October 20, 2022

Popular posts 4: Are these the early days of the self-destruction of orthodontics? Revisited.

This is the 4th popular post that I am revisiting. I first published this in May 2019, which was read almost 14,000 times.  I was about to retire and was in a deep dark place, wondering about the future.  As a result, I wonder if I painted a rather dystopian viewpoint.  So, I have had second thoughts about the content; here is a newer version.

I have just returned from the AAO congress in Los Angeles and took a short break after the meeting. This allowed me to reflect on the direction of orthodontics and its potential decline.

You may feel that what follows is just a rant. However, I am concerned with what is happening to orthodontics.  I wonder that when we look back in several years, we will recognise that these were the early days of losing our speciality?

Is the battle already lost?

I retired three years ago. I was an orthodontist since 1986. During this time, I had a great time and was privileged to see the progression to a research-based specialty; as we started to understand and follow the principles of evidence-based care.

I have also witnessed the other side of evidence-based care. This includes the rise, and fall, of growing mandibles, orthodontic treatment for TMD, the non-extraction at all costs movement (at least 3 times), the hopes and shattered dreams of routine distraction osteogenesis, multiple ceph analyses, self-ligation, orthodontic vibration, and the traumatising of both alveolar bone and patients.

The orthodontic wheel keeps turning. The debate on clinical matters goes backward and forwards in a vibrant mixture of hopes, challenges, and research. Eventually, we reach an equilibrium between clinical experience and research evidence. Nevertheless, I wonder if the stability of the equilibrium is shifting from evidence toward the case report and misleading claims.

Why is this happening?

In the past, the people who promoted “fringe” or extreme treatment could only do this in inferior quality journals, conference presentations, and word of mouth. However,  social media platforms and “conferences” held by supply companies and “Facebook groups” to promote their products are gaining influence.  The companies pay substantial amounts to Key Opinion Leaders or Clinical Salespeople who try to influence clinical practice.  If you want to check this data, you can do this easily on Open Payments; just enter the name of your favourite KOL or company.

You will see that these are incredible sums of money. I have discussed the role of orthodontics KOLs before and pointed out that there is nothing wrong with taking on this role. Nevertheless, they must declare this as a conflict of interest in every presentation, journal article, and social media posting. This is clearly not followed. For example, see my last post on Invisalign Mandibular Advancement.

The “lunatic fringe.”

Apart from the KOLs, we are still being influenced by the “fringe.” I include the orthodontics breathing physicians, myofunctional orthodontists, and tooth movement accelerators in this group. I have discussed this many times in previous posts, but the claims continue. For example, we are still experiencing a rise in the recommendation that orthodontic treatment can change breathing. Remarkably, these claims are without substantial evidence and fly in the face of the AAO whitepaper as if it did not exist. We saw this with self-ligation, and history is merely repeating itself.

Why does this approach work?

As part of my preparation for giving a lecture on Bill Proffit at the LA meeting, I did a large amount of background reading.  I came across a teaching video in which he stated that one problem with research is that it gives answers that people do not want to hear. He also quoted Mark Twain when he considered why people adopted “alternative philosophies”. The quote is

“The lie was halfway down the street, while the truth was still putting his trousers on and getting out of bed”.

I think that this sums it up nicely.

Why am I concerned?

We are indeed in a “race to the bottom,” but I wonder if the fall has slowed? But we must not think that everything is fine. I still feel that it is not a significant jump for us to stop being healthcare providers but dental hairdressers.

It is difficult to think of solutions because this problem is now embedded in our speciality.  However, this is my contribution;

  1. When we see someone recommend a treatment or overall philosophy, we must ask them for evidence. If we think that their concept is rubbish, we should tell them.
  2. We must challenge every KOL/Clinical Salesperson to declare his or her conflict.  The conferences still ask speakers to do this. However, several do not declare or simply offer a vague comment of “I am not being paid to deliver this lecture”.  (But the six-figure payment must have an influence)
  3. The KOL/Clinical Salespeople should ask themselves if they believe what they are saying. This will never happen!
  4. The orthodontics societies should “get off the shelf” and consider whether they want to be associated with those companies that promote unproven treatments. Currently, most of them accept funding for their meetings and advertising in their journals from all the companies. Surely, they should become more critical and decline those making extreme claims?
Rant over?

When I first published this post, several people commented that I underestimated the ability of orthodontists to dismiss many of the claims being made. This is because we include scientific appraisal and completing a research project as an integral part of training.  Several years later, this is reassuring, and perhaps I am not so concerned.  However, in the UK, the completion of a Masters’s level research project has been removed from training.  As a result, I hope that the speciality courses can compensate for and continue to provide the knowledge for scientific appraisal.

Finally, I am more hopeful because the KOLs and the fringe are being challenged more. There are now several large evidence-based and educational Facebook groups with thousands of members.  While the KOLs are not appearing as much on the smaller groups. The speciality needs to keep this up and not let them drag our profession down.

