A daydream of no bias in orthodontics?
This guest post is by Rob Kazmierski; Rob has been a private practicing orthodontist in Moorestown, New Jersey, for 33 years. He is on the Journal of Clinical Orthodontics, editorial board and is a frequent contributor to online discussions on orthodontic social media. I spotted a recent good post from Rob and asked him if I could publish it on my blog. It is on an “orthodontic nirvana” of no bias.
Introduction
This is a thought experiment that I expect is a result of both daydreaming and having read Vishnu Raj’s Facebook post on anterior anchorage. If this spikes your interest, please chime in with ideas that I should have thought of or counter-examples to what I have said.
The question:
What would happen, and how would we look at our speciality differently, if we went without hearing biased information in meetings, reading it in journals, and being exposed to it in online groups such as Facebook?
How would our treatment change or not change if every presenter at a convention had no financial bias if every article we read was by authors without bias, and if the posts we read were filtered to come only from those without bias? Likewise, the Facebook groups we visited were only those in which the administrators were without bias?
I will discuss this under several main headings.
Lecturers
We would hear more of the lectures we used to cherish. There would be near exclusively information intended to aid our understanding of orthodontics. In addition to some genuinely good ways to improve our treatment, as opposed to lectures seeking to influence us to buy a product or service.
Let’s consider the areas of the aforementioned maximum anterior anchorage and the more controversial aspects of clear aligners.
When we consider anchorage, we can all learn a lot and solve many problems by increasing our mastery of the basics of biomechanics. We can then learn to apply it in different ways instead of placing TADS everywhere.
We would also hear a more honest assessment of clear aligner treatment (CAT). For example, what are the actual results when CAT is used to attempt certain tooth movements? Furthermore, we would learn when to use hybrid treatment if we want a particular result with CAT. Finally, we would hear of situations where we can forget about it without using full fixed appliances
From those extensively using CAT who are not corporate affiliated, I expect that we might see a more honest assessment of what can be done by those pushing the envelope in this regard.
Ideally, they might even show some failures to share the resulting punishment when that envelope is pushed too far. I do not believe that we would see anyone claiming that 100% of our patients can or should be treated with CAT.
Journal articles:
Sadly, I expect that a large proportion of the articles in non-peer-reviewed journals will disappear. Some might remain. Those pushing the superiority of a specific brace or arch form or pushing that 100% CAT practice are likely absent.
Facebook groups and posts:
I expect that many of the posts will change. Also, given that administrators could not be biased, certain Facebook groups would not be visited. On the other hand, other non-biased groups currently in existence would experience even more growth. I will defer to Kevin O’Brien’s yearly Facebook review to consider which groups fall into which category.
The necessary exception:
We would have to create one exception to this rule of no bias quickly. There would be an exception for those who have invented a product or system, are within the first few years of this product’s development, and the inventors themselves are the presenters. Invention is needed for innovation, and we want innovation. However, it seems near impossible to be the inventor of a new product or service and not be biased toward it. At a profound level, all inventors are biased. It is their baby they are discussing.
However, that bias is not necessarily bad as it is part of the spark for an invention, giving us the innovation we need. Suppressing this bias would also be stifling innovation. So, giving an exception to these inventors and innovators would still allow us to hear about interesting new products and services such as Isoglide, Grin, etc.
Large corporate interests do not need this exemption for innovation to occur, as they are rarely the source of innovation. For example, while corporations developed CAT treatment, their innovation in this field is now supplanted by unbiased independent research. As a result, for this thought experiment, this limited exception for new inventors and startups would be all that is needed to help innovation.
Final thoughts
I do welcome the input and presentations by inventors. We all appreciate their creativity and can account for any inherent bias that entails. However, that group aside, I would enjoy attending a convention, reading a journal, and interacting in some FB groups more if the bias was removed. It is also sad that the voices of many contributing to our profession selflessly have to compete with the cacophony of noise from those whose sole motivation is corporate interests and their financial ones. I sincerely thank those who still strive to help our patients and profession. They are the ones that make our meetings worth attending, our journals worth reading, our blogs worth following, and our online groups worth interacting in.
Emeritus Professor of Orthodontics, University of Manchester, UK.
That was really well written. Thank for expressing what many think.
Dr Kazmierski’s article is welcome and should make us ambitious to improve standards in research in general as well as reduce bias.
A recent proposal could address some of these issues.
First, a research proposal should be submitted to a journal for provisional agreement to publish.
Second, the proposal is subjected to peer-review and appropriate experts asked to comment on the research design and make recommendations on how to reduce bias and improve objectivity before any research is actually done.
Third, the research is undertaken and the final report submitted to the journal, to verify that the advice given at the planning stage had been incorporated.
Finally, after publication readers would have the reassurance that before even the very first test tube was taken out of the cupboard, the research proposal received careful and expert advice from people who were not invested in the actual research.
This idea might not be the last word, but I think it might take us to a better place.
This article is right on with what is going on in our profession at this time. Unfortunately, those speakers who are on the podium for a corporate entity do have an agenda for the corporation or they would not be there in the first place. These are the booth lectures at our meetings that are not vetted by the meeting organizers and really like the street peddlers of old that sold products on the corner. It is true that our profession is an ART and SCIENCE and sometimes that gets confusing. However, there is basic biological principles and biomechanical principles that are the basis of modern orthodontic therapy. These tenants need to be taught in universities, so that the future of our profession has practitioners that have a good understanding of the principles and can evaluate appliances and outcomes related to a solid core of principles.
Thank you Sir for posting this blog from Dr Rob Kazmierski.
