READERS' FORUM
Letters to the editor*
About light and shadow
e were delighted to find that the American Jour-
W nal of Orthodontics and Dentofacial Orthopedics
has continued to publish on key issues in early ortho-
dontic diagnosis, offering its readers articles that explore
novel diagnostic criteria. An example is the recent article
in the September issue (Baccetti T, Leonardi M, Giuntini
V. Distally displaced premolars: a dental anomaly associ-
ated with palatally displaced canines. Am J Orthod
Dentofacial Orthop 2010;138:318-22) investigating, in
a retrospective study, the association between distally
displaced premolars and palatally displaced canines
(PDC). This well-designed study appears to be a continu-
ation of a number of studies investigating the associa-
tions between dental anomalies and PDC.1,2 The main
motivation for these articles, including this one, seems
to be the clinical significance of early diagnosis of the
likelihood of canine impaction.
The authors, however, did not explain exactly what
clinical significance an early diagnosis of PDC could
have. We doubt that an early diagnosis of PDC might
have an important impact on clinical treatment strategy.
To date, there is a lack of evidence that early diagnosis
may influence subsequent planning of orthodontic treat-
ment for the impacted canines. Successful treatment of
tooth impaction seems to depend, rather, on the accurate
positional diagnosis and the proper mechanotherapy.3
One more question arises in that line of thought. Can
we, as clinicians, be held accountable for x-ray exposure
of our young patients merely to identify a remote “prob-
ability” of PDC, by prescribing radiographic exposure,
when the results will have no influence on treatment
planning? Generally, can we justify panoramic x-rays
and lateral cephalograms at such an early age, as per-
formed in the study by Baccetti et al (mean age, 9 years
7 months 6 1 year 3 months)? Council Directive 97/43/
Euratom4 clearly enough states that radiographic expo-
sure is justified only when the management of the
patient depends on the information obtained from the
radiography. Cephalometrics, for example, was shown
not to be required for orthodontic treatment planning,
since it has no influence on treatment decisions.5
So, the answer to the question of whether the risk of
more irradiation of a growing child is worth the diagno-
sis of PDC would depend on the possible “dramatic”
*The viewpoints expressed are solely those of the author(s) and do not reflect
those of the editor(s), publisher(s), or Association.
2
consequences an impacted canine would have. We
should not overestimate our specialty. Due to progress
in medical technology (such as x-rays—Roentgen re-
ceived the Nobel Prize for its discovery in 1901), it seems
that the clinician is tempted to place a growing amount
of trust in technology and modern computer-assisted
facilities for data analysis, sometimes neglecting his nat-
ural diagnostic potential. X-rays should only supplement
his clinical diagnosis—and only when it is really needed.
Rumors have it that Konrad Roentgen once said, “Where
there is light, there is also shadow.”
Alexander Spassov
Dragan Pavlovic
Kamen Spasov
Greifswald, Germany
Am J Orthod Dentofacial Orthop 2011;139:2
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.11.014
REFERENCES
1. Baccetti T. A controlled study of associated dental anomalies. Angle
Orthod 1998;68:267-74.
2. Peck S, Peck L, Kataja M. Prevalence of tooth agenesis and peg-
shaped maxillary lateral incisor associated with palatally displaced
canine (PDC) anomaly. Am J Orthod Dentofacial Orthop 1996;
110:441-3.
3. Becker A, Chaushu G, Chaushu S. Analysis of failure in the treatment
of impacted maxillary canines. Am J Orthod Dentofacial Orthop
2010;137:743-54.
4. Council Directive 97/43/Euratom. Available at: http://ec.europa.eu/
energy/nuclear/radioprotection/doc/legislation/9743_en.pdf. Ac-
cessed on October 7, 2010.
5. Nijkamp PG, Habets LL, Aartman IH, Zentner A. The influence of
cephalometrics on orthodontic treatment planning. Eur J Orthod
2008;30:630-5.
