A message to the graduating orthodontic residents of 2021
This week’s post is an excellent discussion by Rob Kazmierski, who has been a specialist orthodontist in New Jersey, USA, for 32 years. He provides relevant advice to new orthodontic graduates on some of the current pitfalls in our speciality. I think that he makes very valid points in his message.
Congratulations! You are embarking on what can be one of the most rewarding careers in which someone can engage.
First, let’s cover the tough stuff. You are also starting out in one of the most challenging and turbulent times in the history of our profession. As a result, there is the desire to fully warn you of some of the perhaps unanticipated challenges that you definitely will face. Towards that end, I would like to share three old and new challenges that I wish that I knew 32 years ago.
Following the Gurus
The first challenge is that in orthodontics, there is no safety in numbers. Occasionally, it seems like every orthodontist you encounter, every orthodontist who is in a particular Facebook group, or every orthodontist who is at a specific meeting does what a Guru teaches. They appear to subscribe to a specific philosophy or uses a particular appliance. This does not make it safe to use that technique, philosophy, or appliance. This problem is nothing new in orthodontics. Orthodontists have followed Gurus right over the cliff, to the detriment of their patients, since the very beginning of modern orthodontics.
The founder of modern orthodontics, Edward Angle, thought it was malpractice to extract teeth under any circumstances. We can all envision possibilities where that would be harmful. At the other extreme, far too many overzealous followers of Charles Tweed thought it was correct to extract teeth merely to achieve a certain measured number on a cephalometric radiograph. You can easily imagine the harm that can come from this philosophy.
The point here is not whether extraction, non-extraction, Angle, or Tweed philosophies are correct. To the bane of our profession, the point is that the tendency to follow Gurus blindly, a philosophy, or what everyone seems to be doing has not gone away. The fact that some Guru is promoting it, everyone else is doing it, or some company sells it will not protect us. Importantly, when a Guru, philosophy, or company’s recommendation goes wrong, it will not be the Guru, group, or appliance company standing there by our side for our defence. Unfortunately, we are alone with our decision and its consequences. Currently, orthodontists are doing things merely because a Guru, group or company advocates it. Disappointingly, this is showing no signs of abating.
Doing the wrong thing by a patient is a very individual and personal matter. We are expected to, and should, do the very best for that patient. Our decisions must be based upon a thorough consideration of our education, experience, and interpretation of research. There is no justification in the Guru says this, the group does this, or the appliance manufacture says this, and there never will be. We owe the patient the best of our complete personal and unique consideration.
On line Orthodontic “education”.
The second challenge is that online orthodontic education currently represents the very best and worst of our profession. It can be the very best as information can be quickly and sometimes near-instantly obtained. I have benefitted in any number of ways from online education and interaction. There are excellent orthodontic online and Facebook leaders such as Neal Kravitz and Mo Almuzian, to name two. They and many others give selflessly and seemingly tirelessly to better our profession.
However, IMO, there are also wolves in disguise amongst the sheep. It can sometimes be tough to tell the best from the worst. This issue did not exist to this extent in prior generations. This problem is one of your unique challenges.
In days gone by, for any lecturer to be considered seriously and have their lectures attended, they would need the backing of an accredited orthodontic department of a university. If they were given time and published enough publications, they could eventually earn themselves names that entitled them to complete respect of their own accord. Bill Proffit, Vince Kokich, Charlie Burstone, Lysle Johnston, and many other very respected names in orthodontics were birthed from this system.
Unfortunately, the filter of an accredited orthodontic program of a university has now ceased to marginalize the unworthy in online and “Facebook” continuing education. Many whose only talents are timing, charisma, and the ability to attract followers to their Facebook groups have succeeded in profiting from promoting techniques, philosophies, and appliances that at best do not help patients and sometimes may hurt them. Importantly, if the individual members consistently help one another, and 19 of 20 messages from the administrators are of the nature “let’s help and support one another”, wouldn’t we all think that we are in a helpful and great group?
However, it is a sufficient warning that we are not in a healthy group if we see that one in 20 messages from a Facebook group administrator asks us to pay to take a particular course that is unethical. For example, some have supported courses that violate the AAO white paper’s recommendations on sleep-disordered breathing (SDB) or to use 3D radiographs for a purpose they are not diagnostic for, or using a particular appliance that research does not support. In my opinion (IMO), we are being asked to swallow a poison pill.
