An occasionally irregular blog about orthodontics

I’ve been thinking about the orthodontic fringe or quackery

I’ve been thinking about the orthodontic fringe or quackery

I’ve been thinking about the orthodontic fringe or quackery.

This blog is about the concept of the orthodontic fringe and is a discussion on treatments that some do not consider to be mainstream orthodontics.  When I first thought about this subject, I felt that it would be straightforward, however, defining the fringe is easier said than done. This is because there are rather blurred lines between accepted practice and what some would call the “fringe or quackery”. My first step, therefore, is to attempt to define these terms.

What is accepted orthodontic practice?

Perhaps the most logical definition is that this includes the treatments and concepts that most orthodontists practice or teach.  These can easily be defined as

“treatment based on credible scientific evidence published in peer reviewed journals”.

In the absence of evidence this can include the views of physicians practicing in the relevant area and recommendations of “learned societies”.

snake-oil-salesman-big-250x300What is “fringe or quackery”?

Definition of these treatments is more difficult because of the great diversity of orthodontic practice.  I have looked for definitions and according to Wikipedia, we can consider that the quack

 

  • Promises benefits from treatment that cannot be reasonably expected to occur.
  • Recommends against conventional therapies that are helpful.
  • Promotes potentially harmful therapies
  • Promotes magical thinking…
  • The orthodontic fringe

At this point I stopped and thought and it became clear to me that the fringe does not include the following “controversial” areas of our specialty.

  • The extraction/non-extraction debate
  • Functional appliance philosophies with world wide variation.
  • Different bracket designs

It may then be easy for some to then conclude that the fringe may include

  • Self ligating brackets claims in the face of scientific evidence
  • Newly designed braces that  provide fast treatment
  • Extreme claims on facial growth modification and early treatment based upon variants of functional appliance and muscle training.

However, I would like to be open minded add a further definition of quackery and this is that

“the promoter of such a technique must know that they are mis-representing the risks and benefits of the services that they provide’.

If we consider this we then need to critically evaluate the evidence for both conventional and fringe treatments. While we have evidence underpinning some aspects of “acceptable’ orthodontic treatment, it is also well established that in many areas the level of this evidence is weak. When we look at the evidence for what we may feel is “fringe or quackery” based treatment, this is also weak. Indeed, in some areas the level of evidence is similar!

emperorThis confusing situation is compounded further when we remember that there are also highly respected practitioners who follow philosophies and make claims that are contrary to the evidence.  A good example of this is self-ligation which continues to be promoted by key opinion leaders, in the face of research evidence that contradicts the claims. Yet, these “opinion leaders” are not criticized to the same degree as some of those who are considered to be on the fringe.

 

Is the problem solved?

In summary, the lack of evidence and the rather blurred lines makes it difficult for us to differentiate between accepted and fringe treatments. As a result, I propose that we can only classify as fringe those people who know that they are making claims contrary to the evidence that we have.

Importantly, when that evidence is absent, it is incumbent on the providers of both the fringe and conventional treatments to carry out the studies to obtain the evidence.

Until then each ‘side” cannot be critical of each other.  It is time to work together….

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  1. Ross Hobson says:

    Kevin – nicely said, that the problem is on both sides and research is required. A problem, is a philosophy is exactly that, a “belief” – which may not have an evidence base, and as it is a “belief” is extremely difficult to persuade otherwise. As wewill find when you challenge some believers in a particular orthodontic philosophy.
    I have concerned of those opinion leaders of the specaility in promoting self ligation, some whom have been hailed for their evidence based approach to orthodontics.

    keep up the thought promoting blog

    Happy New year to all thinking and questioning ‘tooth shufflers’
    Ross

  2. Bob Stoner says:

    Where is the evidence for Damon or Invisalign? Yet, the supply houses sell this to the clinicians and they buy it. What does that say about our profession?

  3. Gordon Strole says:

    Not sure what you mean or what your definition of “the orthodontic fringe” but when is the AAO or EOS going to come out publicly and denounce these treatments and the practitioners who provide this type of treatments?These organizations are feckless and incompetent unless they do but I also know where their monies come from.They stand the chance of becoming outdated and unnecessary otherwise.

