July 24, 2017

Facebook based orthodontics

Facebook based orthodontics

A couple of posts ago Mark Wertheimer did a great post on professionalism. In this post he mentioned some of the effects of social media. This has led me to think about a new form of evidence “Facebook based orthodontics”.

As regular readers of this blog know, I publicise my posts using several Facebook groups. I also reply to comments that people make about the posts. Some of these discussions are quite heated. These are on the role of evidence vs personal experience or beliefs that are not founded on science. Unfortunately, these spiral on a slow descent to insults and eventually people accuse me of being prehistoric or a conspirator who wants to maintain the status quo.

Occasionally, I wonder whether I should be having these discussions. I feel that I should do this to challenge the false statements, snake oil and the unfounded hopes and dreams of these practitioners. I think that this is necessary to protect our patients and also address the claims that may subtly start to influence practice via social media. This may be called “Facebook based orthodontics”.

Examples of “Facebook based orthodontics”

I would like to explore this concept by looking at a post in the excellent orthodontic pearls Facebook group. This is a forum in which orthodontists post up clinical hints etc. In a recent posting, an orthodontist put up a panoramic radiograph. He pointed out that it had been taken and read by a general practitioner who told the patient that there was not much to worry about. This is the radiograph.








No other clinical information was provided. The poster made the point that he did not want to receive treatment plans.

When I looked at the radiograph, I tended to agree with the primary care dentist. I was a little concerned with the potentially enlarged follicle of the upper right canine and perhaps submerging lower primary molars. Nevertheless, if this was my patient I would try and palpate the permanent canines. If I could not feel them buccally, I would remove the primary canines and observe. Some may feel that this approach is cautious, but I think that this would be a sensible initial plan. However, the Facebook orthodontists had other ideas. I did an analysis of the responses that they made.

What did they suggest?

They suggested the following treatment plans;

  • CBCT now x 4
  • Extract primary canines x11
  • Extract primary canines and lower deciduous molars and fit lingual arch/lip bumper/nance etc x4
  • Rapid Maxillary expansion x4
  • “This looks like maxillary hypoplasia, address with expansion, then the magic will flow”!
  • Headgear x 2
  • Keep under close review x 3

All these options were suggested from one panoramic radiograph!

There are also other examples on other groups. For example, people comment on clear extraction cases with phrases such as

  • “non exo all the way”
  • “all day PSL treatment to develop the arches”
  • “non ext, I like to shoot from the rough”…whatever that means..
Why does this bother me?

While I tend to see the funny side of these strange phrases and diagnosis using one radiograph. There is an important issue here. This is the effect of this approach on the readers of these posts.

If I return to the Facebook diagnosis and plans from the panoramic film. I was certain about my initial plan, but as the number of alternative plans grew, I began to doubt myself.  I wondered if I was missing something or my plan was wrong. So I looked at the radiograph again and I decided to stick with my plan. However, I am an experienced orthodontist and I have treated many similar cases. But what is the possible outcome for an inexperienced specialist or a GDP looking at all these alternatives? Would I ignore the Facebook orthodontic warriors, or would I note their suggestions and start to change my practice? This change may contradict scientific evidence, particularly if I do not read research papers and only listen to the Gurus at conferences?

I also wonder if this causes some of the changes that we are seeing in practice with younger orthodontists being very engaged with social media. Perhaps, this is why the younger orthodontists proposed less extractions than the older group in the paper that I discussed last week. This may be conjecture, but it could potentially true.

What can we do?

As usual, we can educate. We should use more social media to widely disseminate research findings. I cannot help thinking that the monthly journal, hidden behind paywalls, will soon have its day and research findings will be circulated via social media at no cost to the reader. The orthodontic programmes could also warn their students that Facebook, Wikipedia or other social media are not good sources of clinical evidence.

Secondly, the Facebook Orthodontic Warriors should be more responsible and moderate their responses. They may think that they are orthodontic superstars, but they need to realise the effects of their statements.

I would also like to add a new lowest level of evidence to the pyramid of scientific evidence. This could be called “Facebook based orthodontics”.

