150 Readers’ forum
August 2005
hemisected and closed all space. Patients with CML5 were
compared with 2 groups of patients with Class I occlusions
and much crowding. One group was treated with 4 first
premolar extractions and the other with 4 second premolar
extractions. Contrary to Dr Kessel’s assertion, the incisors do
go back. Certainly, patient needs differ, and, accordingly,
mechanics will differ in appropriately designed treatment. But
to compare the use of increased curve of Spee (or even a
V-bend with connection to vertical slots) to the use of some
appliances that can have a real impact on anchorage would be
tantamount to 1 of Dr Tom Mulligan’s “myths of mechanics.”
When you use a reversed curve of Spee or a tip-back bend, the
molar will be tipped backward; you will be “setting up
anchorage” that will draw the anteriors toward the back of the
mouth (especially if the molar is tied back, as it would be if
you use power chain), flattening the profile. I encourage Dr
Kessel to visit the Angle article and examine the minimal
amount of anterior anchorage loss demonstrated by our data
and exhibited by the stability of the midline in a unilateral
case of agenesis treated by hemisection. The need to remove
the maxillary premolars was avoided, and the profile was
maintained as well as could be for a rather retrognathic
profile. V-bends and pitting 8 against 2 (or, in this case, 10 or
even 11 against 1) would not have kept this midline concen-
tric. As I said in my lecture at the 2005 AAO meeting, in
some cases, we are even corticotomizing the region when the
mesial half is removed and using bone screws in those whom
we determine to be maximum anchorage cases.
As for the stated concern over tipping, a review of our
cases will show that the “bookend” (mesial half of the second
primary molar) causes the first premolar to erupt vertically;
and tipping is not a concern for the molar. In fact, we
experienced a “drafting phenomenon,” where the lower sec-
ond molar follows the first molar forward, seldom requiring
uprighting with fixed appliances.
It is a pleasure to address these items that needed more
attention in the article. For me, this approach has incredible
potential and is in its infancy in terms of application. It should
be considered one of many innovations that might apply
along a gradient of treatment options used to impact anchor-
age. The gradient, depending on the degree of any given case,
might run a gamut such as: reproximation is less aggressive
than headgear, which would be less than intermaxillary
elastics, or maxillary second molar extractions, second pre-
molar extractions, first premolar extractions, bone screws,
first molar extractions, and any combination of the above. I
am certain that I left out other forms of anchorage, but
treatment choices should be determined based on degree of
anchorage need.
I hope this has been helpful.
William Northway
Traverse City, Mich
Am J Orthod Dentofacial Orthop 2005;128:149-50
0889-5406/$30.00
Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.06.014
American Journal of Orthodontics and Dentofacial Orthopedics
REFERENCES
1. Northway W. Hemisection: one large step toward management of
congenitally missing lower second premolars. Angle Orthod
2004;74:792-9.
2. Sletten DW, Smith BM, Southard KA, Casko JS, Southard TE.
Retained deciduous mandibular molars in adults: a radiographic
study of long-term changes. Am J Orthod Dentofacial Orthop
2003;124:625-30.
3. Rune R, Sarnas K. Root resorption and submergence in retained
deciduous second molars. A mixed-longitudinal study of 77 children
with developmental absence of second premolars. Eur J Orthod
1984;6:123-31.
4. Valencia R, Saadia M, Grinberg G. Controlled slicing in the
management of congenitally missing second premolars. Am J
Orthod Dentofacial Orthop 2004;125:537-43.
Evidence-based versus
experience-based views on occlusion
and TMD
It is a sad day when authors take another writer’s words
completely out of context to support their own agenda. It is
blatantly dishonest when these authors change the meaning of
a key statement by changing the words to make it say what
the “quoted” article did not say (Rinchuse DJ, Rinchuse DJ,
Kandasamy S. Evidence-based versus experience-based views
on occlusion and TMD. Am J Orthod Dentofacial Orthop
2005;127:249-54). These authors have shown such a flawed
bias in their article that it is only fair to give space to a
different viewpoint.
The authors seem oblivious of the real rules of evidence-
based dentistry. The first and most critical rule is the
requirement for “homogeneity of sample.” You cannot take a
whole constellation of disorders and treat them as 1 disorder.
Specific diagnosis is a necessary requirement when studying
TMD. Knowledgeable clinicians today routinely classify with
specificity the exact type of TMD being studied (or even
discussed). The authors’ repeated use of TMD, without
differentiation as to type, completely invalidates the conclu-
sions they defend. The basic need for differentiation between
intracapsular structural disorders and masticatory muscle
disorders is only 1 part of a complete diagnostic process,
which I advocated in the article that Rinchuse et al misquoted
and then vilified (Bad advice from flawed research. Acad Gen
Dent Impact 1995;24:30-1).
The authors characterized clinicians who cite experience
of successful treatment as denying “the usefulness of sci-
ence.” Such a generalization is sophomoric and an unfair and
uninformed bias that flies in the face of tremendous efforts to
scientifically study every phase of clinical experience. If the
authors had fairly quoted my article and studied its detail,
they would have seen my plea for more scientific analysis, not
less. They would have seen that the determination and
verification of the precise classification of specific types of
TMD is an absolutely uncompromisable requirement for
predictable occlusal treatment. Contrary to their generaliza-
tion that dentists who rely on experience to aid in their
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 128, Number 2
judgment deny the usefulness of science, the best clinicians
are among the most ardent supporters of scientific research.
