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  • Dr. David Alfaro

Deconstructing Dogmas

Nerd Alert!!!! This is going to be extremely academic and boring, even for people in the dental profession!!

Dentistry is historically full of concepts that have been passed down from teacher to student in a kind of folkloric tradition. Bennett movement. Ante's law. Posselt's envelope. Hinge axis rotation. Hanau's quint. The list could go on and on.


As a dental student, I didn't really look deeply into how these concepts originated. I just believed them to be true because my mentors said so, and they were stated as fact in all of those famous text books we had to (and still have to) read. But then as I progessed through residency, and was exposed to more and more complex clinical scenarios, I began to question things.

In medicine and dentistry, we are moving away from the teaching of traditional "accepted" concepts, and are looking toward evidence based healthcare to assist us in our decision making processes. After gaining a grasp of how to evaluate research, and how to apply those findings to my own clinical practice, I decided to go as far back as I could in the dental research literature to see exactly how the concepts that are so pervasive in our beliefs, came to be.

So I read. And I read. And I read.

I mean, I wasn't simply memorizing article authors and dates like what is required of us specialists for our board exams. It does us no good to pat ourselves on the back when proudly write down "Gargiulo (1961)", or "Fusayama (1979)", and act like we are all smart because we remembered who wrote what when. That is a superficial understanding of the history of our profession. Yet that often is how we are examined.

In my trek through ancient dental research, I searched for original articles, I evaluated methodologies, I looked at statistics (when they were even present), I considered alternative hypotheses, and ultimately, I began to doubt many things that dentists treat as rules.

I became the skeptic that I am today.

One thing that I noticed as I read historical articles, was that more often than not, the papers usually had a hidden purpose of selling some sort of device. Sponsored content! The prosthodontic literature is absolutely FULL of these gadgets. For example, if you read the "classic" articles on occlusal vertical dimension, you will see that many of these techniques have a magic tool that will help you determine the correct place to put the occlusal plane; the Boos Bimeter, The Willis Gauge, The Boley Gauge, and more recentely the EMG (a la LVI).....again the list goes on and on. Not one of these is the absolute correct answer, but they will gladly sell you the device, plus shipping and handling.

Technology has advanced far beyond the rudementary techniques that were available a hundred, fifty, and even twenty years ago. Publication requirements are also much stricter, and there are many more people doing research. So why do we still quote these articles, aside from their roles in history? Do we not have updated data?

Fortunately, other skeptics have taken it upon themselves to re-evaluate the findings of the researchers of yore.

The challenge now is that there is SOOOO much information.

When we go to look at the research on a topic, we sometimes get lucky and find a systematic review or meta-analysis.....which often comes up with "the research is too heterogenous to come to a conclusion". But for those more obscure topics, we are often not able to find a well constructed review paper, and have to dig through dozens, if not hundreds, of articles.

I hope that I am not coming across as an arrogant "know-it-all". I actually hope that it is the opposite; that you see that I feel that we need to question when someone says something very matter of factly, even if they are an authority on the topic. For example, I am sure that many of you have been reading those posts on social medial that are put together by a very popular study club. Some of those have been great technique pieces, others, simply biased.

They recently posted an article on the NTI device. The author stated so matter of factly that the NTI separates the back teeth, thus relaxing the lateral pterygoid, allowing for the condyle to seat, reducing TMJ pain. But did they supply evidence? No. This is a topic that I would love to cover in the future, because I have read research (beyond what is quoted in Dawson or Okeson) and have been left thinking, "but.....maybe......" like the Louis C. K. bit. The author then went on to state potential adverse effects of the NTI, and included eruption of posterior teeth, and loss of habitual bite position. So it may work? may also cause dental changes that would exacerbate the hyperactivity of the lateral pterygoid, if you believe in this concept in the first place.

The stomatognathic system is a very complex anatomical and physiological mystery, which is attached to a highly emotional and often unpredictable mass of neural tissue, which in turn is affected by mood, experiences, fears, beliefs and even worse, can experience pain, which is the ultimate variable. It is easy for me to see why an intervention can work in one person, but can aggravate symptoms in another. There are no cookie cutter solutions.

As important as evidence based dentistry is to our profession, we also cannot be dismissing the teachings of our mentors, because they have come from years and years of clinical practice. This mentor/mentee relationship must work both ways, however, where our senior dentists who have been practicing a specific technique for years, must also be open to changes in the practice that have evolved because someone took a fresh look at an old concept.

And that is what nerds like me do. We read research. So I figured I would start a section to my blog which will cover different topics, looking back at the original articles, and at newer evidence, so we can all see how things have come to be and where they are moving to in the future.

Nerdy, but useful. I hope.

Thanks for reading! Please like, share and follow!

Dr. Dave

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