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Have your say!

  1. The only thing I could say for certain from this radiograph is that I need more information. I’m perplexed as to how someone could prescribe maxillary expansion from this information alone. For ANY type of dentistry diagnosis and treatment should never be made from a single radiograph in the absence of further information, I thought that was clearly taught.

    Social media does present a problem where the people who shout loudest (post most often/most vehemently) get heard and taken notice of, though perhaps it’s only taking over from the dental ‘rags’ such as The Probe which have always presented cases and opinions. Quite often GDPs might ask me ‘what about xyz?’ that they’ve seen promoted to death, it’s sometimes difficult to get the rational evidence based opinion to win over. But we have to keep trying.

  2. Being a young graduate, I was bothered by what goes on in those groups for a long time. Most people agreed with the Gurus and very few voiced different opinions, so I often doubted myself and what I was taught in residency. A lot of what I saw made me uncomfortable, but I didn’t want to leave the groups from fear of missing something useful. It took me a while but when I figured out what was going on I left (or was kicked out of) all the groups besides Orthodontic Pearls. I would encourage all young orthodontists and residents to do the same, or at least be very critical and aware of the admins’ and commenters’ financial interests.

    Thank you for putting so much effort in this blog and keep up the good work on social media!

  3. GPs constantly send me panoramic and ask me “what do you think?” My reply is always the same. “I think I should see the patient.”

  4. Interesting blog post. I totally agree on your preliminary treatment plan and I would also consider this case as more or less, normal bite development. I might even go one step further I wonder why the OPG was taken by the general practitioner in the first place. Intra-oral radiographs of 13 and 23 would be appropriate if you couldn’t palpate the permanent cuspids and apical radiographs in the premolar region if there wasn’t any bite-wing taken where you could see the fives.
    I also wonder why all these treatment actions were suggested on the Facebook page??. I do not regularly use social media, at least not in a professional way and this is perhaps one reason. The orthodontists in our generation you Kevin, myself and others are perhaps not the keenest Facebook users at least not professionally. One solution might be that the serious Facebook groups, invited some older, experienced orthodontists to join the group and to create some balance between treatment eager and those of us who knows that wait and see is often a good alternative. It goes for other treatment plans too extraction especially, I completely agree with you Kevin that extractions are necessary in crowded cases and there is no magic in either brackets or archwire. The alveolar envelope is often limited and extractions are needed to keep the roots inside the alveolar bone and gingival tissues. We can’t change the fact that sometimes teeth and jaws are not of the same size.

    • I agree with consensus; it’s impossible to reach a “diagnosis using one radiograph”, let alone a treatment plan. My question is: What is the diagnosis in this case? Instead of rushing prematurely to a treatment plan, we first reach a working diagnosis (which is typically in three parts; orthodontic, craniofacial and airway) derived from: facial photographs; intra-oral photographs; 3D CBCT scan and study models inter alia (e.g. overnight sleep study, radiology report etc). From these data we prepare a list of treatment objectives – only then do we devise a treatment plan based on risks, benefits and alternatives; as well as providing an estimated treatment time, based on patient compliance.

  5. That’s a pretty normal opt, no need to do anything. But yes, listening to everyone else you do start to doubt yourself. My only hope is that with experience will come wisdom (and the ability to read an opt). Mainly the wisdom not to do stuff that is not needed, and the honesty to advise appropriately. I suppose alot of it boils down to financial incentive. Depressing.

  6. “Perhaps, this is why the younger orthodontists proposed more extractions than the older group in the paper that I discussed last week.” Would not it be the reverse?

