Critical Appraisal --- The Response

We would like to first of all thank Dr. Stefan Ihde for the “Critical Appraisal” that he has done regarding our article in Ann Maxillofac Surg 2017;7:237-44. We have gone through it and wish to put forth our explanations to the points that he has raised (we are doing it in a manner similar to Dr. Ihde's – under specific subheadings – so that there is uniformity).

MATERIALS AND METHODS

1. (a) The study setup is true. (b) The cases included are those of patients who opted for implants

2. Legends, if inadequate, may kindly be cross-referenced from the article itself

3. Any medical or dental treatment outcome, whether by implants or otherwise, can be by chance also, at times. It is virtually impossible to predict how the body behaves to a particular treatment (medical or surgical) in individuals accurately, all the time

4. The article does not claim to have done any statistical analysis – when only four cases are presented, there is no scope for statistics, obviously

5. If there is any discrepancy between the clinical pictures and written text, kindly let us know

6. This question is irrelevant, as there is no “control group” in this study

7. Whether the “assessments drawn from the clinical cases are proper”[1] or not, is quite subjective

8. The study has its own drawbacks, some of which we have mentioned in the article itself under the subheading “Limitation of Study.”[2] We certainly do not claim to be all knowing

9. It is for the reader to decide whether the article “provides valuable information for decision making”[1] or not. Obviously, it cannot be one person's views alone that counts.

ANALYSIS OF THE CITATIONS, RESULTS

As Dr. Stefan Ihde himself admits, we “do not claim that the cases were treated consecutively.”[1] We certainly “do not report on a cohort study,” as admitted by him again.[1] As a consequence, whether “it meets the minimal requirements for being published in a reviewed journal”[1] or not is best left to the editor of the journal, in our opinion. Is it that all journals publish articles that are based on “cohort studies”[1] only, we are left to wonder. The only thing we can assure Dr. Stefan Ihde is that we did not use any coercive or subversive methods to get the article published.

Case 1 – Diagnosing periapical lesions from an orthopantomogram (that too, without knowing the history) need not be accurate. Again insisting that some implants are within the maxillary sinus just from radiographs is a bit incomprehensible to us. Even if they are in the sinus, does it mean that they are a failure? Those of us who deal with zygomatic implants would certainly beg to differ. At the same time, we admit that some of our pictures may not have met the highest “standards of intraoral photography.”[1]

Case 2 – Just because the “panoramic overview of the finished case nor clinical pictures of the case after finishing”[1] were not in the article, insisting that “the esthetic outcome of this case is in fact a disaster,”[1] seems to us the height of “critical appraisal.”[1] However, we will take it as a backhanded compliment of the “functional” success of our implant treatment.

Case 3 – We are thankful to Dr. Ihde for pointing out our shortcomings – they will be certainly looked into.

Case 4 – “On our request, the authors have failed to address this point in the correspondence which had taken place before the preparation of this publication. They also refused to submit 3-year postoperative pictures nor radiographs.”[1]

We do not intend getting into a debate with Dr. Stefan Ihde about his allegation, as we believe in professional etiquette. Permit us to state that we had informed him (more than once) that we will reply to his letter after analyzing it, which is the norm – this in spite of the tone of the letters (Refused to submit ? certainly not true).

GRAPHS

There are a lot of assumptions on the part of the “critical appraiser”[1] in this section (like in the other sections). Since we never knew that in “critical appraisal,”[1] you can allege anything you want just because the appraiser is assuming, we prefer to stay away from such assumptions. It is also a fact that most of what is written in the “ Critical Appraisal” was beyond our comprehension (We are not very sure).[1]

ADVANTAGE OF BASAL IMPLANTS

It is a fact that no periotest or any other device was used to check the implant stability. However, as the article mentions, this was a clinical study about a 3-year follow-up – the only thing done was to check the stability of the implants clinically (we certainly did not claim that these cases are part of any experiment).

DRAWBACK OF BASAL IMPLANTS

Claim 1 – We admit that using the term “prosthesis,”[2] here was wrong. However, it is also a fact that this mistake does not make us change our opinion that “replacing a basal implant is difficult.”[2]

Claim 2 – Dr. Stefan Ihde seems to be laboring under the assumption that his opinions are final. Unfortunately, we beg to differ.

Limitations of the study

“Cases are chosen specifically to prove something (the study is obviously biased)”[1] – Now we come to the real point of this “critical appraisal.” Could it be that we have an interest in a particular system and so we are trying to run down the other system/s?

We wish to state categorically that we do not have any stake (commercial or otherwise) in any implant system nor do we advocate the usage of any particular system.

We choose implants according to what might be suitable in a particular situation. We hope that Dr. Stefan Ihde also does not advocate any particular system and only chooses implants (from any system) according to the clinical situation.

Regarding his allegation that “the corresponding author was asked three times in writing to explain various suspicious aspects of this article (namely through E-mail on 3.1.2018, 24.1.2018, 4.2.2018), he acknowledges the receipt of the questions – but he failed to give any answer at all”[1] – you will notice that within a period of just 1 month, he sent us three mails (in not-so-friendly tones), demanding an immediate reply. In our mail, we requested for some time because we could not understand quite a few things that were in his letter – for example, severe underequipment,[1] with so much fgodod bone,[1] etc., to name just a few. It is also a fact that we being full-time maxillofacial surgeons in academics, patients suffering from cancer, fractures, etc., as well as students are given priority than a reply (“within-a-week”) to a tendentious “critical appraisal.”[1]

Dr. Stefan Ihde has graciously provided an article on “Critical appraisal skills.”[3] It appears that without acquiring real competency in the art and science of “critical appraisal” (as conveyed in this article by Mhaskar, et al.[3]), the same has been used to “cut and paste” certain words/sentences from it. We admit that we are guessing when we say that, if critical appraisal had been used routinely, the journal “Implant Directions” published by the International Implant Foundation[1] would have been functioning and publishing research of very high quality, which would have been a boon to the field of implant dentistry.

Last but not least, as stated earlier also, for us, etiquette (personal as well as professional) is of paramount importance as it is part and parcel of our life – personal as well as professional. Hence, we politely decline to comment on Dr. Stefan Ihde's statement that “his license as treatment provider should be under consideration by the relevant authorities.”[1] Suffice it to say that the last we checked, the Dental Council of India seems to be quite capable of deciding such matters – sans gratuitous advice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.