Volume 64, Issue 5 , Pages 753-754, May 2006
“Something Old, Something New, Something Borrowed, Something Blue”: Assessing Time-Honored Clinical Practice
Article Outline
- Yesterday’s “Great Result” Is Tomorrow’s “Malpractice”
- Conventional Wisdom May Be Neither
- Too Soon Old and Too Late Smart
- One Person’s Truth May Be Another’s Prejudice
- References
- Copyright
Rarely does an issue of JOMS reach so deeply into the past while envisioning the future. In the May issue, our authors examine the beginnings of time in medical/surgical intervention while looking toward the emerging brave new world of biotechnology. To reach so far, each of these authors has examined and challenged time-honored practice.
Yesterday’s “Great Result” Is Tomorrow’s “Malpractice”
Before maxillary dysplasias were accepted as a source of malocclusion, nearly all orthognathic surgery was performed in the mandible. Today, the majority of orthognathic surgery is performed taking into account the combined nature of maxillomandibular deformities. Surgeons have looked at the results of the first years of orthognathic surgery and found that new technology has revealed new solutions. Current advances continue to reveal new shortcomings in contemporary orthognathic treatment.
For the past two decades, surgeons have provided maxillary intrusion and mandibular advancement for vertical maxillary excess and mandibular deficiency. Treatment is often performed at the expense of posterior facial height because of the presumed occlusal instability of counterclockwise rotation. The result for many patients has been a loss of mandibular angle projection, esthetic compromise, and decreased upper airway size. That time-honored clinical practice is called into question by the evidence in Wolford’s paper. Goncalves et al1 demonstrate stability and improved airway with counterclockwise rotation. “Good” results of the past are questioned by changing the outcome assessment toward the more comprehensive functional parameters such as airway function and posterior facial height.
Conventional Wisdom May Be Neither
Kobayashi et al2 question the continued acceptance of neurosensory deficit in the sagittal split osteotomy by re-examining something old, the inverted “L” osteotomy. They find less neurosensory disturbance in the older operation for prognathism and beg the question as to why the inverted “L” osteotomy was so quickly abandoned in the 1970s for its “more effective” successor, the intraoral sagittal split osteotomy.
Too Soon Old and Too Late Smart
Imagine the past thousands of years when hunter-gatherers in China suffering from arthritis, fractures, kyphosis, or tuberculous osteomyelitis sought remedies in the natural world. How could our ancient forebears have selected substances and had the courage to grind, cook, combine, and then consume, inhale, or apply them? How could they have possibly found effective remedies? To imagine their success, one must understand their obvious failures through countless generations of courageous trial and error.
Ricky W.K. Wong and A. Bakr M. Rabie3, 4 evoke those earliest of scientific investigators in their assessment of Gusuibu, a dried rhizome believed effective in promoting bone formation. In this, as well as many other, new investigations, natural remedies are evaluated using modern clinical study design based upon the scientific method. In some evaluations of natural remedies, their use has not demonstrated efficacy. In others, such as for Gusuibu, the results have been intriguing. Wong and Rabie use standard contemporary study design to rigorously assess Gusuibu. The results leave no doubt that Gusuibu is a potentially profound osteoinductive substance.
The conventional scientific evaluation of herbal remedies has been stalled by the presumed unscientific founding of their use. Chinese herbal medicine is based upon the concept of holism; that the human body is an organic whole integrated with nature. While this is an odd concept to those with Western medicine sensibilities, it has gained new stature with greater understanding of complex ecosystems and the relationships among organisms.
Like the hunter-gatherers of the past, major pharmaceutical firms now scour the rain forests and oceans looking, like our ancestors, through trial and error, for new, valuable compounds. We now know that all organisms evolve to create antimicrobial, anticancer, or other positive metabolic qualities. Exploring nature’s pharmacology laboratory with modern science overcomes time-honored prejudice against folk medicine and will inspire new promising treatments.
One Person’s Truth May Be Another’s Prejudice
Which is it?
Overcoming societal prejudice allowed us to enter into promising new areas of investigation such as face transplantation and stem cell research.
Or:
The legitimate ethical concerns of patients, doctors, and society must limit the utility of these new technologies.
Is it a prejudice or a societal mores? Does it depend upon the observer?
In this month’s JOMS, Toure et al5 examine the current literature of facial transplantation. Remarkably, the majority of papers on this subject address ethical issues rather than the surgical and behavioral science aspects of this subject. Authors, too, are intrigued more by the societal context of this technology than its clinical propriety.
Clinical science depends upon the user’s bias to a far greater extent when the evidence is still emerging. Granstrom6 and Donoff7 depend upon limited evidence to support their positions regarding the utility of prophylactic hyperbaric oxygen therapy. Relying on case series and pathophysiologically based opinion, they formulate plausible evidence-based opinions. However, their opinions are in sharp contrast. Even topics with an unfettered scientific basis can remain controversial.
While apparently disparate, each of these authors presents the work like the young bride, seeking to apply something old, something new, and something borrowed to create an exciting, better future. These articles all seek the wisdom of time-honored practice while proposing potentially important new technology. They reach deep into the past to find contemporary clinical guidance. Our authors still leave room for their private opinions based upon their culture, ethos, and personality.
As for something blue: that is the repository of our past as well as our advancing knowledge; our blue Journal.
References
- Postsurgical stability of oropharyngeal airway changes following counter-clockwise maxillo-mandibular advancement surgery . J Oral Maxillofac Surg . 2006;64:755
- Neurosensory alteration in the lower lip and chin after orthognathic surgery (Bilateral sagittal split osteotomy versus inverted L osteotomy) . J Maxillofac Surg . 2006;64:778
- . Effect of Gusuibu graft on bone formation . J Oral Maxillofac Surg . 2006;64:770
- . Traditional Chinese medicines and bone formation—A review . J Oral Maxillofac Surg . 2006;64:828
- Facial transplantation (A comprehensive review of the literature) . J Oral Maxillofac Surg . 2006;64:789
- . Placement of dental implants in irradiated bone (The case for using hyperbaric oxygen) . J Oral Maxillofac Surg . 2006;64:812
- . Treatment of the irradiated patient with dental implants (The case against hyperbaric oxygen treatment) . J Oral Maxillofac Surg . 2006;64:819
PII: S0278-2391(06)00279-5
doi:10.1016/j.joms.2006.03.003
© 2006 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Volume 64, Issue 5 , Pages 753-754, May 2006