  7. I want to thank you for your contribution to orthodontics. As far as the term “playing from the rough”, I believed that I coined that term and what it means is that sometimes it is harder to the complicated treatment over the simple approach but IMO not the best for the patient. It is a fun way of saying that sometimes we have to do the heavy lifting for the patient over the expedient treatment plan. Also since I have practice 38 years and I have acquired orthodontic knowledge in every way possible, I am a supporter of the facebook orthodontics which is nothing more than going to meetings and talking to your buddies on how to treat cases. It also shows all the different ways to treat cases as you have mentioned. Sorta of similar to our residency where all the instructors had a different approach to the case. Just as we read research to learn , we should listen to all possibilities and make decisions for ourselves. I see nothing wrong with this since we are intelligent students of orthodontics. Roy King

  8. I guess this raises the question about the value and timing of interceptive orthodontics – interceptive in terms of improving the developing malocclusion and also intercepting the patient before they go to the orthodontic practice down the road. It also brings to mind the saying “When all you have is a hammer, everything looks like a nail”.

  9. With respect, I think some are misunderstanding the role and behaviours of the ‘instant’ opinion forum that is currently serviced by Facebook.

    If anyone seriously thinks that ONLY the information or suggestions upon instant-communicative Social Media literally are all acted upon, are either antiquated or inexperienced using Facebook forums.

    Think of it more like “what is the range of possible opinions I might find out there about this” and you will then get the shotgun approach of instant thoughts.

    There is no negative marking or failed vivas here, just mass sharing of opinions which the reader can project up on a screen, next to their existing knowledge, experiences and cynicism but within the varied replies, there may well be one golden nugget of something worthy of further exploration.

    Taken in this CONTEXT such worldwide and instant communication tools such as Facebook has a very useful role in the dissemination of opinions AND the ability to debate, question and even disagree – but to assume someone is going to change or act upon anything is in itself flawed and unevidenced!

    Don’t be blinkered to a whole new world of communication out there – don’t assume when people talk Religion or Politics or football stats, that Orthodontics is any more evidence-based or valid or narrow in it’s approaches, in such worldwide connected communications too.

    Welcome to the 21st Century….. emBrace it 😉

    Yours inclusively,


  10. I have little to add to the well reasoned comments above. Planning any orthodontic “treatment” off of a single diagnostic piece of information is obviously not nearly up to par. Your point about “FB Ortho” is well taken, just like the entirety of your blog. Well done, Kevin!

  11. You are absolutely right, you cannot make a diagnosis from a radiograph. I looks like normal development stage with possible crowding and a wait and watch approach is to be taken. I would be seeing the patient in 6 months to take another OPG to monitor the upper canines and the possible submerging lower deciduous molars and if all is well then review as normal.
    Self doubt is normal, I guess, because it keeps us from getting swollen heads. – It forces us to ask questions and keeps us current.

  12. I read this opinion keenly because I greatly respect what you have brought to the profession. I feel as though you are taking the Facebook groups entirely too seriously.

    The original poster of the radiograph was inviting discussion about a case, which is something that is done, formally and informally, every day in a residency training program. The day that you leave a training program is the day that your opportunities and time availablefor this casual and formal exchange of ideas diminish, especially for those who are solo practitioners (which is still the vast majority).

    A colleague was reaching out for advice, however the treatment decision is still his own. It is your prerogative to comment that not enough information was presented, which happens in these groups as well. (And by the way, some instructors may choose to not comment on these cases in residency due to not enough information.)

    My point is that these groups are fostering discussion, and that they are a tool which easily allows for this. Thousands of conversations similar to these occur daily via text message, phone, email, or just pulling a colleague aside. Facebook is simply another venue for this discussion. As with any of these venues, you have the right to withold your opinion or to disagree with others’.

    Also you cited diverse treatment plan options for this patient that were proposed from the group. My guess, without looking up the conversation again, is that less than 1% of members in the group contributed to the conversation. Don’t you think it’s possible that the other 99% (assuming they all saw the post) had the same initial reaction that you did (and the General dentist) and they promptly ignored the discussion?

  13. As my ortho boss used to say “I don’t understand….” – The poster of the OPT said he didn’t want to receive treatment plans, and he still got nearly 30 treatment plans?

    I think facebook groups are like any other group, it depends on whose in them. You may well be influenced by the company you keep – in real life or online. Andy Warhol is alleged to have said the best party to be at is the one where you’re the dullest person in the room, and if you want to learn from a FB group, or study club or whatever, you need to see if you’re the dumbest person in the group and the clever people are doing stuff you want to do. The problem is you also have to be satisfied that they’re doing stuff that’s reasonable to do.

