I think that I should become an Orthodontic Key Opinion Leader…

I’ve taken my bows and my curtain calls

I am now rapidly approaching full retirement and I need to maintain my income and number of overseas lecturing engagements. Perhaps I should become a Key Opinion Leader?

I have discussed potential changes in my career before. I have thought about becoming a Snake Oil Salesman and decided that this was a step too far. But, should I become a Key Opinion Leader? I have seen them speak and looked at their posts on Facebook and it looks as though they are having a great time. But what do they do?

The definition of a Key Opinion Leader is

“Doctors who influence their peers practice. Including but not limited to their treatment behaviour. They give lectures promoting products and are frequently paid for their time”.

“Key Opinion Leaders are often chosen for their high prescribing habits rather than their knowledge”.

I want fame and fortune and everything that goes with it

I have looked at these definitions and decided that I am not there yet. So what do I need to do to satisfy my ambitions?

First, I need to really get involved with one orthodontic company. I will buy a lot of their products. I will get to know the company representatives and I will offer to do presentations on their products. Hopefully, they will notice me and make me a KOL so that I can sell their products educate people.

I will also need to forget all the science and evidence base that I have learnt (assuming that I learnt this when I was in training). I shall put all this to the back of my mind so that I can promote our product.

When unfavourable research on our product is published, I will ignore it. I may try to criticize the research, but I will find this difficult because I have forgotten my research knowledge.  However, when someone publishes favourable research, I will promote it without any criticism. Even if our company funded it and it is poorly done.

People may challenge me about the research on our product. I will tell them that we are currently working up projects and they will be published soon…..

We are the Champions!

I will appear in slick videos of me being on stage with loud music, flashing lights, and “walls of teeth” with our product. I may even be asked to line up with the other KOLs on stage, so that the delegates can worship at our feet. We will be like an all-conquering sports team. We are “powerhouse” speakers.

I will rock the house…….

When I am asked to speak at orthodontic conferences, I will start talking about the subject that the conference has agreed. However, after about five minutes into my talk, I will change the emphasis and start to talk about our product. Even when it has nothing to do with the presentation. I will be passionate about my new education role and blessed to be honoured as a KOL.

No time for losers

We will post up pictures of my KOL life on social media. I will be sitting in business class seats, dreamily looking at computer screens or sitting on exotic beaches with my KOL chums after a hard day of selling our product and our great company.

Will I sleep at night? Yes, it is only the Snake Oil Salesmen who cannot sleep at night…..

Postscript…Its no bed of roses..

Since I published this I have had several comments suggesting that I am being unfair to most KOLs.  This was not my attention and I simply wanted to draw attention to the practices that I have observed over the last couple of years in a light hearted way.  I am sorry if I have offended anyone.


Which is better a bonded or a vacuum formed retainer?  Here is a new trial.

One of the many controversial areas in orthodontic is our choice of orthodontic retainer. This new study gives us useful information.

I have posted on retention several times. I have concluded that there are disadvantages and advantages of the main types of retainer. However, in general the type of retainer we use depends upon our own and our patients choices. Nevertheless, there is not much information to inform these choices.  I thought that this study goes some way to providing us with clinically useful information. A team based in the North of England did this new trial.

Incidentally, the North of England seems to be a hotbed of clinical trials in orthodontics. This may be a result of the weather.

The EJO published this new study.

Bonded versus vacuum-formed retainers: a randomized controlled trial. outcomes after 12 months

Part I lead author K Forde. doi:10.1093/ejo/cjx058

Part II lead author Madeleine Storey doi:10.1093/ejo/cjx059

As usual, these very useful papers are behind the EJO paywall.  The authors have also published this study in two parts. I have decided to incorporate them into one concise post.  This makes it easier to read and reduces duplication.

The study team set out to answer the following question

“Is there any difference in the effectiveness, patient perception and periodontal outcomes of lower vacuum formed retainers (VFR) and lower bonded retainers (BRs)”.

What did they do?

They did a two arm parallel group RCT with a 1:1 allocation. Their PICO was

Participants: Patients completing fixed appliance therapy

Intervention: Upper and lower VFR worn at night only.

Comparison: Upper and lower BRs

Outcomes: Retainer survival, patient satisfaction measured by questionnaire, relapse measured by Little’s Irregularity Index and periodontal health

They carried out a good sequence generation, concealment and allocation via sealed envelopes.  It was not possible to blind the patient or operator. Importantly, it was not possible to blind the person who was recorded the relapse from the dental models.

They recorded the data at the start of treatment and several time points. I am only going to discuss the data at the start and after 12 months.

I thought that it was great to see that they did an Intention to Treat analysis. This meant that they collected and analysed data for the participants who dropped out or failed to wear their retainers.  They did the relevant statistical analysis.

What did they find?

They enrolled 60 participants. 30 were treated with BRs and 30 received VFRs.  The groups were similar at baseline.

When they looked at stability, they provided a great deal of data.  I have concentrated on the main findings. This table includes the amount of relapse measured by Little’s Index.  They found that the data was not normally distributed so they presented this as the median and inter quartile range.

Maxilla1.1 (1.56)0.76 (1.55)0.61
Mandible0.77 (1.46)1.69 (2.0)0.008

They found that there was no difference in survival of the retainers in the maxilla. 63% of the BRs and 73% of the VFRs survived 12 months.  However, in the mandible 50% of the BRs and 80% of the VFRs survived 12 months. This difference was statistically and clinically significant.

The data on patient satisfaction showed that more patients reported difficulty speaking and eating from VFRs and greater discomfort from BRs.

Finally, they showed that the presence of BRs increased levels of plaque, gingival inflammation and calculus when compared to VFRs. However, at 12 months the data suggested that there were no real implications for periodontal health.

The authors conclusions

Their overall conclusions were that when they compared BRs with VFRs:

  • There was no difference in periodontal health
  • No difference in relapse in the maxilla
  • In the mandible the BR is more effective thant VFRs in preventing relapse
  • No difference in the survival rate of the maxillary retainers. However, in the mandible the BRs had a higher failure rate.
  • VR is easier to clean than the BR
  • BR causes less speech and mastication difficulties
What did I think?

In summary, I thought that this was a nicely done study. They used good methodology and the findings were interesting.  However, we need to be a little cautious in our interpretation because the sample size was based upon arch alignment changes. As a result, it may not have been sufficiently powered to detect any differences in the other outcome measures.  This is particularly relevant when “no difference” between the interventions was detected.

Some may criticise the investigators for not measuring compliance with the VFRs.  I feel that this step was not necessary as the intervention was the prescription of the retainer. If the participant did not wear the appliance this reflects the real world situation.

The study provided a lot of useful information.  My feeling is that the BR has some disadvantages, for example, the high failure rate and the plaque and calculus retention.  However, the VFR also has problems, for example, the patients reported that they had mastication and speech difficulties. Nevertheless, as they were asked to wear these at night, I wonder if this is a big issue.  I also was not sure the difference in the relapse was clinically significant.

My favoured retention regime is VFRs at night only and this study reinforces my practice.  But you can interpret this data to inform your retention protocols.