I have kept the comments people made the last time I posted this.  They are very interesting and relevant.


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Have your say!

  1. Too little to late. Rip.

  2. %100 agreed . so sad to see this happening .

  3. Well noted Dr. Kevin. The rise of extreme commercialisation and illogical themes are a threat to the profession. Where are the ‘Good Ole Days’ gone?

  4. very rightly analysed Sir… Lost are the days of Bjork… Tweed..Ricketts…Burstone… how sincerely and meticulously our leaders had paved the way for evidence base orthodontics… there were Principles we followed and taught to our students too.. Now in the last 10 years things have the pace of inventions and their propagation into practice is all social media platform driven…The fact is” appliances are for patients ” but the current scenario is” patients are for the inventory and appliance…

  5. As someone once said:

    “there’s nothing more dangerous than a vested interest posing as a moral principle”

  6. I feel that this is an issue not only with the orthodontic specialty but in dentistry as a whole profession.
    The rise of instagram dentists has led to the need for a before and after photo that gives a wow factor. I constantly see the disclaimers, ‘the patient did not want ortho’ and ‘no drilling or injections required,’ as if this gives free reign to provide 8 composite veneers that will require long term maintenance and all the other potential complications.

    Patients attend with an idea of what they think they need but they don’t know what they don’t know. It is our job as a profession to educate patients on the value of each treatment and the long term complications. We also have to maintain our own professional integrity so that when the patient declines ortho this does not mean we can carry out treatment that we know the patient doesn’t need.

    So it seems i ended up on a rant there myself which is only partially related to the article! These things are massivley important to highlight and continue to write about!

    Many thanks for all the valuable, evidence based knowledge you provide!

    • Totally agree with your commentary!! Overall dentistry nowadays is living a complete lack of good sense and responsibility!! False lecturers and leaders are arising and emerging from social medias “scientific centers”.

      • Orthodontics does not deserve to be considered a dental speciality when the slippery slope of orthodontic standards has slid downwards to the point where there is now little difference between treatments provided by orthodontists and general dentists. Unfortunately this slide in standards has been unchallenged by many clinicians and Associations and is, in my opinion now beyond the point of retrieval.

  7. Kevin you know this resonates with me from past communications and articles etc. It worries me somewhat that some are saying “too little too late”. That is tantamount to rolling over and playing dead. We need to fight every little battle to try and restore some sanity despite the fact that we may not win every battle. Anything else is too ghastly to contemplate.

  8. Unfortunately this seems to be the end of time. A beautiful chronicles. A hug from Brazil.

  9. Dear professor O’Brien,

    Unfortunately, I agree that our specialty is losing the battle. My take goes a little deeper regarding the reasoning though.
    Above all I blame the diversity of our specialty education programs. There are numerous which still promote growing mandibles for example. Our new colleagues need to have a sound base in order to avoid being led to by KOL.
    The same applies for dentists who are practicing orthodontists. There is simply no control.
    I disagree that our specialty has anything to fear by considering our patients also as consumers. Afterall most of them choose to have a treatment and they don’t differ in my eyes from the patient who enters the plastic surgeon’s office for a nose job. They should just be properly informed and let to choose if more than one option is available.

    • I don’t disagree that there is anything to fear by considering our patients consumers. I just don’t understand why we should. Ask any ethical professionals, business persons or sale persons what kind of relationship with clients they are most proud of. Most would tell you that it is a relationship that their clients trust them enough that they can say no to their clients and tell them their honest opinion. That is the relationship we have with our patients and this is the relationship other professionals are envious of. I don’t understand why we want a downgrade!

  10. Thank you very much for writing what you believe. Thank you for your Courage to talk, to fight for Ethics in Orthodontics. We can’t give up being honest. We are doctors.

  11. A good response to this reality is to educate common ppl through social media’s and make them aware of the fact that most adverts are misleading and false , it is orthodontist who choose you the best ,based upon on the true diagnosis not jus machines or unqualified technicians..
    My friend Dr dovi prero educare this Instagram followed that


  12. Thank you for the post Kevin. These are concerns shared by many of us who are confronted with the chimerical claims made with astounding audacity. I do agree with Mark Wertheimer, and we absolutely need to tackle this issue at every juncture. It is imperative to demand proof when tall claims are made. That is not “bullying” or “shaming”. It is our responsibility to our profession and patients (not customers)

  13. One of the most respected medical researchers that I know of wrote this:

    “…readers might imagine that I was an experienced respectable physician whose opinion everyone accepts on sight. I finally decided that the simplest solution was to admit my biases in advance to warn my readers.” This can be found on page 4 of Effectiveness and Efficiency, the 1972 monograph by A.L. Cochrane, CBE, FRCP. If a researcher such as Cochrane would be willing to declare his biases, why not anyone else? What is there to fear or hide by making such a statement of bias? Are any of us better than Cochrane?

