We do many things the way we do, in both our personal and professional lives, for no other reason than we were taught to do them that way. I heard a charming illustration of this maxim at a banquet during the 2007 European Orthodontic Society Congress in Berlin. It went something like this:
A young bride was preparing supper for her new husband. Just before placing the sausages in the frying pan, she cut off both ends. When her groom asked her why, she replied, "My mother taught me that if you cut off the ends of the sausages before you fry them, you will have a delicious meal. That is how I have always done it." This explanation didn't really satisfy the husband, so the next time he saw his mother-in-law, he asked her about it. Her reply was the same as her daughter's: "My mother taught me that if you cut off the ends of the sausages before you fry them, you will have a delicious meal. That is how I have always done it, and that is how I will always do it." Still skeptical, the husband sought out his bride's grandmother and asked her about it. The elderly lady looked puzzled, then chuckled. She led the young man back to his apartment, where she questioned her granddaughter. "You are still cutting the ends off the sausages? Why?" "Because that's the way the women in our family have always done it," her granddaughter replied. "May I see the pan you are using?" the old woman asked. As the young lady brought out her frying pan for her grandmother's inspection, the old lady roared with laughter. "Oh, my goodness! You are still using my tiny old pan!"
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Of course, the only reason the grandmother had ever cut off the ends of the sausages was that she didn't have a big enough frying pan. It had no effect on the flavor of the outcome.
Once in a while, I find myself doing something in my orthodontic practice simply because "that's how I've always done it". Take, for example, the exercise of sealing or tying off the jackscrew of a rapid palatal expander (RPE) after the expansion has been completed and transverse treatment goals have been realized. Most of us were taught that if we didn't do that, the expansion screw would "back off" and some of our meticulous expansion would be lost. I know I have followed this protocol for years, ever since the completion of my graduate training, without ever questioning whether there was any evidence to support it.
As it turns out, there is none. In this issue of JCO, Drs. Luis Tomas Huanca Ghislanzoni, Lorenzo Franchi, and the late Tiziano Baccetti present a well-conceived clinical study that tests the old paradigm of sealing off the expansion screw in a simple yet elegant manner. Forty-eight consecutive cases were treated with an RPE. Following active expansion, the twice-daily turns of the screw were discontinued and the appliance was left in place, with no mechanism applied to prevent the screw from backing off. Not wanting to spoil the surprise, I'll leave it to you to read the entire article for the thrilling conclusion--and a well-thought-out theoretical explanation of why things turned out the way they did. Suffice to say, the results did not concur with the way we were all taught.
While evidence-based decision making has its detractors, it has gradually become the law of the land in dentistry. There's a lot to be said for track record, but cold, hard, objective evidence wins the contest every time. "That's how I've always done it" or "That's how I was taught to do it" is no longer a good enough rationale for any clinical procedure. In this month's article, Dr. Huanca and colleagues call into question a time-honored, widely accepted "way of doing things" and demonstrate convincingly that conventional wisdom isn't always correct. Based on their findings, I'm going to take a good look at the way I'm doing everything in my practice and make sure there is cold, hard evidence to support my "paradigms". You can bet that I will not be cutting the ends off my sausages.
RGK