Authors’ response
W e would like to thank Dr Spassov and coworkers for
their interest in our research work. The concerns by
Dr Spassov and his team probably derive from their lack
of awareness of the effectiveness of early interceptive
treatment of a PDC to prevent impaction. Our research
group has published to date several randomized clinical
trials on this topic, with the consistent result of an in-
crease in the prevalence rate of spontaneous eruption
of PDCs after different interceptive techniques (extrac-
tion of the deciduous canine, rapid maxillary expansion,
Readers' forum
headgear, transpalatal arch, and so on).1-3 Dr Spassov
and colleagues are invited to consider these studies
that can provide a very favorable impact on everyday
orthodontic practice. In the light of the results, it is
highly recommendable to be able to diagnose PDC as
early as possible also by identifying risk indicators
such as associated dental anomalies. All of this can be
done by using the usual panoramic x-ray that is needed
routinely for orthodontic diagnosis and treatment
planning. Therefore, it is a definite therapeutic advantage
with the usual dose of radiation. Nothing to worry
about.
Tiziano Baccetti
Maria Leonardi
Veronica Giuntini
Firenze, Italy
Am J Orthod Dentofacial Orthop 2011;139:2-3
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.11.013
REFERENCES
1. Leonardi M, Armi P, Franchi L, Baccetti T. Two interceptive
approaches to palatally displaced canines: a prospective longitudi-
nal study. Angle Orthod 2004;74:581-6.
2. Baccetti T, Leonardi M, Armi P. A randomized clinical study of two
interceptive approaches to palatally displaced canines. Eur J Orthod
2008;30:381-5.
3. Baccetti T, Mucedero M, Leonardi M, Cozza P. Interceptive treat-
ment of palatal impaction of maxillary canines with rapid maxillary
expansion: a randomized clinical trial. Am J Orthod Dentofacial
Orthop 2009;136:657-61.
Lack of evidence forces practitioners to
make clinically based decisions
I n their recent guest editorial (O’Brien K, Sandler J. In
the land of no evidence, is the saleman king? Am J Or-
thod 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 ap-
pliances. The purpose of my letter is not to dismiss their
valid concern about the marketing and promotion of
new treatment methodologies by orthodontic suppliers.
Rather, I aim to defend the use of new treatment modal-
ities by myself and other practitioners as carefully
considered decisions, not a baseless impulse purchase
by fools who are easily duped.
American Journal of Orthodontics and Dentofacial Orthopedics
3
Drs O’Brien and Sandler attempted to paint the
case that practitioners are making treatment decisions
based on slick marketing in the presence of contradic-
tory evidence. Certainly, the assumption that a wise
orthodontist will reference the literature when new
products enter the market is one on which we can
all agree. However, their conclusion that the clinician
using new “unproven” appliances or tools is either
ignorant or in denial is one that I vigorously dispute.
I would argue that, at this point in history, there is
precious little evidence about self-ligation available
and certainly not a vast body of research on which
one can draw decisive conclusions. Current studies
about self-ligation are too frequently designed to dis-
credit the marketing claims made by manufacturers,
not to elucidate the biologic effects of self-ligation.
Where are the histology studies showing the cellular
elements involved with self-ligation? Where are the
3D studies that detail the physiologic changes taking
place over time? Where are the animal studies that
describe the in-vivo changes? As we all know, these
studies have not been done. Drs O’Brien and Sandler
cite 6 sources as evidence that the claims of self-
ligation are false. The principal investigator in 4 of
the 6 is the same. No cited study predates 2007,
despite the availability of self-ligation since 1995.
I point this out not to discredit the cited studies (or
others) but, rather, to support my argument that
much further evidence is required before the claims
promised by these new technologies can be either
supported or refuted.
For the past 15 years, a void of evidence has forced
practitioners to make clinically based decisions about
self-ligating brackets. The significant amount of time
that self-ligation has been in the marketplace has allowed
individual clinicians to draw pertinent conclusions about
the effectiveness of self-ligating brackets in their
offices. Using the platform of “evidence-based research”
to discredit clinical decisions made by thoughtful, experi-
enced, and ethical practitioners demands a thorough
scientific understanding of the clinical decision in ques-
tion by the accuser. I do not believe that a thorough
knowledge base yet exists. That said, I look forward to
the continued pursuit of the evidence by our academic
counterparts and will certainly take it into consideration
as it presents.
Christine Porter Ellis
Dallas, Tex
Am J Orthod Dentofacial Orthop 2011;139:3
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.11.015
January 2011  Vol 139  Issue 1