    He goes on to say that “One should, therefore…be delightfully surprised when any treatment at all is effective, and always assume that a treatment is ineffective unless there is evidence to the contrary.” Why did he write this? Partly because earlier research had shown that changes in environment had more to do with improvements in life expectancy than any single advancement in medicine in the late 19th and early 20th centuries, perhaps with the exception of Joseph Lister’s introduction of carbolic acid for surgical cleanliness and the development of sulfonamide antibacterials in that time period [see Lister, J. Illustrations of the Antiseptic System of Treatment in Surgery. The Lancet 90(2309), November 1867, p-668-669, and Domagk G. Ein Beitrag zur Chemotherapie der bakteriellen Infektionen, Dtsch med Wochenschr 61(7), 1935].

    Cochrane further makes the point that it was (and maybe still is) an uncritical belief on the part of patients in the doctor’s ability “to at least help if not cure”, creating a desire on the part of the doctor to help and on the part of the patient be helped, but that in the long run it didn’t matter what doctors did because it was all so ineffective; time was the healer of all wounds, and as Voltaire said the art of medicine is amusing the patient while allowing nature to cure the disease.

    Moreover it is the uncritical belief on the part of modern practitioners to have faith that what they’re being told is true and unbiased, and only partly because the bias is not disclosed. There is a synergy between uncritical thinking, KOL’s and others similar to what Cochrane observed between doctors and patients; the desire to help and the belief that there was a simple pill, treatment, mechanism or some method that would be ‘the cure’ for the disease. The late Everett Shapiro used to tell us residents that no-one ever died of a bad bite. Turning this on its head, to paraphrase Lysle Johnston, no-one has yet died of bad orthodontics. We have seen that everything that is done to patients seems to result in nice looking teeth (“everything works therefore nothing matters”; we’re “…just tryin’ to keep the customer satisfied…”); whether orthodontic treatment is stable without lifelong retention or harmful to the periodontium in the very long term is as yet unknown (When interproximal reduction was introduced orthodontists and periodontists fought over the long-term consequences of reduction of alveolar bone width between the roots as the tooth width was reduced; what was the answer to this question? Is there a definitive answer? Maybe, maybe not, but we almost all practice using IPR as a method to relieve crowding). Without even knowing these few simple long-term outcomes, surely the jury is still well-out on the supposed benefits of orthodontics to treat all manner of systemic problems??

    We have collectively forgotten much of what we do now, and what is being pushed by manufacturers and distributors of products on convention floors, was tried before and abandoned as ineffective. One only need look as far back as the 1930’s when the first self-ligating brackets were manufactured. Between their initial demise and their subsequent re-introduction in the more recent past the only significant difference in the appliance seems to be the availability of shape-memory alloy wire. But these brackets are now touted as some sort of magical appliance capable of astounding feats and benefits for patients, yet back then and even now teeth and bone don’t know what is attached to them; the teeth, periodontal tissues, alveolar and basal bone still behave the same ways when forces are applied to them. Various forms of Class II correctors have also been available for a very long time, some using combination of lingual holding arch and Class II elastics; these types of methods go back to Tweed and earlier, yet now there are new appliances (that do the same thing) that are somehow superior? It beggars belief that Class II problems have changed that much that they would now respond better to a new appliance that uses the same underlying thinking as an old one.

    Providers of information, whether funded by the NIH, AAOF, university or by any of the various medical device manufacturers have a moral duty to declare their source of funding, which should give some indication of their biases. Of course they could, like Cochrane, declare their own biases outright (in the spirit of which; I am a full-time university professor, and I have practiced an 018 straight wire technique for 22 years. Approximately 30-40% of my cases have been extraction cases. I am not paid by any manufacturer or outside source to promote any product or therapy). But by the same token the doctors in the audience have an equal moral duty to question those sources of information, and apply a skeptical eye to the information that is presented.

  14. Kevin — Very well said and 150% on target! Orthodontics used to be a beautiful specialty but it is rapidly becoming nothing but a cosmetic service. Faustin Weber assessed it as follows-“ Jim, it has taken generations to get dentistry out of the barbershop. Unless things change, you will see it in the basement of the barbershop.” I fear we are already there. But those of us who believe in patient service above self and evidence based treatment must continue to fight the good fight and keep our fingers in the dyke! You post is wonderful!

  15. I am glad you are making this battle more bold! Thanks for this contribution. However, if we continue raising the awareness, I don’t believe we will lose!

