Are these the early days of the self-destruction of orthodontics?
I have just returned from the AAO congress in Los Angeles and took a short break after the meeting. This gave me the chance to reflect on the direction of orthodontics and its potential decline.
You may feel that what follows is just a rant. However, I am genuinely getting concerned with what is happening to orthodontics. Somebody has to try to make a stand. I wonder that when we look back in several years we will recognise that these were the early days of the loss of our speciality.
Is the battle for the speciality lost already?
I am now in the last few years of my career as an academic research/clinician. I have been an orthodontist since 1986. During this time, I have seen the progression of an active research-based speciality, as we started to understand and follow the principles of evidence-based care.
I have also witnessed the rise, and fall, of mandibular growth modification, 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 and even orthodontic vibration.
In effect, the orthodontic wheel keeps turning. The debate on clinical matters goes backwards and forwards in a vibrant mixture of hopes, challenge and research. Eventually, we reach a balance between clinical experience and research evidence. In effect, this is an equilibrium. Unfortunately, I fear that the stability of the equilibrium is shifting away from evidence towards the case report and misleading claims.
Why is this happening?
In the past, the people who promoted the fringe or extreme treatment were only able to do this in inferior quality journals, conference presentations and word of mouth. However, social media platforms and “conferences”, held by the supply companies to promote their products, are gaining influence. The companies also pay substantial amounts to Key Opinion Leaders or Clinical Salespeople who try to influence clinical practice. For example, here is information on the payments to the highest earning orthodontic KOLs in the USA for 2017. If you want to check this data, you can do this easily on Open Payments.
These are incredible sums of money. I have discussed the role of KOLs before and pointed out that there is nothing wrong with taking on this role. Nevertheless, it is essential that they declare this as a conflict of interest in every presentation, journal article and social media posting. It is clear that this is not followed. For example, see my post on an article in the JCO on self-ligating.
Should Clinical Salespeople be biased?
This is easy. They should act as clinician scientists. As a result, they should not be biased towards the techniques that the companies pay them to promote. This is because they have an ethical duty to put their patient’s interests above their own. However, this is only relevant if they treat our patients as “patients”. Unfortunately, there appears to be a subtle change away from this basic tenet of being a health care professional.
For example, At the AAO meeting, I saw a trade show presentation on the HSO stand by Dr John Graham, who has recently joined as a new KOL. In a quickfire, slightly shambolic, performance he was discussing non-extraction treatment with a self ligating bracket. He stated the following.
“They are not patients, they are customers. Because they can leave your office and they are just fine. We should give them what they want”.
This takes us away from the patient/healthcare provider concept.
“I treated this really crowded case non-extraction because the parents were Jehovahs Witness’s and they did not want a blood transfusion if anything went wrong with the extractions”!
To be honest, I am not sure what he meant by this?
“There is a clear association between extractions and sleep apnoea. I can find you loads of papers on this, just ask”.
This was the “old chestnut” of I can find some papers, but I cannot quote or discuss them here. Altogether rejecting the AAO white paper and plugging the “airway friendly orthodontics” theme that is coined by HSO.
In addition to all this, Align were promoting their mandibular advancement device and their research on a stand densely populated by their KOLs. I have posted about this before and drawn attention to the lack of evidence.
I have discussed this many times. We are seeing the rise of the recommendation that orthodontic treatment can change breathing. Remarkably, these claims are without substantial evidence and totally flying 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.
Other areas are myofunctional orthodontics, orthotropics and even the strange concept of holding your tongue in the roof of your mouth to change your facial skeleton, called Mewing.
Why does this approach work?
As part of my preparation for giving a lecture on Bill Proffit at the 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?
I am concerned because it appears to me that we are in the early stages of the decline of orthodontics as a profession. We are indeed in a “race to the bottom”, and we are halfway there already. If we start thinking about our patients as being consumers, then 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 is a problem that 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 KOL/Clinical Salespeople should ask themselves if they really believe what they are saying.
- The orthodontic 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. Should they become more critical and decline those who are making extreme claims? I know that this is going to be difficult, but they do have an ethical responsibility.
I am sorry if this appears to be a rant. However, I really care about what is happening. I will certainly be challenging the KOLs more strongly from now.
My next few blog posts will be based on the Proffit memorial lecture that I gave at the AAO. Perhaps, this will encourage us all to go back to sensible orthodontics.
Emeritus Professor of Orthodontics, University of Manchester, UK.