  4. This is complex area tugging at our emotions; a bit like religion, [but let’s not get into that discussion]. Unfortunately, for so long the ‘healing arts’ have followed leaders, [gurus?], whose own assertions may be based on little more than feeling or very good marketing. Love them, hate them, use them or not, none of us can deny Damon has played the marketing game to perfection. Have these brackets damaged our patients; I think not. Rather, some introspection into our diagnosis or treatment might reveal the blame. Kevin, thank you so much for your blog; it is a constant reminder to us all to reflect on the scientific foundations of our treatment and underlying ‘philosophies’ in order to better care for our patients.

  5. John Mew says:

    You are right no one knows!

  6. William M. London says:

    Quackery is well defined as: “Promoting health products, services, or practices of questionable safety, effectiveness, or validity for an intended purpose.” [NCAHF, 1986] It doesn’t require intentional misrepresentation. Most quacks in areas outside of orthodontic care are sincere, but mistaken or deluded, believers in the nonsense they promote. The key word in the definition is promoting. Quacks make lots of noise (especially through advertising and publicity) to attract or keep customers, clients, or patient. Use of questionable methods without promotional efforts isn’t quackery. The bottom line is: quacks quack.

  7. Spyros Papageorgiou says:

    Hi Kevin and a happy 2015!

    Congratulations on another very interesting post, which applies (unfortunately) overly-well to orthodontics. I think personally this has to do with treatment providers (and maybe patients) taking orthodontic interventios all too lightly, mainly because we do not deal with life-threatening conditions.

    A couple of thoughts on your concluding remarks:
    1) Wouldn’t it make much more sense to move some of the weight of proof to the persons/companies that sell these products/ideas? Maybe by making the criteria of new products’ approval a little stricter based on preliminary but sound clinical evidence? Why do we have to sort out if existing and already-applied treatments do actually work?
    2) I think both sides should be critical of each other. Of course, we must use all existing evidence (even low-ranking, if it’s the only one we have), personal experience and doctor/patient preferences for clinical decision-making. Critical thinking however can differentiate between little-but-convincing evidence and non-existent evidence. I would prefer to explain to a mother that we have some clinical evidence (though not perfect) for the treatment I am about to do on her child, than no evidence at all.
    3)Maybe it would help, were we to differentiate between “quacks” and “cranks”.
    -The term quack has come to mean any dishonest, ignorant, or incompetent practitioner, regardless of formal training. Quackery can be distinguished from rational therapy in that it does not derive from any coherent or established body of evidence, and it is not subjected to rigorous assessment to establish its value.
    -A crank on the other hand is somewhat different: “Often, scientists working in isolation publish in obscure journals or write books that are published by nonacademic presses. A fascinating subset of the isolated scientist is the crank who may publish internally consistent work without reference to what others have found. […] Criteria for identifying cranks :
    (a) Consider themselves geniuses but regard colleagues as ignorant blockheads
    (b) Consider themselves unjustly persecuted
    (c) Attack the greatest scientists and best established theories
    (d) Tend to write in complex jargon, often of their own invention
    (e) Contribute to journals that they edit
    (f)Publish books privately or with nonacademic publishers

    I think, it is very easy with very little effort to find many instances of quacks and cranks in orthodontics…

    PS: The quack and crank definitions are taken from Chapter 8 – “Quacks, Cranks and Abuses of Logic” from D.E. Brunette’s book “Critical Thinking: Understanding and Evaluating Dental Research, Second Edition”-one of my all-time favorites. I would very easily suggest it to every clinical dentist or researcher!

  8. Kevin O'Brien says:

    Thanks for the great comments that are all very sensible and have made me think a little more. I am due to write an editorial for the AJO-DDO soon and I shall try to include your views.

  9. One of prominent quack nowadays are osteopath and their claim about solving TMJ problem, accelerate tooth movement with manipulation, cure crossbite by retraining body posture, the quack of myotherapy should be include in this list. I can’t count the number of question in my website regarding osteopathy and orthodontic treatment. Therefore, i think you should address that in your AJODO editorial among other things. Best regards.

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