  16. Kevin, paradoxically I believe that much of the pseudoscience and non-evidence based treatment modalities that are being shovelled into the twittersphere by individuals with vested commercial interests actually serves to encourage the younger generation of orthodontists to become better critical thinkers. People are no longer afraid to call out the nonsense when they see it (especially on social media), and to that extent the online spread of the orthodontic quackery can be shut down pretty fast. Young orthodontists who often populate these forums are smart and bright and I believe they see the buffoonery and they’re just not buying into it. Well maybe some are, but I don’t think they’re all being corrupted quite as much as we think. Interestingly – some of the most “liked” orthodontic posts on Facebook are from seasoned clinicians demonstrating sound biomechanics with great records. This is probably because it’s refreshing to see colleagues doing good work without any hyperbole or miraculous claims tagged on.
    My observation is that most orthodontists (young and old) actually have fairly sensitive BS-meters and can see the statements of the KOL’s for what they are – thinly veiled marketing strategies. I also think that more than ever, university academics and tutors like yourself are preparing the next generation of orthodontists to be better evidence based clinicians and are also preparing them for an onslaught of wingnut orthodontics upon graduating.
    We can only hope that the next gen don’t go weak at the knees when faced with the material you speak of and to coin an Australian phrase – “keep the bastards honest”.
    I am confident the pendulum will swing away from the clinical salespeople and back to the science in due course – perhaps sooner than we think. So maybe we are entering the orthodontic dark ages, but I don’t think it will last very long.
    I only wish I could say the same for orthodontics in the general dental practice setting…

    • I wish I shared your confidence in the younger generation. Unfortunately they are vulnerable due to things like debt, looking to make a go of things asap, and often want to be part of the “cool” crowd. They often hang on every word of the KOLs

    • I agree Howard, and I think there is an opportunity to engage and be proactive in social media and call out poor treatment and educate to what is an appropriate standard of care through sound evidence. Our generation spends inordinate amounts of time trolling social media, and are influenced from those who shout the loudest, and I don’t see that changing, so the opportunity is there. Kevin is doing a great job and should get more support from his peers. Unfortunately, there will always be confirmation bias and the art of critical thinking and associated literature review should be at the core of undergrad and postgrad curriculums. I was a general dentist for 15 years and am now in specialist training and have had my eyes opened to how to truly analyze research, and have become a total skeptic of claims and opinion. Social media is great in so many ways and as a profession, we have an opportunity to educate the public and our colleagues in a synergistic way. There will always be commercialism vested in education but it’s important to see it for what it is and offer alternatives to those who want to learn more. “With enough mental gymnastics, just about any fact can become misshapen in favor of one’s confirmation bias”.

    • Where did you get that Australian phraseology from, Howard?

  17. Your excellent tribute to Bill Proffit at the AAO gave me some hope that ‘personality-based’ orthodontics had been replaced by a genuine desire to find the science behind the art, exemplified by your slide showing the exponential rise in papers which purported to be evidence-based after Proffit’s multi-centre study published in 2004.

    The salesmen will always attract the low-hanging fruit. I would like to think that the majority of our profession are more discerning than the companies and their paid disciples would like to believe.

    Keep the flag flying high for those of us that still feel that an understanding of biology trumps unfounded gadget claims every time.

  18. Once again, thank you for a wonderful post.

    I would like to think that it is the early days, but I fear that we were far too comfortable back then. We allowed cranks and people with alternate beliefs to have their say without seriously questioning them. We have brought it upon ourselves by being polite.

    We gave the myofunctionalists, for example, a platform, when we should have removed the rug from under them.

    We politely allowed friction and self-ligation into our homes. I canceled my subscription to Seminars, many years ago, after they published an entire issue on self-ligation in which the KOL likened it to finding a cure for scurvy. The designer of his favorite bracket surely deserved a Nobel prize. I saw this KOL lecture a few years ago and he now states that the problem with the evidence, is that it compares like with like! He was not callled out. We were far too polite.

    Will we now take a deep breath and politely allow the airway friendly cranks to pedal their wares? Will we allow them to suggest that they have clinical “evidence” with a sample of one?

    As HL Mencken said: Every normal man must be tempted, at times, to spit on his hands, hoist the black flag, and begin slitting throats.

    Is it time to make a stand, or do we allow the snake oil salesmen to win again? I politely suggest the former with a sharp tongue and perhaps a cutlass

  19. We must honor our Code of Ethics the basis of which mandates (is not a suggestion) that we as professionals (vs. salesmen) and health care providers “provide the very best treatment possible, regardless of financial renumeration”. We should never mix “economics with ethics” and unfortunately that seems to be happening more and more due to the changes we see within our profession – competition, debt, social media, etc. Providing the very best treatment definitely relates to evidence based studies which in turn in linked to education. We must continue to fight for our profession by providing quality treatment, educating our patients and making sure that graduate programs provide a quality / evidence based education at a reasonable cost.

  20. It strikes me that the problem started when we finally accepted that most treatment was cosmetic This has enormous implications and essentially creates the “customer” culture. There is no way of getting around this and it seems to lead to 2 extreme options 1: invent new diseases for orthodontics to treat (sort of denial that it IS cosmetic), 2: treat everything as long as the patient wants it and has the money. I like to think that there is an alternative (maybe I’m deluding myself) that involves doing all the usual stuff (sorting out impacted teeth, crooked teeth, overjets) using methods that are shown to be the most effective (ideally simple and lacking too much Woo factor) and sometimes advising that there are alternatives such as not bothering in those cases that are doomed to relapse.
    So I’m trying to use the evidence on what works best (maybe not functionals) and advising when treatment is likely to be a waste of time (mild stuff) and, most importantly, TELLING the patient that it is cosmetic and not for health reasons. Our professionalism goes out the window when we refuse to advise appropriately and just treat everyone that wants it. We should be aiming at the shortest treatment times and on those cases that will benefit. So much treatment carried out around the world must be a waste of time, we need to stop doing this and be honest. Rant over, thanks.