But they are equally demanding that, if you continue to treat
TMD as an all-encompassing syndrome, your so-called sci-
ence is no science at all. Treating TMD without differentia-
tion breaks the most inviolate rule for evidence-based re-
search. TMD is not a disorder. It is not even a multifactorial
disorder. TMD is a nonspecific term for many different
disorders, any of which might be multifactorial. Unless the
rules for evidence-based research are followed and the spe-
cific type of TMD being studied is isolated and precisely
classified, the research is flawed. Different types of TMD
require different treatments. Occlusal treatment is specific for
specific circumstances, and my article pointed that out.
To quote directly from my article:
The clinician or researcher of today must be able to
tell the difference between pain from intracapsular
disorders versus pain from occluso-muscle disorders.
There also can be layers of pain from both muscle
and intracapsular structures and additional layers
from other causes such as fibromyalgia, odontalgia,
sinusitis, arteritis, etc. Dentists must be able to
separate dental problems from non-dental problems.
Despite the attacks on the role of occlusion in diagnosis
and treatment of specific types of masticatory system disor-
ders, proper occlusal treatment, when warranted, is close to
100% effective, and it is predictable. The principles are
scientifically based, learnable, and practical, and apply to
orthodontics, restorative dentistry, and treatment of many
orofacial pain patients. If such information is not found in the
16 Rinchuse articles used to document their own conclusions,
perhaps it is time to go outside such a limited viewpoint to
find out what is going on in the rest of the dental world. There
are some very credible researchers who have much to offer,
and there are some very scientifically minded clinicians who
are putting it all together.
Peter E. Dawson
Saint Petersburg, Fla
Am J Orthod Dentofacial Orthop 2005;128:150-1
0889-5406/$30.00
Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.06.011
Authors’ response
We thank Dr Dawson for reading and responding to our
recent article. He has had a long and dedicated career in
restorative dentistry; in fact, his 1972 book on occlusion/
TMD was an early read of the first author. Nonetheless, we
respectfully disagree with many of the contentions in his
letter. Foremost, we did not misquote him, change the
meaning of a key statement, or quote things out of context,
and we invite readers to look up Dr Dawson’s article (Bad
advice from flawed research. Acad Gen Dent Impact 1995;
24:30-1) and see for themselves.
On the other hand, we believe Dr Dawson used spin
tactics to misrepresent our views in several of his remarks.
Readers’ forum 151
For instance, he wrote that “The authors characterized clini-
cians who cite experience of successful treatment as denying
‘the usefulness of science’.” This is not what we wrote or
implied. We believe that relying on clinical experience alone
can lead to misunderstandings and incorrect clinical deduc-
tions, for the many reasons enumerated in our article.
Dr Dawson also claimed that our definition of TMD was
incorrect or inadequate and that we used TMD too generically
without discussing particular types or subclasses of TMD.
The definition of TMD we used in our article is the most
current one as developed from the ADA’s first conference on
TMD in 1982 (published in the Journal of the American
Dental Association in 1983). We stated on page 249 of our
article: “TMD is now considered a collection of disorders
embracing many clinical problems that involve the mastica-
tory muscles, joints, and associated structures.” Hence, we
acknowledged that TMD is a nonspecific term for many
different disorders. Furthermore, the claim that we used TMD
as an all-encompassing syndrome, without differentiation as
to type, is inaccurate and also irrelevant to our article. Our
purpose was to offer an explanation for why an experience-
based view of TMD is still popular in an age of evidence-
based dentistry. Differentiating between subclasses of TMD
was not part of our article, and our general use of TMD was
therefore appropriate and correct.
Dr Dawson’s letter is unsupported by any evidence—ie,
not 1 reference of his work or others. What evidence does he
offer for his claims that “Despite the attacks on the role of
occlusion in diagnosis and treatment of specific types of
masticatory system disorders, proper occlusal treatment when
warranted, is close to 100% effective and it is predictable.
The principles are scientifically based, are learnable and
practical, and apply to orthodontics as well as to restorative
dentistry and treatment of many orofacial pain patients,” or
that “Occlusal treatment is specific for specific circum-
stances”? These claims do not appear to agree with current
evidence-based thinking.1-3 In addition, he says that “some
very credible researchers have much to offer,” and that “some
very scientifically minded clinicians” are putting it all to-
gether, but he fails to disclose who these researchers are and
what they have published.
We stand by our efforts to promote an evidence-based
approach to TMD problems. Contrary to Dr Dawson’s expe-
rience-based view, our article was supported by 2 national
ADA conferences on TMD,4,5 the 1996 NIH conference on
TMD,6 a compelling research study (evidence-based model
level 2),7 and several systematic reviews of literature (evi-
dence-based model level 3—the highest level),1-3—7 refer-
ences cited in our article (beyond the 16 Rinchuse references).
Donald J. Rinchuse
Daniel J. Rinchuse
Pittsburgh, Pa
Sanjivan Kandasamy
Perth, Australia
Am J Orthod Dentofacial Orthop 2005;128:151-2
0889-5406/$30.00
Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.06.012