the treatment of Class III malocclusion, data heterogeneity and between-studies variance impose precaution in the interpretation of the results.

And then what? We start to use it or not? I do not understand. I have to wait for new clinical articles are produced and a new enlightened author insert them into a new meta-analysis ?

Example No.2: The self ligating systems increase the expansion of the arches?

Article: Shanghai Kou Qiang Yi Xue, 2014 vol. 23(3) pp. 367-72
Influence of self-ligating and conventional brackets on dental arch width in non-extraction treatment: a meta analysis. Zhang, DP; Liu, J; Liu, Y; Sun, N; Yi, JC

Conclusions: Current clinical evidence suggests that there is more increment of the dental width in upper first premolars and the lower first molars using self-ligating brackets than conventional brackets, and self-ligating brackets can superiorly control upper incisor inclination. The results need to be verified via larger and higher quality trial.

The authors suggest that it demonstrated an increase in amplitude of the upper interpremolar and the lower intermolar diameters. But they require more qualitative trials to prove it really. So what? What do I do? I say scientifically and choose low friction brackets for greater expansion or work with conventional brackets?

Example No 3: The Frankël III is effettive in treatment of class 3 malocclusions of growing patients?

Article: Am J Orthod Dentofacial Orthop, 2014 vol. 146(2) pp. 143-54. Treatment effectiveness of Fränkel function regulator on the Class III malocclusion: a systematic review and meta-analysis
Yang, X; Li, C; Bai, D; Su, N; Chen, T; Xu, Y; Han, X

Conclusions: Clinical evidence suggests that the FR-3 might restrict mandibular growth but not stimulate forward movement of the maxilla. Further high-quality studies are necessary to confirm the effectiveness of the FR-3.

Example No 4: I use a lot the miniscrew and want to know if the thickness of the cortical influence primary stability.

Article: Angle Orthod, 2014 vol. 84 (6) pp. 103-1093. Does cortical thickness influence the primary stability of miniscrews?: A systematic review and meta-analysis. Marquezan, M; Mattos, CT; Sant’anna, EF; de Souza, MM; Maia, LC

Conclusions: There is a positive association between Mini-implants primary stability and Cortical Thickness of the receptor site. However, there is still a lack of well-designed clinical trials.

Even so, the authors fail to prove something that seems so trivial to appear foolish to doubt him. Primary stability increased in case of thick cortical is not demonstrated with certainty because they serve even better designed clinical trials!

I could go on and on. Few answers clear, few precise directions. Is this is true for any topic, controversial or not.

Need do something. Academics must act to find a key to allow the clinician to scientific literature: the attempt to reduce the distances operated through the affirmation of the EBM has effectively led to a greater distance.

Maybe the EBM’s pyramid is not very useful because the search for absolute truth is philosophically impossible? Or that the relativistic attitude that denies the possibility of finding absolute truth should guide the academies to different scientific production? Closer to clinicians and patients? If the study groups, the exchange of views and experience, the expert’s opinion, the case reports are highly appreciated, there must be a reason! But it is the base of the pyramid and between the first level and the peak there are many step of scientific value progressively larger. Maybe indicate a lower level of the pyramid where to find useful scientific information to work better, it could be a key.

In other words it happens that the strength of the conclusions of the majority of systematic reviews on the orthodontic topics is low or very low, and the information produced for the clinician to apply the most effective method are questionable. And so the orthodontist, who is not accustomed to consult the literature before taking action, when it does, it gets disorientation and prefers the conduct suggested by more experienced colleague, reducing the critical attention and exposing themselves to the error.

Gianluigi Fiorillo






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