  21. You are right on the spot. The sad thing is that many young (and old) orthodontist are now embracing these “a la mode” trend as they want to get as much patient as they can. They tend to forget their role as an healthcare provider. They fear to lose a patient if they recommend extraction or if they don’t use Aligners. Money talks…

  22. Thankyou for having the courage to say what must be said. May the rest of have the guts to take a stand.

  23. I am a recently graduated orthodontist, so I don’t have personal experience, but it seems like there has always been people out there spewing nonsense trying to make money. Maybe it’s more in your face now because social media has given everyone a bigger platform, but that only kills the profession if enough of us decide to listen.

    I found myself slightly insulted by this rant, as the assumption seems to be that I, and other young orthodontists, can no longer think for ourselves. Weren’t most of us taught in residency how to sift through the nonsense, how to interpret research, and how to carry out sensible orthodontic treatment? I know I was. Just because someone or some entity is yelling really loud doesn’t mean we have to listen, and I believe most of us won’t.

    I don’t think the profession is dead or dying because I have faith in myself and the younger generation of orthodontists to not listen to all the noise. And if you are legitimately concerned about all future orthodontists buying into the nonsense, then maybe there should be more focus on changing the training programs and less hand wringing about these KOLs that we should all just ignore anyway.

    Now I guess I’m the one who’s ranting; and maybe it’s naive of me to think we can just ignore these people, but I see that as the best way to fight against it.

  24. The data on OpenPayments is very revealing:
    The data on Align Technology 2017 payments (https://openpaymentsdata.cms.gov/company/100000005613/general-payments) indicates they paid $6.2 Million in ‘general payments’ and a mere $127K on research.

    I think that says it all!

    • Dr. Hobson the actual figure is $128,899,000 in R&D for 2018, which is staggering. As best as I can tell, there is no other company in the entire dental industry allocating this much capital for research, which approaches some biotech company budgets.

      • Barry
        R&D is not “Research” as academics such as Kevin, I and others would define it. R&D can cover a vast range of activities!
        The number i would like to see is how much is spent on independent research eg RCTs of appliance effectiveness – the outcomes of which are published in high quality referred journals without deferring to the sponsor/manufacturer

        • Ross,
          I certainly agree with you that independent research should be conducted before a new orthodontic product is brought to market. Unfortunately in the United States, and I think in most other countries, the regulations for medical device companies (all orthodontic companies are medical device) introducing a new product depends on the potential health risk. As an example, a new pacemaker would most likely require significantly more rigorous independent testing with the pacemaker developer required to fund independent testing compared to a new orthodontic appliance that has a much lower threshold for approval. This is similar to the introduction of a new drug’s clinical trials that are part of the developmental costs borne by the pharmaceutical company. As I understand it, usually about 90% of an R&D budget for a new drug is spent on internal research and development with the remaining balance allocated to clinical trials.

          With Align Technologies, I think that a fair assumption would be that their very robust budget for R&D activities involves product development and improvement for their Invisalign orthodontic system and Itero scanner series. This is certainly a good thing but adding compulsory independent research (for all companies) would certainly make it better. People complain about government regulations but sometimes they serve a very good purpose.

      • hi
        can you expand on what R&D means.
        can you also point me towards published research resulting from this spend

        • Interesting comment Steve. I’m sure that you are aware that if you search library of medical sciences, clinical trials, the product that you are interested in, and read the papers, you can read the source of any funding or financial interest – if the journal and author/s are doing their jobs. Question – if an investigation is funded or facilitated by the manufacturer of a dental product, how much credibility will you give it? None, Some, Depends?

          I’m conflicted by the notion that research needs to be published in order to “exist”, or to be deemed valid and useful. Much orthodontic research is tested in the university setting by external examiners (and hopefully unbiased mentors) , posted and / or presented at meetings but may never reach the journals. Does this mean that it does not count as research? Personally, I feel that just because you may read some black and white that has been through an editorial process, a process that I have taken part in for more years than I care to count.., does not in my mind make it the only evidence that exists, nor indeed the most credible. Yes, perhaps the most accessible to the specialty.

  25. I truly appreciate all that you have done for the profession. Sadly this isn’t the beginning of the demise of our profession. This has been going on for a very long time.

    It is good that you are tracking the money but it’s just the tip of the iceberg. Few have the time or inclination to go down that rabbit hole only to find out that no one is listening or that they now have bullseyes on their backs. It would be interesting if orthodontic residencies began doing this type of research (following the money) though. And no, I won’t be holding my breath for that to happen.

