Sir, I have followed the recent series on orthodontics with interest. In general it has been a fair presentation, however part 7 (BDJ 2004 196: 143) addressed some of the current controversies under the title 'Fact and fantasy in orthodontics' and here I think the authors stepped to one side of the balance of the evidence in an effort to justify current establishment views.

Evidenced based dentistry is the buzz word of today but it must be remembered that evidence can only confirm or disprove, it can never explain, only logic can do that. The authors condemn 'anecdotal evidence' as the 'weakest' form but it is the foundation of most current orthodontic treatment. They accept that 'there are few well designed random controlled trials', this is not surprising as there are just too many uncontrolled and confusing variables for us to be certain about any clinical treatment. As they suggest, we do not even know if it is better to take teeth out or not.

It is certainly misleading for them to say 'Temporomandibular joint problems are not caused or cured by orthodontic treatment', the only evidence we have is negative 'it has not been shown that they do cause or cure problems'. Again I know of no existing theory that can explain all the varied symptoms of TMD1.

The authors rightly say that 'dished in faces' are found in both extraction and not extraction cases. This is why research on facial damage is so difficult and yet every dentist and orthodontist knows that faces are sometimes damaged. More to the point every study I have seen shows that orthodontic treatment tends to lengthen faces and also that longer faces are less attractive.

The problem is that we can see if a tooth is one millimeter out of line but may not realise if a face has been damaged by ten or even 20%. Orthodontists tell me that they are currently extracting fewer teeth and yet statistics suggest that the ratio is still over 70% and we must not forget that many of these patients will eventually lose eight permanent teeth.

How can anyone be so sure that extractions are wise when views in the past have oscillated so widely and my recent research in Kenya has found so many primitive villagers with 32 teeth and space to spare?

They are correct in saying there is insufficient evidence to show that 'functional' appliances work but again, there is also insufficient evidence to show that they do not. Clinical evidence is inherently unreliable and it is probably wiser to rely on more basic evidence (Mew 2002). The unanswered question is 'Why is malocclusion currently endemic in civilized society when our direct ancestors of 20,000 years ago had few such problems'?

Sir, I have been following with interest the series of articles on orthodontics. In Part 7: 'Fact and fantasy in orthodontics' (BDJ 2004, 196: 143) the authors state in the summary of evidence-based dentistry that 'Orthodontics has little gold standard evidence'. I wonder where that leaves the basis for these articles, upon which the BDA has committed significant resources to create a handbook for general dental practitioners.

Could it be that, put into perspective, this whole series is another missive of well held opinions and that the material put forward by the authors, in the absence of 'gold standard' evidential support, falls into the realms of fantasy? The closing paragraph refers to this domination of forceful opinion and I believe it would be most helpful to the dental profession as a whole if this was acknowledged by the orthodontic establishment.

H. Jones Surrey

Sir, I have enjoyed so far the orthodontic series by Drs Roberts-Harry et al. However I was surprised to see in the risks article such distinguished authors trotting out the old dogma on endocarditis at-risk patients. The excellent paper by Lucas et al published in the EJO in 2002 clearly concluded that only the placement of separators induces a significant bacteraemia.

The over prescription of antibiotics has been well documented – let's educate our colleagues to use them less!

R. Bateman Kent

The authors respond: We would like to thank Drs Jones, Mew and Bateman for their letters. We would disagree with Dr Jones' view on the validity of the series of articles. The series covers a range of important principles ranging from patient assessment to appliance choices. For example, it is an empirical and scientific fact that fixed appliances are better than removable at most tooth movements (part 5) and that patient assessment is essential when devising a treatment plan (parts 2, 3 and 4).

In part 7 we highlight and acknowledge that like most clinical sciences, orthodontic proof is in its infancy. Recent publications in the Journal of Orthodontics and the American Journal of Orthodontics and Dentofacial Orthopaedics from the academics in Manchester have shown quite clearly that orthodontics is doing much to increase the scientific basis of clinical practice.

Although we do not presume to be the orthodontic establishment we feel that our closing paragraph acknowledges the 'domination of forceful opinion' and how misleading this can be. The same is true for almost all branches of dentistry.

We are grateful for the interest Mr Mew has shown in this series and his comments. Unfortunately we are not the 'establishment' and our views are based on the available evidence and not personal opinion.

We are also grateful for the interest Dr Bateman has shown in this popular series.

At the time of writing the orthodontic articles the Lucas article had not appeared in press. We disagree that we were 'trotting out old dogma'. We presented a balanced view supported by guidelines.

Further the article by Lucas et al is at variance with data from two other studies. This is acknowledged by Lucas et al in their discussion and reasons for this are presented. In their conclusions they suggest that a larger study is needed to clarify which procedures require antibiotic prophylaxis in children and adolescents with predisposing cardiac lesions. We accept the paper by Lucas et al is a quality manuscript. However we do not understand how anyone could take a dogmatic stance on this difficult topic when the authors of the Lucas paper are themselves unsure.