One of the benefits of being an orthodontist is that, when appropriately practised, we neither save nor cost people their lives. The rules on SDB are pretty straightforward. We should refer patients with known or suspected SDB to those most qualified to diagnose and treat them, physician’s board-certified in sleep medicine or groups who contain a physician with this certification. Doing otherwise needlessly places the patient’s life at risk. Unfortunately, the charlatans are willing to take the risk with others’ lives for their profit.
It can be hard to tell the bad Facebook groups and administrators from the good. Some have even created faux universities. They use their names to provide the illusion of accredited orthodontic program backing. To make it even more complicated, the charlatans themselves are all charismatic. The noticeable jerks get filtered out quickly. Jim Jones was very liked by his congregation and had a beneficial and supportive message. It was only once that he asked them to drink Kool-Aid. My advice, if you see an administrator doing these things, booting anyone from the group who disagrees with their promotions, or attacking anyone who disagrees with them while they claim to be attacked, be aware of where you are. Someone asking you to do something unethical just once is enough warning. This pearl is, don’t drink the Kool-Aid.
The companies and the Key Opinion Leaders
Third, and then I will leave you alone. Starting about 20 years ago, it became common in orthodontics for corporations to make a claim that sounded logical, had no basis in research, had compelling key opinion leaders (KOLs) backing it, and then make hundreds of millions of dollars off of this claim. Many, if not most, of the products they sold in that way have since been proved ineffectual and sometimes harmful. Other companies have now learned from the prior companies’ success at this technique. Unfortunately, it has become commonplace for claims to be made without any research justification. They will make money, regardless, and if, 20 years from now, the product has been proven ineffectual or harmful, they will argue about the research while they start promoting the next greatest thing. The use of charismatic KOLs is commonplace here, and big money changes hands, both directly and indirectly.
This situation is not normal, and orthodontic products should not be brought to market in orthodontics in this way. This pearl is to question everything that a company tells you and question the information from KOLs of that company, no matter how likeable they are. That being said, not all companies and KOLs are bad. There are an incredible number of honest and reputable companies and KOLs out there. We all have much that we can learn from them. We need to be very active in separating the wheat from the chafe.
In anticipation of specific arguments against this, requiring research before making claims does not stifle innovation. There are many new orthodontic products from reputable companies developed and brought to market without making false and unproven claims. We all know what they hope these products will do. It is just proper to wait until research proves that they do it before a company or KOL claims that they do it.
Despite the difficulties listed above, there is much in your favour. Most of our fellow practitioners strive very hard to provide the best ethical treatment for our patients, aid our fellow practitioners, and positively influence our profession. It is hard to attend an AAO and not feel collegiality. With this collegiality, many of us who have been in the profession longer wish you who are just starting to be fully protected with as much information that we can provide to you.
I hope that my message is useful to you. My sincerest best wishes to you, the future of our wonderful profession!
Emeritus Professor of Orthodontics, University of Manchester, UK.
Have your say!
This is an excellent discussion. My program director, Charlie Smith use to tell us that he would encounter docs who professed to be a Tweed man or a crozat guy, he felt that we should be first and foremost orthodontists, to know what we are doing and why. If it doesn’t make sense, be cautious and for goodness sake, think for yourself.
you said it all. congratulations.
Vital points, well narrated.
Excellent, ideally its reading would be universally necessary in all graduate programs
So true and beautifully presented.
This information applies to all branches of dentistry, as well as medicine.
Thanks for posting
Colin RIchman DMD
I agree, Dr Kazmierski:
Singh GD. The guru phenomenon. Br. Dent. J. 176: 296, 1994.
Doi or link reference please
Kevin: excellent piece!!! I was trained 40 years ago (University of Michigan), and it makes me very sad to see the decline our specialty has had over the years in many aspects. We were taught to use our brains, to think, to challenge everything we were told or was published, and to discern truth and real science from opinion or science fiction. Now, sadly, gurus appear as wild mushrooms, appliance (money) driven advises have clouded the judgement of many, and, sometimes I seems to me that, for blindly following philosophies or techniques, we are not serving the patients best interest, but making happy gurus. Orthodontics is a very complex and challenging specialty, and oversimplifying diagnosis or treatment planning, following flawed advise, simply doesn’t cut it. For the residents and young orthodontists: when we graduate, we do so at a point where, hopefully, we may be the least dangerous to society. At that point, our brains are filled with islands of information, and no bridges. It will take about 6 years to be able to connect this islands, and make sense of all we learned during our training. Now a days, and with the advent of information technology, the danger is to be exposed to the wrong gurus, especially when we graduate, as we are seeking for answers that only time, practice and sound continuing education can provide.