  26. Well said Sir,
    Thank you very much for your efforts to criticize these marketing based ways of treatment.
    And yet, you did not mention the -do it yourself- trend.

    Respects and regards.

  27. well said. well written!

  28. Thank you very much for this blog, I thought I was doing something wrong after leaving AAO meeting this year. The exhibit hall of all the sponsors is where most people spend time after lectures and it has become a good target to get new Orthodontists seeking for technology rather than evidence. This sponsors now promote there sales persons to do lectures and they even promote themselves on social media as AAO speakers. AAO should do something about it, quality control is lost.

  29. Please read:
    Arnold J. Malerman, DDS. “The Disappearance of Excellence: One Orthodontist’s Opinion”. EC Dental Science 5.3 (2016): 1079-

  30. Dr Roth said it perfectly about 25 years ago….once our profession becomes cosmetics It is the end of orthodontics….thanks to many universities and teachers…students have been taught to embrace cosmetics….the results are here

  31. Previous “non extraction at all costs” treatment failed in a manner that was plainly visible to the patient, namely, the lack of stability caused the teeth to quickly get crowded again.

    Bonded retention and retention for life eliminated that problem and the profession seems to be willing to turn a blind eye to some of the biological limits of tooth movement that are understood but not held out as a treatment standard.

    Modern wires and brackets have made tooth movement and alignment so easy and this lack of accepted biological limits to where a tooth can go gives everyone license to put the teeth anywhere to “make the patient happy when they walk out the door”.
    CBCT has given us well documented evidence of teeth being moved to biologically precarious locations in the name of alignment or attaining class 1 molar.

    The profession needs to agree that teeth are better off if they remain surrounded by bone and we come up with some numbers that dictate the understanding of the limits of the adaptability of that bone. Until that happens, market forces will make it much more lucrative to ignore biology and align those teeth anywhere and anyway anybody sees fit.

    • John you are once again dead on. Our Specialty programs, for the most part, are institutionalized preceptor programs. I for one have used skeletal anchorages devices to move teeth beyond their biological limits. I did not realize this until I began evaluating results with CBCT. Now use this technology to treatment plan so we do not violate the biological limits.

      The. AAO must accept some of the responsibility of the, “Demise of the Specialty”, and take the necessary bold steps to change our direction. Both Jimmy Vaden and Bill Proffit Told me, The Horses May be out of the barn, but we all must do our part to get them back in.”

  32. Be sure to read the letter to the editor by Ackerman and Ptoffit published in the AJODO of march 2002, and later the reply to this iconic letter in Aug. 2002. You will find it all there, from prophet to the biblic oldest profession ever. I am sure you will quote it in your next letter.

  33. Well stated point of view. I totally agree with your thoughts and your perception about the future of our specialty. Some, including me, will always choose evidence-based science and, possibly, we will be the ethical future of orthodontics, when all masks fall down.

  34. Dear Professor O’Brien,

    While I agree with your concerns about KOL’s and pseudo-science in our profession, I think we all agree that this is nothing new. In fact, the founder of our specialty would be considered a rampant non-extractionist by today’s standards and Edward Angle was probably the most formidable KOL that the profession has seen.

    Furthermore, orthodontics is not limited to the English speaking countries of the world and while we may have dropped the ball in North America, the UK and Australia, quality research will always come out of Scandinavia. There will always be truth seekers, like yourself, keeping us in check. The specialty will live on.

    The real threat comes from big businesses whose best interests don’t necessarily align with the best interests of our patients. I’m referring here to the stock market listed dental corporations as well as Align technology.

    In our quest for clinical efficiency, we have chosen to subscribe to the fantasy of ‘shape driven’ orthodontics. Wouldn’t it be wonderful if we could set up a digital target for Invisalign, incognito, suresmile or insignia and we can then delegate our treatment mechanics to the lab. If only perfect bracket positioning, wire shape and aligner shape could allow us to walk through a series of aligners or wires towards a perfect result we could delegate all of it and sit at home on our computers. ‘Shape driven’ orthodontics is the death of our specialty. We have only ourselves to blame for the rise of smile direct club. Who can blame them for believing the fantasy to which many of us subscribe.



  35. Das Problem liegt tiefer, auch seriöse KFO gründet auf Treibsand. Es ist ein Treppenwitz der Medizingeschichte, dass die Entwicklungsbiologische Grundlagenforschung von Prof. Rolf Fränkel zu keiner Zeit verstanden wurde. Es sind nicht seine Geräte, es ist ihr intellektueller Gehalt, der dabei wichtig war. Keiner hat bemerkt dass in seinem Buch,

    „Funktionskieferorthopädie und der Mundvorhof als apparative Basis“ von 1967

    Eine universell gültige Gesetzmäßigkeit verborgen ist und genetisches Wachstum im Einklang mit der Biologie erklärt, auch und sogar vermehrt, nach dem jetzigen Wissensstand.

