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. 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, Manchester, Pennsylvania, and North Carolina ) 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.” I could not find this claim in that article.
A similar curiosity was noted in the article by Keski-Nisula et al. A close reading of the article showed that the authors did not state or conclude that the samples of the RCTs were flawed. 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 Johnston 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.