Raúl Morales, DDS MSc
Great article! We should also include generalizations in there! Yes Dr. Angle believed in maintaining all the teeth, but he did remove teeth on occasion. Also Dr. Tweed’s work was motivated by poor facial results post orthodontic treatment. He never advocated treating to a number per se. He used cephalometric’s as a tool to achieve facial balance and harmony.
Thank you for your sincere and inspiring words.
Well said Kaz!
Wonderful discussion! Excellent comments about sleep Disordered Breathing and implied OSA appliance use.
You might also include warnings concerning the current high cost of an orthodontic education and its impact associated with financial pressure on graduates. Making the exhorbitant educational monthly loan payment may have more impact on ethical treatment decisions and following the herd over the cliff than we would like to admit! G-d help us!
Hey Bruce well said..hope you are well and keeping fit.I loved the broad based education I received at U of L and thanks for your in put ..Stephen Herriott Australia
Following a guru or a philosophy cannot be entirely avoidable, there are some who seek above all to respect the biology of the patient, achieve health and well-being over cosmetic attributes, those are the ones we should listen to and follow, there is always good and bad leaders, this is a good way to tell them apart.
Bad leaders will usually only talk about devices, techniques and mechanics and nothing about how the organic response to all that is, nor do they really understand if their Tx is for the good or bad of the patient.
At the same time, following evidence is not a guarantee of executing an ethical and responsible profession, it seems that the reality is much more complex, currently based on this, the use of articulators, cephalometry, the use of tomography as means of Dx, etc, etc., are reviled sometimes, or more than one would expect, the evidence instead of bringing more light to Dentistry causes more controversy and darkness.
The name of the game is “who cites the most biography” (evidence), this game is not new in our profession and has led to many divisions, in this game we can very often find evidence that is opposed to another.
There are already voices of alarm that point out that the evidence can be just a dance of numbers without context that do not contribute anything and cause more confusion, this issue has to cut a lot of fabric for a while.
The best screen for an Orthodontist and that can separate the good from the bad is to always read, always learn from everything, always listen to everyone with an open but critical mind at the same time, one must know all the systems, techniques and philosophies that are to be able to find the right path, learning is a long road, it never ends.
Dear Professor O’Brien
Another very thought-provoking offer from you….thanks.
To your mentioning, ‘One of the benefits of being an orthodontist is that, when appropriately practised, we neither save nor cost people their lives…..’; I’d like to point out a middle ground between ‘saving a person’s life’ and/or ‘causing a person’s death’, and that is, improving their Quality of Life(QOL). There are myriad published articles, by McNamara and others, within the Orthodontic canon that attest to improved QOL, often attributable to RME (references upon request). Furthermore Prof. O’Brien, as maxillary transverse deficiency (MTD) and Class II mandibular retrognathia can both be frequent malocclusion phenotypes associated with SDB co-morbidity, recently published papers from the NIH (‘Study links sleep apnea in children to increased risk of high blood pressure in teen years’-https://www.nhlbi.nih.gov/news/2021/study-links-sleep-apnea-children-increased-risk-high-blood-pressure-teen-years) and JAMA-Cardiology (‘Association of Pediatric Obstructive Sleep Apnea With Elevated Blood Pressure and Orthostatic Hypertension in Adolescence-https://pubmed.ncbi.nlm.nih.gov/34160576/), maybe it’s time to re-consider when might be the best time to intervene for at least MTD and Class II retrognathia? As for what you accurately stated about whom should appropriately diagnose suspected SDB, of course sir, qualified physicians should be the only individuals actually diagnosing SDB, and orthodontists should stick to their scope of practice by appropriately diagnosing malocclusions….whether or not associated with SDB….who does not know that sir?
This may seem obvious to you. However, unfortunately, there are too many that do not realize that orthodontists should not be the patients PCP (primary care provider, or only provider, or gatekeeper) for SDB. There are also too many making money off of this unethical practice.
That is not to say that an orthodontist cannot participate in the care of SDB patients. To do it ethically, it should be done as part of a group or team that includes a physician board certified in sleep medicine. Treatment as part of that team is where consideration of your thoughts on the benefits of orthodontic intervention should be considered.
Thank you for your honest advice! Unfortunately, I believe we have many of these “wolves” in our profession and even as lecturers at the AAO meetings! Shouldn’t the AAO be more careful about who they invite as guess lecturers??
