Am I being too critical?
One of the goals of my blog is to raise questions about all aspects of orthodontic treatment. To achieve this, I have covered various topics, including growth modification, the effects of orthodontics on breathing, methods of dental expansion, the ongoing pursuit of speeding up tooth movement, and the claims made by various companies.
In these posts, I acknowledge that I have occasionally been quite blunt. This is partly due to my writing style for the blog and I have felt it necessary to express my points firmly.
I also understand that some readers feel I am overly critical. I hope to address these issues in this post.
Let’s look at Evidence.
When evaluating research evidence, it is essential to recognise that practising evidence-based care involves three key elements: research evidence, clinical expertise, and patient choice. The influence of these elements on our practice can vary based on their availability.
If we rely solely on evidence from a retrospective study, we must acknowledge that such information carries a degree of uncertainty about the treatment’s effectiveness. Thus, we should avoid making bold or unfounded claims from retrospective studies.
Absence of evidence
There is also confusion about “absence of evidence.” This issue was discussed well in a paper by Altman, where he states
“Randomised controlled clinical trials that do not show a significant difference between the treatments being compared are often called ‘negative.” This term wrongly implies that the study has shown no difference, whereas usually, all that has been shown is an absence of evidence of a difference”.
My interpretation is that when evidence is absent, it is because we have yet to discover an effect or, alternatively, it really is “absent”. Importantly, when a study demonstrates a lack of evidence, we must consider the ethics of promoting treatment and obtaining patient consent without supporting evidence for our claims. I suggest that this practice is unethical.
Furthermore, when there is absence of evidence, we can only say that “our new treatment may have some effect, but we are not sure whether it does.” Of course, this is not as convincing as the harder sell approach of stating “our new appliance reduces treatment time by 40% and and it will cost you $1000”!
The randomised trial
There is also a perception that I only consider evidence from randomised trials and systematic reviews. This perspective is echoed by those who suggest that a Cochrane review is unnecessary to recognise obvious truths, like the sky being blue or parachutes’ effectiveness. While it’s true that one doesn’t need a review to acknowledge these clear facts, we do need research to guide us when there is uncertainty about the effects of a treatment. Importantly, we have yet to have 100% certainty about most orthodontic treatments. As a result, we should operate to the highest standard of evidence possible and not cling to information from flawed investigations.
The sceptic
I have reflected extensively on this topic and have always been a proponent of innovation. I was involved in the early trials of visible light-cured indirect bonding, temporary anchorage devices, fixed twin blocks, and innovative designs of functional appliances and treatment timing.
Furthermore, I have provided guidance on the development of innovative treatments. My advice includes conducting retrospective studies to find potential treatment effects. We can then test these findings in randomised controlled trials (RCTs). If conducting such studies isn’t possible within your timeframe, it’s essential to avoid making misleading claims to practitioners and patients.
What do I think?
To summarise, I am not inherently sceptical or opposed to innovation. Orthodontics is a great speciality that is characterised by innovation and discovery. Yet, I do oppose the spinning and exaggeration of low-quality information that misleads patients.
The history of orthodontics is filled with examples of this issue, like the treatment of temporomandibular disorders with orthodontics, the practice of articulating all patients, the use of self-ligating brackets, claims of speeding up treatment with vibrations or localised trauma, and the introduction of fancy appliances.
I want to finish by quoting Jimi Hendrix.
“And so castles made of sand. Fall in the sea, eventually”.
Only time will tell us what happens to the current orthodontic “castles”.
Emeritus Professor of Orthodontics, University of Manchester, UK.
For the salesperson:
Too critical = anyone who who properly evaluates claims instead of accepting something because the nice salesperson said it is so, it is new, or everyone else accepts it.
Thank you for being properly skeptical of new claims, holding all new claims to the appropriate scientific standard, and sharing what proper procedures should be followed before claims can ethically be made.
Perfectly stated
Dear Mr O’Brien
Your blog comes to me as a welcome and refreshing piece of information in a quagmire of orthodontic BS. Unfortunately manufactures often promote their products and techniques in very well thought out ways to expedite sales which doesn’t mean at all that that product or technique is the right one for the job. Specialists with a tertiary education are supposed to be able to objectively assess whether something is of value or is just sugar-coated candy. Unfortunately, it is not always so. Please continue to be critical. I would rather read a criticism of a product or technique from someone like you than the virtues of a product or technique extolled by the sales department of an orthodontic manufacturer. Let’s look for the truth. There’s too much nonsense in this world already. Thank you for your immeasurable contributions to orthodontics
Tell it how it is Kev👍
KEEP UP THE GREAT WORK!!!!
Kevin, I have found you to be blunt, but right on target. People get their feelings hurt, including me. I remember well the first paper I ever put in for publication with the AJODO, one of the reviewers came back and ripped me pretty good and the other one was reasonably kind. I wasn’t too far out of my departure from Chapel Hill, so naturally I called Dr. Proffit to whine about how unfair I thought it was. He listened and then gave me a good lashing on the fact that “That’s the way it works. You want everything challenged because what we are looking for is THE TRUTH. You expect that everything in medicine should reach the same standard of skepticism. Dr. Proffit advised me to get over it and asked me the question as to whether I thought the criticism was fair. I replied that I felt that the reviewers were in error, so he advised me to issue a rebuttal. The editor of the AJODO at that time was Dr. Tom Graber, and he picked up the phone, called me, and said that my rebuttal was better than the original paper and could he publish both? So, the point is that the back-and-forth debate is an important part of the scientific process and is of immense value in navigating to as close to the truth as we can get. Of course, Dr. Graber did not publish both, but it was his way of reassuring me that this is a process. I find your site to be of great value and encourage you to keep up with the bluntness.
The role of critical appraisal is important within orthodontics, and Kevin you champion this necessary role.
Although our opinions may differ on occasion, i would like to encourage us all to support efforts in understanding and revealing the truth, sometimes uncomfortable, and yes can reveal we have been doing ‘it wrong’, it is ultimately objective science which we should engage with to service our patients the best way possible.
A quote from Lysle Johnston ” It isn’t unprofessional to question a person’s science. It’s not uncollegial to demand proof. And, it’s not impolite to point out glaring conflicts of interest”
Thank you Kevin for another year
No.
Don’t change, Prof! We love it as it is. An honest, intelligent, comprehensive appraisal of all that is presented to you!! Practically perfect in every way!
The nature of the scientific process is a healthy degree of skepticism without cynicism. However, people (including referees, peer-reviewers and journal editors) are emotional by nature and this can cause conflict in the dispassionate assessment/interpretation of data. Add to that issues like selective reporting, misinterpretation, doctoring results, plagiarism, and fake news and you (Kevin) come across as well-balanced as could reasonably be expected – so no need to be inappropriately defensive.
An excellent post! Critical evaluation is essential otherwise orthodontists just become sellers of the “latest” fads!! Keep up the good work. Have a Happy Christmas and New Year Kevin.
Dear Professor O’Brien,
I’d like to extend to you a complement I once received. “You are an SOB, but you are our kind of SOB”.
Keep blogging the way you have. It is food for our thought.
The word “blunt” has a slightly negative connotation and is probably used mostly by people who’s opinion is not supported by the data you discuss, so don’t give it to much weight. I would describe your style as “polite but firmly anchored in truth, in a very British sort of way”. I think it is just what the profession needs. Keep it up.