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;
- 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.
- 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)
- The KOL/Clinical Salespeople should ask themselves if they believe what they are saying. This will never happen!
- 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?
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.
Emeritus Professor of Orthodontics, University of Manchester, UK.