READERS' FORUM
Letters to the editor*
Concern about interpretation of the
data
n an interesting study published last year, Smith et al1
I evaluated airway volume, soft-palate area, and
soft-tissue thickness before and after rapid maxillary
expansion. They explored the reliability of measure-
ments made on 3-dimensional images and used the
intraclass correlation coefficient (ICC). In this letter, the
rationale of applying the Bland-Altman plot and related
suggestions to its use instead of the ICC are given.
Validity and reliability of data according to the type
of variables (categorical or continuous) can be measured
with various indexes. The ICC is one of the most
frequently used indexes of reliability for continuous
variables.2 It measures an absolute or true agreement
between 2 or more methods or observers. This possibility
in case of measuring absolute agreement rather than
only consistency and correlation makes it a more
appropriate tool for the assessment of reliability.3
Moreover, the ICC considers not only consistency, but
also some systematic patterns between methods.
However, its indication to measure both reliability and
validity of continuous measurements compared with
the Bland-Altman plot is questionable.4,5
Accordingly, I would like to recommend that Smith
et al should apply the Bland-Altman plot on their data
to provide more information regarding the extreme
and outlier values, the magnitude of disagreement,
and its pattern between 2 or more methods.
Manoochehr Karami
Hamadan, Iran
Am J Orthod Dentofacial Orthop 2013;143:446
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.02.004
REFERENCES
1. Smith T, Ghoneima A, Stewart K, Liu S, Eckert G, Halum S, et al.
Three-dimensional computed tomography analysis of airway
volume changes after rapid maxillary expansion. Am J Orthod
Dentofacial Orthop 2012;141:618-26.
2. Fleiss JL. The design and analysis of clinical experiments. Wiley
Online Library; 1986.
3. Szklo M, Nieto FJ. Epidemiology: beyond the basics. 2nd ed.
Sudbury, Mass: Jones and Bartlett Publishers; 2007.
*The viewpoints expressed are solely those of the author(s) and do not reflect
those of the editor(s), publisher(s), or Association.
446
4. Bland JM, Altman DG. Statistical methods for assessing agreement
between two methods of clinical measurement. Lancet 1986;1:
307-10.
5. Altman DG, Bland JM. Measurement in medicine: the analysis of
method comparison studies. Statistician 1983;32:307-17.
Author's response
T hank you for showing interest in our article. The
suggestion of the Bland-Altman plots is excellent.
The plots provide more detailed information regarding
patterns and magnitudes of disagreement than can be
achieved with a single statistic such as the ICC. We
included examination of Bland-Altman plots during
our analyses, as indicated in our article. We did not
include the plots in the published article because of
space considerations (19 plots, 1 for each airway param-
eter) and because we thought that the addition of those
19 plots would take the reader's focus away from the
primary intent of the article.
Ahmed Ghoneima
Indianapolis, Ind
Am J Orthod Dentofacial Orthop 2013;143:446
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.02.005
Assessing salivary biomarkers for
analyzing orthodontic tooth movement
W e read with interest the article by Professor Fl
Moreno et al1 in the January issue investigating
salivary levels of sRANKL and OPG and their ratios
orez-
during orthodontic tooth movement, in an effort to
determine the possibility of using these as biomarkers
for chair-side point-of-care testing. The authors based
their methodology on the premise that, as the different
mediators involved in alveolar bone remodeling are
being continuously washed into saliva by gingival
crevicular fluid, unstimulated whole saliva could be an
easier alternative to gingival crevicular fluid sampling
of isolated sites. Although it is not our intention to
detract credit from the findings of their study, we would
prefer to interpret their findings with caution in light of
the following.
First, current ELISA techniques used to quantify
RANKL and OPG levels even in serum are not very sensi-
tive.2,3 Since sensitivity of assays is a critical factor in