    Stephen Murray
    Swords Orthodontics

    • The most satisfying part of Facebook groups and other forums is realizing that I am not the dumbest person in the room.

  14. As a clinician and being in academics for 29 years I strongly place an emphasis on develop a diagnosis with the all diagnostic means available in order to develop an appropriate treatment plan.
    I am worried on the increase number of “gurus” in the Orthodontic Facebook World, that post any comment that influence the mind of young residents.
    I encourage my residents to read and challenge any post that they see on Facebook.

  15. It was indeed interesting to read Kevin O’Brien’s latest blog, some of which followed up on some of my thoughts a few weeks back, as well as some of the comments that were made on various Facebook forums. I am in agreement with Kevin on the whole and the topic of the effect of social media on our specialty is indeed close to my heart. At the same time it concerns me greatly due to the effect it has on the orthodontic landscape. Whilst many posts on social media are helpful and provide great information, they can for the most part only be regarded as anecdotal or opinion based. They do take many forms and I am not referring here to those that quote articles since that is an entirely different thing altogether. As such, they can only be viewed in general terms as the lowest form of evidence when one compares them with other categories on the hierarchy of evidence. Occasionally, they may well fall into the category with “Ideas, Opinions, Editorials” but one could hardly place many of them higher up the hierarchy.

    Blogs on the other hand have various different formats. Kevin O’Brien’s blog generally critiques articles or highlights current information and is not for the most part an opinion-based blog. As such, this blog must surely rank higher than mere opinions voiced on Facebook threads. For some to voice the opinion that their Facebook group carries greater weight than a blog of this nature is without foundation.
    Sweeping statements, some of which Kevin gives examples of in his recent blog, and made by personalities who appear to have self-proclaimed “guru status” and who often have the “loudest voice”, cannot be viewed as examples of “high-level evidence”. Posts for the purpose of advertising products, courses etc should also be viewed with some circumspection due to the financial advantages that are gleaned by those associated with them.
    Whilst many of the “Pearls” can be extremely helpful to practitioners, one should not confuse these with “evidence”.
    It is noteworthy that there are many posts of cases by individuals that show only what the person posting them would like to show. In my mind this makes me suspicious, since it makes me wonder what they are conveniently hiding. I liken it to the concept of “selection for projection” by lecturers who cherry pick what they show. The problem here is that the social media platform has a massive audience, and some are not critical of the material they see. I am, therefore, not convinced that this may always be in the best interests of the patients that land up on the receiving end of treatment protocols learned on Facebook.

    • With over one third of the worlds population already on facebook, I don,t think this type of discussion ,on facebook, is going to diminish in frequency.
      Secondly ,and with respect,the differences in reactions to the pan. and proposed tmnt. are ,in my view,related more to whether one is approaching the case from an NHS or”private” viewpoint . I have experienced both modes of practice.Please dont tell me the expectations re final result and service level are the same !!

  16. Hi Kevin,
    his seems to be a critical area and problem for our profession.

    Online diagnosis is probably and extension of online knowledge building and that has been in progress for some time.

    Good science is not a free for all.
    If we are learning a new language we learn the vocabulary and apply the appropriate grammar and rules. We don’t get to choose the parts we like and rely on our own beliefs. Science should be at least dealt with in the same way.
    Interestingly in Australia we have a health insurer running a dental tourism business to Thailand.
    At launch,diagnosis was a routine examination (Check-up) by your dentist and an OPG. Implant treatment and other complex restorations were planned off that.

    The original consultant had no formal post graduate training,reviewed/ audited results by viewing an OPG, his corporate dental group was contracted to maintenance and he was the only dentally qualified person on the complaints panel.
    Our activism changed some aspects and drove others into un-findable fine print.
    Good outcome data and pressure from funders seems to be reducing the subjective treatment plan in medicine. It still seems a long way off for Orthodontics or most oral health practice at the moment.

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