Quo Vadis Orthodontia – Are we in the midst of a perfect storm?
This is a guest post by Dr Mark Wertheimer from South Africa. This is about his feelings about potential issues with professionalism, new treatments and advertising.
Mark is the WFO Council member for South Africa and past president of the South African Society of Orthodontists. He has been in private practice for 21 years.
A perfect storm is “an expression that describes an event where a rare combination of circumstances will aggravate a situation drastically”. However, it is also used to describe “an actual phenomenon where circumstances occur in such a confluence, that they result in an event of unusual magnitude.”
Orthodontics and the perfect storm
You may inquire how this relates to orthodontics. Let us first consider the combination of issues that confront us at present. Simplistically, let us think of it in terms of:
The motive in this case is easy to determine as there is a massive network standing to financially benefit from orthodontic treatment delivery.
The means is through the provision of treatment and includes all in the chain of treatment provision who may benefit.
Opportunity includes the fact that there are patients who desire treatment. It also includes the opportunity provided by a rich media network to discuss all aspects of orthodontics, particularly on social media.
There are many social media groups advertising products and philosophies. Some of these may be useful. For example, those where practitioners present cases seeking advice on how to treat, or showing treatment progress and results.
However, we also have self-proclaimed experts who use social media to promote their philosophies. They frequently use platforms created by themselves or companies that stand to benefit from the philosophies presented. They also use a technique that points out that we should embrace the changing times or fall behind, or even treat patients according to their wishes despite the approach being illogical, possibly detrimental, and possibly bordering on malpractice.
The mainstream literature provides much information on a multitude of pertinent aspects regarding the practice of the specialty. However, the sometimes-inconvenient truths therein are the subject of cognitive dissonance amongst many in our discipline.
In addition, we have treatment modalities promoted by companies via marketing with huge budgets.
The effect of advertising
The primary aim of orthodontic companies is to keep shareholders happy with a healthy bottom line. To sell their products they, of course, advertise. A current advertising approach is to convince practitioners that it is easy to use their product. The target is not only the specialist but the general dental practitioner. Importantly the GDP does does not have the orthodontic knowledge of a specialist, and is may be easily influenced. Various forms of customized setup and aligner therapy are examples of this.
These treatment modalities are also attractive to the public who are interested in orthodontic treatment. They are also attractive to many in the profession since they provide a source of income, sometimes without the expenditure of huge effort or resources.
What is there not to find attractive with this? We have graduates of orthodontic residency programs with huge accumulated debt that they need to service, who are anxiously seeking their slice of the pie. In some instances, key opinion leaders who have their ear and credibility merely because they have loud voices, influence them. Furthermore, the KOLs are given a podium to preach their message from, have a presence on social media or even publish their own orthodontic magazine!
Social media based treatment planning
Social media has provided a platform for communication of treatment approaches. Importantly, diagnosis and treatment planning are often reached by consensus on these platforms. As a result, the final plan is possibly influenced by the forceful nature of the persona who advocates it.
Ponder a recent example of a case posted by a general practitioner wishing to carry out her first case of treatment with the admission that she had never done it before. She asked for fellow members of the Facebook group to help with the treatment plan.
My question is as follows….
“How would you feel as a parent knowing that your child’s treatment plan was hatched on Facebook by people who’d never seen her and examined her and themselves weren’t specialists”?
They were suggesting a treatment approach to the treating practitioner who didn’t know where to start and would be continuing to manage the treatment which she’d never done before and didn’t know where she was going to end up. This is hardly comforting, in my opinion.
Learning from the past?
We went through the years following the Brimm case which led to TMJ being investigated in relation to orthodontics. Then came the effect on facial aesthetics, and now, it’s all about sleep apnea. The question is whether orthodontic treatment, especially that involving extraction, is related to any of these three issues. But, is that the correct question? I believe that the correct question is rather – Is it possible with inappropriate treatment to influence the TMJ, facial aesthetics and sleep apnea? My answer to that would be ……. certainly!
In all three instances, we have had fringe champions promoting an all or nothing argument and throwing out a challenge to everyone to disprove them. Researchers have used considerable resources to discover little of this matters when sound logic could’ve come to the same conclusion. Some have read too far into these conclusions and veered off in the opposite direction…and then, depending on where their personal interests and beliefs fell on the spectrum, we ended up just arguing in circles instead of progressing. Does the real answer not lie in learning as much as possible about the topic, with objective assessment, and individualized treatment based on the patient’s needs and treatment goals. In addition to an evidence based approach that leads us to the ultimate treatment plan?
The plastic “revolution”.
We have been through the era of examining the proposed advantages of self-ligation and more specifically, the creation of bone. Lysle Johnston referred to this as the appliance “speaking the language of the cellular environment”.
Today we have the “Fantastic Plastic Revolution’’. Whilst aligner therapy has its place. The question that needs to be asked is whether the boundaries are being pushed unrealistically, and if so, by whom and for what reason.
Two major methods of creating space to accommodate crowded teeth include expansion and IPR. There is much evidence to suggest that there are limits to expansion and the belief that this may be more stable purely because one is using “Fantastic Magic Plastic” seems somewhat lacking in foundation. We have little long term data on the effects and stability of aligner treatment as well as that of aggressive IPR. What will the future hold? Are we to believe that “Fantastic Magic Plastic” has the ability again to communicate via some “special communication” with the biological environment?
Various media bombard practitioners expounding the advantages of various treatment modalities.
Paradoxically, when “things don’t work out” the practitioners forget their scientific training. They do not query the gurus on why the appliance/philosophy is not working. They simply accept the guru’s message which is to persevere and have faith or you must’ve done something wrong, because it doesn’t suit them to admit the truth.
The perfect storm
In summary, I fear that we have a cascade of events with multiple influences in the direction that drives financial gains. Not only a cascade of events but a combination of influences promoting the approach. Whilst some may consider this to be over dramatic or maybe even melodramatic. I wonder if it lays the foundation to a “perfect storm”?
Where will this leave our specialty? If the research is one day forthcoming that refutes much of this treatment, will orthodontics have been reduced to quackery? If that is the case then all in the profession are likely to be tarred with the same brush. Importantly, the specialty as a whole will be tainted.
Who will have been the architect of this catastrophic event? Will we have given the various detractors ammunition to use against us? Have we been complicit in allowing this to go so far that we now have a runaway train?
Is this a time for introspection by the members of the specialty. Or should we merely march forwards without giving it any thought whatsoever and contemplate the epitaph on the tombstone of orthodontia?