Great piece from Robert as always
Well done Dr Kazmierski and TY for presenting it Dr O’Brien.
Follow the golden rule, don’t do anything that wouldn’t make your Mom proud and think first, cut second.
This was an excellent and timely article. I was pleased to read it.
…and be sure to wear sunscreen.
Over the 32 years of practice, I’m curious as to what he learned and implemented that was new to him since he graduated and what orthodoxies he’d been taught that he had to reject over that time.
To answer your question, I think that I will use an analogy to the book “Every thing that I need to know I learned in Kindergarten”. That author points out that all the secrets of life are taught then.
Be kind to others.
Don’t push or hit.
Wait your turn.
Milk and cookies are good for you. Etc.
That is not to say that education after kindergarten is unnecessary. Just that the basic foundation of being a good human is taught there.
To carry the analogy over, at some level, all the basic principles I needed to practice properly, I learned in residency. This is not to say that education after residency is not necessary. Just that the basic principles of how to treat patients, critically read research, and adjust my treatment I learned there.
The rest has been 32 years of constantly trying to implement and improve my execution of these basic principles.
I hope that is a good answer. I have been blessed with many fine teachers and mentors.
Alway impressed with Robert opinion
Thanks for sharing your honest opinion
Some very fortunate graduates.
Thank you for posting this wonderfully personal and relevant essay Kevin.
Just a niggle in my mind regarding the following: “There are many new orthodontic products from reputable companies developed and brought to market without making false and unproven claims. We all know what they hope these products will do. It is just proper to wait until research proves that they do it before a company or KOL claims that they do it.”
Can we finally please define as a profession, what this research / evidence needs to look like?
Research is not always research; a publication is not always research, is not a text book, is not research….- as your blog amplifies.
It cant be that difficult, can it? Study design, Sample numbers, Confounding variables, Bias, (appearing in ref journal likely doesn’t cut it anymore), passing thesis Defence – can we prepare some protocol by putting our minds together with the aim of providing 21st century social media relevant check list that passes muster?
Thank you for this wonderful post highlighting the vital points which definitely are a guide to all the graduating residents of 2021 including myself. I can surely say I’m lucky to be reading this and being addressed to us residents from stalwarts of our field.
Thank you for the thought-invoking article. I feel there are other challenges which graduating orthodontist might face in the future:
1) Demise of the bracket
2) Mail order aligners
3) Environmental impact of aligners
4) More GDPs performing orthodontic treatment esp with aligners
5) The increasingly demanding patient
We are living in exciting times with improvement in technology such as the availability of NiTi wires, SLB, TADs, aligners, etc but these have also provided challenges for the future Orthodontists.
I agree, I think that you will face many challenges that I did not list. I view those that I did list some of the big picture ones that will effect your overall treatment philosophy. If a ship is headed in the wrong direction, there is little importance to the smaller turns it may take along the way. Heading your ship in the right direction would be the first step.
To your other points:
#1. The bracket will not disappear in either of our life times. There are many things that we now know aligners do not do or do not do efficiently. Those telling you differently as almost always being paid to do so.
#2 Mail order aligners. What is best for the patient should be our primary concern, not what is best for us. DIY currently hurts patients. It is a disgrace that the dental boards have not shut them down for practicing without a license. Either way, they will not hurt our jobs. These patients will eventually wind up in our offices. Harmed or just not helped.
#3 Yes, that needs a solution. Nobody has figured it out yet.
#4 This is nothing new. The better GPs are already getting out of it as they are “better”. The unethical GPs don’t care. These are the same practices that you don’t want to have a filling in either. If all you need is a GPs education to do orthodontics, there is no reason to be an orthodontist. We all know that, that is not the case.
#5 Nobody said this was going to be easy. Well an old orthodontist once told me before I went into it. He later admitted that he lied.
#6 SLB is a lifestyle choice, it is not a superior bracket in any way over less expensive twins. It is the orthodontist that moves the teeth not the bracket. The only “magic” we will ever see in orthodontics is the magic that we ourselves provide and the magic that god gave us by allowing teeth to be moved.
Great message! May I translate and use this message in our society’s FB page and Whats App group?
Robert, my congratulations for your analysis of state of affairs in our profession. Unfortunately, it has been the same over the last 50 years. Where do we go from here ?
The most important message to any profession is: Use the critical thinking in everything you do. There might be some philosophies, schools, ideas, findings but at the end its a matter of proper application of knowledge and not blind following of someone idea or copy-paste approach.
Great to see there are some good guys left