Can good orthodontic evidence get us back on track?
I have just returned from the European Orthodontic Society Conference in Dublin. This was a great meeting. There was a strong mix of well-known speakers delivering keynote presentations. In addition, many younger orthodontists presented short papers on their work. Importantly, most presentations were grounded in high-quality evidence and research. This was refreshing and has encouraged me to be more optimistic about the future of evidence-based orthodontics.
Should we practice evidence-based orthodontics?
The easy answer here is yes! It goes without saying that we should use the highest level of expertise when discussing treatment with our patients. Aside from the obvious issues with informed consent, we should not charge additional fees for unproven treatments. If we do, we are entering the realms of “quackery”, and it is unethical.
Nevertheless, we are all aware that science does not underpin everything we do. Importantly, many treatments are based on years of clinical experience. For example, clinical experience suggests that the most severe cases of crowding should be treated with extractions.
Looking back?
At this point, I feel it is useful to look back over the development of evidence-based orthodontics. We, as a speciality when compared to other health care fields, “discovered” randomised trials rather late. This may have occurred because we had stores of study models and radiographs that we could analyse using retrospective methods to obtain results quickly and cheaply. It was not until the mid-1980s that we realised these methods were biased and that trials were necessary in some areas of orthodontics.
At that time, I placed great emphasis in writing and presentations that promoted the value of trials. Looking back, I think I failed to consider that evidence-based care is grounded in a combination of research evidence, patient opinion, and clinical knowledge and expertise.
This does not mean that these three components are equal. The extent to which each component influences a final clinical decision depends on its relative weight. For example, if good scientific evidence is available, it should outweigh clinical experience. In fact, we are not practising ethically if we do not explain to our patients whether high-level research findings on our treatments are not available.
So where are we now?
Over the past few years, I have been depressed about the direction we were going. This was because we were subject to multiple waves of orthodontic quackery, underpinned by low-level evidence disseminated via social media and low-quality “journals”. In addition, recent conferences seemed to be dominated by “show and tell” lectures based on case reports.
In retrospect, I wonder whether I was too concerned about this situation. For example, while I accept that the current debate about breathing and orthodontics is getting out of hand, I thought it was incredibly reassuring to see Dr Ben Pliska give a great lecture on “OSA and orthodontics: Can common sense save us from ourselves”? If we combine this approach with the recent AAO White Paper, perhaps we have nothing to worry about, and this current wave will disappear in a sea of sense. Or am I being strangely optimistic?
A word of caution?
Nevertheless, I am aware that I may need to be cautious and not let myself be carried away by a single excellent conference. Disappointingly, I have logged on to social media this morning to see that the orthodontic fringe are still posting extreme claims and misinterpreting the literature to suit their aims.
I hope that the other conference organisers break the mould and, along with journal editors and societies, follow this conference’s lead in promoting more research evidence and get our specialty back on track.
Emeritus Professor of Orthodontics, University of Manchester, UK.
why o why, do orthodontists only attend orthodontic meetings???
For many many years there has been, and continues to be, great orthodontic and related research being presented and debated annually at IADR (International Association of Dental Research- https://www.iadr.org/) – mainly within the Cranio Facial Biology group
And also avaiable at ‘local country branches’ eg BSODR https://bsodr.org.uk/.
As a speciality we need to look outside our ‘box’ and be prepared to learn from others
Thanks for posting this issue.
Usually, thinking of the ‘art and the science’ of an entity in medicine or dentistry, the art usually proceeds the science.
The science may appear later or years later.
Where does this fit into the spectrum, limited specifically to not blatant selling of product or equiptment related to the entity being identified.
I believe (through evidence based data) that in medicine the delay from identifying a concept, until that concept becomes clinical reality might be up to twenty years. Hence the dichotomy.
From ChatGPT:
Key peer-reviewed references:
Balas & Boren, 2000 — often cited as the source of the “17-year” estimate, stating that research evidence takes an average of 17 years to reach clinical practice.
Morris, Wooding & Grant, 2011, Journal of the Royal Society of Medicine — reviewed the literature on translational time lags and concluded that the “17 years” figure is widely repeated, but difficult to define consistently because studies measure different start and end points.
Westfall, Mold & Fagnan, 2007, JAMA — emphasized that moving discoveries into everyday care is slow and requires practice-based research networks to bridge the gap between academic research and real-world patient care.
Contopoulos-Ioannidis et al., 2008, Science — found that the life cycle from discovery of a medical intervention to broad clinical use can be very long; some estimates approach two decades or more, depending on the intervention.
A careful way to state it in scholarly writing would be:
“Peer-reviewed implementation-science literature commonly cites an approximate 17-year lag between generation of medical evidence and its routine use in clinical practice, although this estimate varies substantially depending on how translation is defined and measured.”
I hope that these comments create a robust review of this most important topic.
This sounds like a new addition to the “Pyramid of Denial” Bingo. I suppose one could call it the “I will be proven right 17 years later” addendum to the Pyramid.
What happens when “after 17 years” the concept you pushed is disproven? Who is accountable for all the $$, morbidity, needless treatment and other biological costs incurred by the patient/s?
This is the EXACT problem we have with the purveyors of pseudoscience – They have already convinced themselves (by virtue of financial or other biases) of the fact that their “intervention” works, and are only waiting for “data” to prove their hypothesis.
These very same excuses were made by so many. Acceldont, Propel, Damon, LightFarce, KLowen, Brius are just a few of the many examples of this type of marketing.