    Das Prinzip der „ Funktionellen Orthopädie“ und das „Prinzip der indirekten genetischen Kontrolle“.

    Das Grundverständnis genetischer Entwicklung der Zahnmedizin ist falsch und damit bewegt sich die komplette Zahnmedizin weitgehend außerhalb der Biologie. Dadurch gibt es kein Halten mehr. Ob ich ein großer oder kleiner Scharlatan bin macht keinen nennenswerten Unterschied. Was ist dabei seriös oder unseriös sind marginale Fragen. Erklärt aber das Unbehagen von Professor O’Brien. Die Zahnmedizin braucht ein Fundament auf dem sich seriös (Evidenz Basiert) argumentieren lässt.

    Das wird in dem Blog sehr deutlich, mit dem bisherigen Verständnis von Wachstum und Entwicklung lässt sich jeder Blödsinn und jede Fehlentwicklung begründen. Und was schlimmer ist, auch nicht aufhalten.

    Grüße aus Deutschland

  36. Dear Kevin,
    Thank you for another engaging post.

    The problems you identify are not confined to Orthodontics but pervade dentistry and all health fields to differing degrees. This is a dynamic and, in some ways, evolutionary process where we may end up with a sleek apex predator or a platypus. If I was making a Platypus I’d do it differently but it fits into an ecological niche.
    In our case, that niche is a social one and currently we are in an era where “the narrative” seems to be winning over rational discourse and debate. Look at political campaigns and results in the USA, UK and Australia as experimental data on how we make choices.

    In that environment which of these two arguments is most compelling to a concerned and usually anxious parent who wants the best in life for their child:

    https://www.eodo.com/ OR


    “Evidence-Based Practice” needs to be a metaphor for the social and clinical processes involved in delivering the best care appropriate to individuals and break away from its specific rational clinical decision focus.

    It’s a social process in a complex environment.


    This blog is part of that process, as is improving our advocacy at all levels in any translational approach addressing cultural, economic, political, social, cultural, structural and hierarchical contexts.


    Healthcare delivery structures and cultures are the new Coca-Cola. Corporatisation and commercialisation generate funds that will exert their influence in the same way and we are seeing that.


    Perhaps we need to do more to address the big picture contexts and our methods of communication to evolve the system and stand slightly more upright.

  37. Have hope!

    It was a pleasure to meet you after your lecture with the selfie crowd. Seeing the various treatment examples of difficult cases made me respect the need for multi-disciplinary care more than ever. It is important to expose the things that work and don’t work- whether dogma or manufacturer claim. Mail order can only do so much without eventually getting into a class action.

  38. Dear Dr O’Brien.
    I’m glad to realize that I’m not the only one who feels overwhelmed and distressed by the path our specialty is taking. Because of people like you, or me and a bunch of others that truly love and believe in what we do, I think we’re not in total darkness…. yet. We MUST do something on a larger scale…. I just don’t know what..

  39. there has always been a type of clinician willing to tell lies, mislead and over prescribe to increase their earnings. This has gone on for hundreds of years. In more recent times I have known orthodontists in the UK to tell patients that NHS care is for those under 16 (lie) and that they will need to self fund, that they will treat one arch and see how the other goes (even though both arches required treating (and then charge privately for the untreated arch) and finally to extract upper 4 (unrestored) to speed treatment rather than the grossly hypoplastic upper 6’s (which crumbled shortly after debond).

    Furthermore most/all clinicians can spot manufacturer lies and exaggerations though some choose to promote them.

    The psychology of selling feeds into patients desires, if it didnt there would not be millions spent on anti wrinkle/ageing creams etc etc – just because 80% of a group of 10 women feel that by being given a free pot of very expensive face cream containing super hydroxy lysosomal boswolox and natural amino acids – does not mean it works.

    From my 20 years or so of orthodontics i feel the new generation are more concerned about doing the right thing and not being sued, it is the more experienced practitioners who fall into the trap of becoming a shyster.

    I recommend that clinicians who are tired of this manufacturer driven force feeding of “evidence” simply buy their orthodontic equipment from other providers. After all a bracket is just a bracket.

  40. I totally agree and share the same feelings .

  41. So true, Kevin… During the past few years of lecturing and teaching I felt more and more like the old grouch who is criticizing all new developments. I feel that some of our younger colleagues just prefer “easy living”. Not thinking and just doing what the KOLs tell you certainly is more easy than doing most of the work “the hard and serious way”. We lost the battle and orthodontic future will not be too bright…

  42. So as i 2015 graduate of dentistry who will be applying to orthodontics next september .. should i avoid that ? Should i opt for another speciality? Help please !

  43. Thank you very much Prof O’Brien for revisiting this blog.

    This palpable feeling of impending doom is all around us nowadays but I feel that not everything is lost.

