Author's response

Abstract

When the editorial entitled “One phase or two, and Buridan's paradox” was written, it was intended to point out that there was good evidence to support early treatment performed to reduce protruding incisors.1Behrents R.G. One phase or two, and Buridan's paradox.Am J Orthod Dentofacial Orthop. 2016; 149: 775-776Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar The editorial also pointed out that evidence supporting early treatment for Class II malocclusion was lacking, and as a result claims made contrary to the evidence might not always be properly motivated. Because of the latter discussion, it was anticipated that opposing viewpoints would be generated; thus, the response from a knowledgeable, experienced person such as Dr Leonard J. Carapezza was not a surprise. In his letter, Dr Carapezza argued that the real ethical dilemma is whether the clinician should settle for growth modification or camouflage treatment. In this regard, it should be pointed out that the 4 randomized clinical trials (RCTs) referred to (Florida,2Keeling S.D. Wheeler T.T. King G.J. Garvan C.W. Cohen D.A. Cabassa S. et al.Anteroposterior dental and skeletal changes after early Class II treatment with bionators and headgear.Am J Orthod Dentofacial Orthop. 1998; 113: 40-50Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar Manchester,3O’Brien K. Wright J. Conboy F. Sanjie Y. Mandall N. Chadwick S. et al.Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 1: dental and skeletal effects.Am J Orthod Dentofacial Orthop. 2003; 124: 234-243Abstract Full Text Full Text PDF PubMed Scopus (217) Google Scholar Pennsylvania,4Gafari J. Shofer F.S. Jacobsson-Hunt U. Markowitz D.L. Laster L.L. Headgear versus function regulator in the early treatment of Class II, Division 1 malocclusion: a randomized clinical trial.Am J Orthod Dentofacial Orthop. 1998; 113: 51-61Abstract Full Text Full Text PDF PubMed Google Scholar and North Carolina5Tulloch J.F. Phillips C. Proffit W.R. Benefit of early Class II treatment: progress report of a two-phase randomized clinical trial.Am J Orthod Dentofacial Orthop. 1998; 113: 62-72Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar) did not pose that question using those words, but they did compare phase 1 and phase 2 treatment outcomes, and they were basically equivalent. Thus, the posed dilemma of selecting a bad treatment over a good treatment does not seem to have meaning. In his argument, Dr Carapezza pointed to a reference where he suggests that “Tulloch et al claimed that late Class II camouflage treatment is the gold standard supported by the results of randomized clinical trials.”5Tulloch J.F. Phillips C. Proffit W.R. Benefit of early Class II treatment: progress report of a two-phase randomized clinical trial.Am J Orthod Dentofacial Orthop. 1998; 113: 62-72Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar I could not find this claim in that article. A similar curiosity was noted in the article by Keski-Nisula et al.6Keski-Nisula K. Lehto R. Lusa V. Keski-Nisula L. Varrela J. Occurrence of malocclusion and need of orthodontic treatment in early mixed dentition.Am J Orthod Dentofacial Orthop. 2003; 124: 631-638Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar A close reading of the article showed that the authors did not state or conclude that the samples of the RCTs were flawed.2Keeling S.D. Wheeler T.T. King G.J. Garvan C.W. Cohen D.A. Cabassa S. et al.Anteroposterior dental and skeletal changes after early Class II treatment with bionators and headgear.Am J Orthod Dentofacial Orthop. 1998; 113: 40-50Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar, 4Gafari J. Shofer F.S. Jacobsson-Hunt U. Markowitz D.L. Laster L.L. Headgear versus function regulator in the early treatment of Class II, Division 1 malocclusion: a randomized clinical trial.Am J Orthod Dentofacial Orthop. 1998; 113: 51-61Abstract Full Text Full Text PDF PubMed Google Scholar, 5Tulloch J.F. Phillips C. Proffit W.R. Benefit of early Class II treatment: progress report of a two-phase randomized clinical trial.Am J Orthod Dentofacial Orthop. 1998; 113: 62-72Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar Instead, Keski-Nisula et al pointed out an understood fact about RCTs: the results of an RCT may not be necessarily generalizable. In other words, the results of a RCT may apply to similar samples and treatments but not necessarily to all samples and all manners of the treatment (appliances and appliance strategies). Since they were first presented, the 4 RCTs in question have been read by many, and the information provided has been accepted by many as a way to follow the path of evidence-based treatment. Others have partially accepted the information, and still others have denied the value of the RCTs totally and often offered criticism of the study designs as the reason. It is suggested that this latter group has strongly held beliefs, and the results of the studies just did not line up with those beliefs . . . or as Lysle Johnston7Johnston LE Jr. Personal Communication, September 9, 2016.Google Scholar has been heard to say “People don't like the RCTS because they tend to come up with the wrong answer.” Well, it has been some time now since the classic RCTs were presented, and there has been ample opportunity for more RCTs; certainly, there are both prospective and retrospective study designs available. Thus, I would encourage Dr Carapezza and other passionate persons to put their ideas, ministrations, and arguments to the test. On the one hand, strongly held beliefs can be accepted, never tested, and never changed. On the other hand, they can be tested, and our knowledge can be refined and extended. No matter what we know, and no matter what we think we know, I would argue that we need much more (and new) information if we are to serve the best interests of our patients in the future. For me, I will continue to love great ideas, great theories, great articles, great appliances, and great treatment strategies . . . as much as I love dogs. But, I must admit that every once in a while I have concluded that “that dog won't hunt” and it's time to move on. One phase or two, and Buridan's paradoxAmerican Journal of Orthodontics and Dentofacial OrthopedicsVol. 149Issue 6PreviewOver the years, a question that I have routinely been asked is some version of “Do you believe in 1 phase of treatment or 2?” I have always been able to provide an answer, but recently I was looking at some old textbooks, and I realized that my thoughts on the matter had changed quite bit over time. Full-Text PDF The paradox of 1-phase vs 2-phase orthodontic treatmentAmerican Journal of Orthodontics and Dentofacial OrthopedicsVol. 151Issue 1PreviewPhase 1 and phase 2 orthodontic treatment may be framed as early vs late orthodontic treatment and the methodology chosen based on the goals of treatment. Full-Text PDF