In 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. 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 modalities by myself and other practitioners as carefully considered decisions, not a baseless impulse purchase by fools who are easily duped.

Drs O’Brien and Sandler attempted to paint the case that practitioners are making treatment decisions based on slick marketing in the presence of contradictory 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 discredit 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, experienced, and ethical practitioners demands a thorough scientific understanding of the clinical decision in question 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.