Evidence based orthodontic treatment-no good deed goes unpunished. Part 2: Let them eat cake
Let Them Eat Cake
This is the second part of our joint lecture at the recent British Orthodontic Conference. Lysle Johnston has based this post on his presentation. This was about the value of alternatives to the orthodontic randomised controlled trial. It is the first guest post on my blog.
In Boston Society, it is said that the Lowells speak only to the Cabots and the Cabots speak only to God. From my standpoint, this is an elitist ethos shared by the RCT folks, who seem to speak only to and about each other and their RCTs. If the masses want evidence, let them wait for an RCT! (Qu’ils mangent de la brioche). As someone who has toiled for over 50 years in the vineyards of orthodontic research, I feel somewhat insulted to find that my research generally is considered too far down the pyramid of truth to be considered or even discussed.
Do not misinterpret this lament—I agree that systematic reviews are at the top; however, as I see it, there is a problem in the orthodontic application of the RCT. Orthodontic treatment options aren’t just pills of different colors. To randomize treatments, there not only has to be true equipoise, but also, and perhaps more problematic, the investigators must seek to elicit a preference from each fully-informed participant. Does the following scenario seem realistic?
“Mrs. Jones, we think you can be treated equally well either by adult orthodontics or by surgery. We are truly uncertain and would like you to participate in a study designed to compare the two options. We flipped a coin, and it came up surgery. Sign here”.
The orthodontic treatment options to which a subject might reasonably be indifferent are limited and may be of minimal interest to the topic of evidence-based orthodontic practice. This problem consigns many of our most difficult questions to the dust bin of the un-answerable. The RCT-or-nothing attitude has the unwanted (or ignored) side effect of granting license to any treatment, no matter how lunatic, until a never-to-be-executed RCT signs in. The Cowardly Lion became brave when given a medal; apparently, the orthodontic researcher becomes truly “medical” when he or she has conducted an RCT. Alas, the cognoscenti may be good at discerning the mote in the eye of a lesser investigator, but quite willing to ignore the log in their own (Matthew 7:3). Hawthorne effect? Data peeking? Lack of blinding? No long term data? Alas, it is probable that both the question and the researchers will be dead when the time comes to look at the surprisingly small percentage of subject who might be willing to return for records. (In my experience with recalls, the cooperation rate is about 1 in 10). The important thing seems to be the secret handshake.
My message is that there are lesser, more timely strategies, many of which may be quite good at minimizing the various biases that proliferate unchecked in today’s orthodontic marketplace.
In the American South, there is an old saying: “Never try to teach a pig to sing; it wastes your time and annoys the pig.” My visit to the British Conference at Brighton left me with the impression that the rank and file may not be annoyed, but clearly they have a limited interest in finding out whether popular, salable treatments get the RCT seal of approval. As long as everything works and nobody dies, proof may be beside the point.