    Orthodontic treatment is one of the rare instances where medical intervention if not done right can actually make the matters worse. What I mean is that the worst that can happen in case of an inadequate root canal therapy is the outcome that would probably have occurred anyway without any intervention for a pupally-involved tooth. However, when ‘shake-o-dontics’ goes wrong (just moving teeth to look straight without any regard towards stability or oral health), the patients fortunately can tell that something is a miss.

    The fear of litigation and increasingly discerning, dentally-aware patient should be able to keep the rot at bay for now until it becomes fashionable to practice evidence-based medicine. This is going to take time though. A long time.

    Thank you for showing the way.

    Sincere regards,


  44. Hi Kevin – thanks for using the correct terminology. Orthodontics is a specialty, within the profession of dentistry.
    I would like to defend, once again the “KOL” and now the sales person against discriminating assumptions. Firstly, do we even know what / who a KOL is? How much money needs to change hands before a lecture? An airfare, accommodation, honorarium? How large does the honorarium need to be to attain label of KOL? Many considered to fit the label were or are still working in academia. I know that you have a blog on this point. Are you a KOL? Were the great Ricketts, Andrews and Burstone, among others KOL’s, for being paid to teach their techniques- and perhaps holding financial interest in appliances? Was it not possible to listen and learn from these greats? Do you even use a prescription slot? I did, attended all of their courses, challenged them – never fun with Ricketts – and was able to remove the BS and ego from content when required.
    I don’t consider myself one, but guess I fall into your rabbit hole. As you know, I present lectures aiming to educate my peers in a particular appliance system – Invisalign. For most, not all, of these presentations I am paid a sum of money. I assure you that I can earn twice as much per hour if I stopped “teaching” and remained in my practice, especially when taking into account the time it takes to prepare presentations. I do not receive discounted or free cases (apart from those that may apply to case quantity, like everyone else is entitled) and I have never owned shares, or options. I don’t believe that I am the only one with the desire to share knowledge and experience of an appliance system in all arenas, at the university where I teach, at professional congresses and company events. I try not to discriminate.

    So, to your statement: ” The KOL/Clinical Salespeople should ask themselves if they believe what they are saying. This will never happen!”

    Please, if we are aiming to be objective and claim to be evidence based, refrain from statements that are untrue. Worse, you are labelling and insulting individuals such as myself, and good, hard-working and experienced sales people and clinical support staff who may assist us and our patients in our practices every day- and in my experience most believe in what they are selling. This is their job and if they don’t believe in their product, they likely won’t last long, either because the product will fail or their customers will see through a fake pitch; as the audience may deduce when listening to a heavily biased or unfounded lecture (all lectures with a premise hold some degree of bias). We all have the right and free will to learn about and utilize various mechanical systems within our competency, and to share our learnings without being shamed. Companies, KOL’s and Salespeople are not forcing anyone to use their products.

    If we really want to call out all bias in an unbiased and evidenced based fashion, we must include scrutiny of every speaker, sales pitch, blogger, research project and publication. The notion that a non-KOL presenting at a conference holds no or less bias than a KOL is ignorant and laughable. Anyone making this assumption has never worked in academia, never written a research proposal and sought and investigated sources of university funding, never been an examiner for a thesis, never edited submissions for peer-reviewed journals and never discussed with individuals their motivation for conducting research or has been present when protocols are being planned (often the aim is simply to prove a preconceived conclusion…) – or ,they may simply be haters ( of KOL’s, companies, salespeople. ) Unfortunately, universities are not immune, the only difference is a thin protective veil of being classed as “researcher” or “academic”, and that of a “middle man” for money exchange. I have witnessed in major universities over a few continents more pressure on individuals to spruike some conviction or publish some black and white rubbish than that experienced as a “KOL”.
    As far as I can tell, over my career, nothing has changed in this regard. To me, the real change and distress in the comments above is due to laziness and apathy in many areas, lack of willingness to, and an increasing pace of change. The onus then, is still on the audience and their capacity to rationalize and question, as bias is everywhere in our specialty. It is not the exclusive property of the KOL and salesperson. On that note, I am concerned to hear that a research thesis is no longer required for graduation with an orthodontic degree in the UK. As Howard Holmes pointed out, we need to maintain the ability to think critically.

    Lastly, a suggestion. I wonder if not the biased academic or the KOL, who may we learn from? I would love to hear from our many peers in their twilight years or recently retired. To me, this is a large, untapped resource and may help the next generation to avoid the pendulum swings that we have witnessed many times over. May we consider a format for a blog from our veterans, summarizing their life lessons- like the post you prepared upon your retirement, Kevin?

    VV Presents lectures sponsored by Align Technology Inc.

  45. Agreed sir. However, when a well known clinician endorses these products it also make it quite evident who these clinicians are. They stick out like a sore thumb in the sea which is the global orthodontic fraternity. What we can do is take their “preachings” with a grain of salt unless adequate high quality evidence is provided instead of the hundereds of case reports which actually showcase only pretreatment and post treatment occlusions (almost like a magic trick seen at the local fair) without shedding light on the actual biomechanics being utilized.

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