Taking the bias out of our decision making is the ever- present challenge to all practitioners of ‘all’ professions. Being only human, we need to tackle this bias every minute, every hour and every day of our waking lives.
The more we work on removing bias, the better we get at it, it’s like meditation. The process can be therapeutic and soul enriching for those who enjoy this. For those who find it difficult, it is still worth persevering with trying to argue with ourselves and removing bias from our clinical decision making everyday. We may not succeed at first but every attempt makes the next one much easier. Makes it all very enjoyable.
Thank you.
Yours sincerely,
Karun Sagar
Great presentation; however, nobody dies, everything “works,” nothing matters. Under these circumstances, there are no natural economic forces that would place a premium on a lack of bias. Nice try….
I, for one, don’t see ANY great creative thinking coming out of academia. Virtually all of the innovations in orthodontics has come from practitioners trying to solve clinical problems. Not all of their ideas are good or stand up to research scrutiny…that is for sure! Many are garbage but survive only because orthodontists financially support them else they wouldn’t survive. But it is unfair to criticize many ideas as being antidotal when there is no capacity for large sample research in a private clinical practice environment focused on helping patients more than producing research data. Besides colored alastics, self-ligating brackets, and TADS there have been very few innovations in orthodontics in the last 60 years and none from academia. No their job is to produce nonsense research and criticize.
So until academia starts to make any contributions, unbiased orthodontics will continue to be a daydream..
Agree Dr Nicassio. As mentioned in previous blogs, those who choose to believe that academics are immune to bias either have not stepped into a grad clinic for decades or wear rose colored glasses. Enviable. Take off the glasses and re-read this blog and tell me there is no bias in appliance choice.
“We would hear more of the lectures we used to cherish” I cherished attending lectures by Burstone, Melsen, Ricketts, Andrews and many more. All had / have financial interest of some sort – a bracket “system”, “prescription”, text book, family with interest in an appliance we cannot educate ourselves and apply the skill required to dissect and analyze the validity of information provided, then we should not graduate with an orthodontic masters degree. Critical evaluation of literature and lectures is a competency that should be well satisfied before earning the title “orthodontist”. Letting go of this responsibility and living the “daydream” above is a scary notion. Who determines sanctioned information and non/sanctioned? (My vote is for Dr Johnston:) We are not children who require our home sterilized and babyproofed.
“The necessary exception:
“We would have to create one exception to this rule of no bias quickly. There would be an exception for those who have invented a product or system, are within the first few years of this product’s development Do you know how much capitol goes into developing any significant product in the first few years? If it were not for VC of Sand Hill road, and someone in our specialty with vision, we would be decades behind in digital orthodontics – and if we followed the daydream, we would not have reached it. There was no digital orthodontics before “you know who?”.
” …and the inventors themselves are the presenters.” Yeah, great idea. If only! Look what happened to Professor Robert Boyd. Way before he had a financial interest in an appliance that he helped develop and initiated the feasibility study, he was decimated by peers who should have had the collegiality and intelligence to question and learn, rather than cover their eyes and ears to innovation and publicly and cruelly attack something we all knew / know very little about. Shame. Inventors cannot present their inventions and innovations if they are not orthodontically educated. They have an idea that then needs to be placed in the hands of our specialty for evaluation.Who better than an orthodontic chair? … So, the financial interest came via the university and study grant supported by the company? There was / is bias – in every academic research project.
“Large corporate interests do not need this exemption for innovation to occur, as they are rarely the source of innovation” Hmmmmm – the most significant innovation in orthodontics in a century would not have been possible if a large corporation were not behind it. Without hundreds of millions of dollars, innovation particularly where a new technology needs to be invented and continually improved. Who do you think pioneered computerization of tooth movement software? Who invented CPA? Who innovates scanner technology? What was the first software to integrate roots from conebeam to crowns and face? Just because they didnt go to market first, doesnt mean they didnt have the technology. If only Dr Baumrind could be with us. Sean Carlson knows. No, the most significant innovation in orthodontics in the last century and possibly ever (ok maybe Buonocore, Angle, Andrews), arose from an idea from outside our closeted specialty and could never have changed the face of our careers and those coming after, if it did not become “a large corporation”. You may not love the changes, but you gladly sit and glean off the surface: a new patient large pool of individuals who would never seek treatment with fixed appliances, technological advances in digitalization that were so successful competition is rife with aligners and digital fixed appliance software- change that allow us to now choose tooth moving software for teaching, diagnosis, treatment planning, programming, scanner technologies, virtual monitoring and treatment evaluation tools to name a few.
Yes there is “bad” with the “good” – in everything – but we can choose. Nothing stands still. To have a stagnant specialty; for a moment remove all of these “firsts”, inventions and innovations, software, scanners, new patient pools – do you want to be back there?
Personally I don’t believe anyone should be told who is trustworthy and who is not, what to believe and what is not credible. That simply leads to corruption, class system. Democracy has its flaws but what is the alternative? I do enjoy daydreams, but this would quickly turn into a nightmare.
**VV provides lectures for Align Technology. VV has never owned shares in AT
Agree with Dr. Kaz- as an ortho who was also trained in BioMechanics a UConn, It shocks me how often docs resort to TADs when the are absolutely NOT needed! I’ve used a few in my career, but I’ve been pleasantly surprised how a solid foundation in biomechanics and treatment-planning, can create incredible, surgical free outcomes!
Thanks for your post Dr. O’Brien.
I was at the AAO congress in Chicago and what we saw was an avalanche of information all based on studies sponsored by companies, which makes us suspicious of the veracity of the information. Magical treatments seem to be what everyone is looking for but only a few have the discernment to assess the veracity of the information. with time many sand castles will fall