Is orthodontic misinformation lies, mistakes or ignorance?
This post is about orthodontic misinformation. I will consider whether this arises from dishonesty, mistakes, or ignorance of research methods and clinical standards.
Introduction
I trained as an orthodontist in the mid-1980s, and since then, the field of orthodontics has undergone significant changes. We have shifted towards being a more evidence-based speciality. However, this journey has not been without its challenges, and we have faltered at times. Nevertheless, our progress has remained steady. Unfortunately, I have recently become concerned that this momentum has begun to derail.
My concern about the state of the world profoundly shapes my perspectives on our progress. This anxiety is intensified by the unsettling perception that lying has become acceptable, with individuals often prioritizing their own needs at the expense of others. While some may argue that politicians and leaders are justified in their dishonesty, it is utterly unacceptable for healthcare professionals to emulate such behavior. Moreover, we must critically evaluate whether what we perceive as dishonesty from clinicians is actually rooted in ignorance, which can lead to unintentional mistakes. We owe it to ourselves and to our communities to demand honesty and integrity in every sector, especially in healthcare where trust is paramount.
These factors may be interconnected. They form a complex web in the context of academic publishing and the promotion of treatments to orthodontists and our patients.
Looking back
I would like to begin this discussion by sharing an experience from my early career in the mid-1980s involving functional appliances. When we examined a patient with a Class II skeletal pattern, my clinical instructors asked the patient to move their mandible forward. This adjustment noticeably improved the patient’s facial profile. After observing this change, we all nodded in agreement and concluded that using a functional appliance was necessary, as we believed it would help promote mandible growth.
Was this a lie? It would be easy to accept that it was. However, in retrospect, it likely stemmed from ignorance, as we genuinely believed we grew mandibles. It wasn’t until the mid-1990s that research shattered our hopes and dreams, exposing our ignorance.
Did we cause harm? I’m not sure. We successfully treated many patients, but some mandibles grew while others did not. We couldn’t predict which cases would succeed or fail. After a few years, I observed some treatment failures, and we proceeded with surgical interventions for some of my patients. Others moved on and didn’t return. Nevertheless, I genuinely believe we didn’t cause significant harm. At least, I hope so.
Making progress
Sometime in the late 1990s, our specialty began to recognise the importance of evidence-based practices. We conducted numerous well-designed randomised trials focusing on Class II and III treatment, anchorage reinforcement, methods for speeding up treatment, treatment mechanics, and bracket designs. These were genuinely golden times for our field.
Unfortunately, since then we have faced challenges to evidence-based care through misinformation. For instance, there has been a rise in myofunctional orthodontics and orthotropics, methods aimed at moving teeth more quickly, and the emergence of orthodontic breathing specialists. This brings me to an important question: Are the advocates of these treatments deceiving us and simply ignorant of research methods, or are they overly optimistic about outcomes that may not be achievable?
Where are we now?
I want to examine a theoretical study that claims orthodontic treatment alleviates childhood sleep-disordered breathing. Upon closer inspection, we find that the study suffers from several issues, including selection bias, inappropriate statistical methods, selective reporting, a lack of sample size calculation, and limited data presentation. Despite these shortcomings, the study reported a positive treatment effect and was unfortunately accepted by a predatory journal. We must consider whether the authors deliberately produced a poor paper to support their beliefs or if they genuinely tried their best but lacked knowledge of proper research methods. We cannot determine their true intentions, although we may have suspicions.
Next, we should consider the Key Opinion Leader who receives a substantial payment from a company. They want to contribute to the profession by sharing their cases on social media. However, these posts showcase a series of poorly treated, unfinished cases. Should we view this as a lie or simply a misunderstanding of acceptable standards of care? The truth is, we do not know.
This is our dilemma.
Solutions?
In the short term, we should raise questions about these outputs. We can do this at conferences, on social media, through blogs, and in academic journals.
I have attempted to do this on this blog for a few publications. I received a lot of “social media heat.” I will continue to raise issues with poor papers that make claims.
A highly respected academic orthodontist once warned me that I may run out of energy constantly playing “whack a mole” with these papers and other outputs. At present, I still have a lot of energy so I shall continue.
It would also be great if conference organisers make sure that speakers take questions about their presentations. Some conferences do an excellent job of this. However, others allow speakers to spout total nonsense and do not allow time for questions. This is an easy change to make.
Additionally, we could tackle the lack of research training or experience on training programs by embedding research methods in the curriculum. However, this is a long-term goal that will not resolve immediate concerns.
Finally, we can focus on ensuring that we are individually knowledgeable. This way, we can identify whether erroneous conclusions arise from dishonesty, ignorance, or simple mistakes. Ultimately, like many aspects of life, we must decide, as individuals, what action to take.
Emeritus Professor of Orthodontics, University of Manchester, UK.
As always an interesting blog
A tiny part of the solution would be for the BOS to employ a statistician to write a report on each publication and to provide help to contributors surly money well spent
You suggest statisticians, while others present the issue as lack of methodological knowledge. The question that you might have asked is how and where clinicians update or gain new knowledge. Is it in academic papers that nowadays only seem to fatten publications’ lists? This is why I’ve followed this blog for decades: trust and quality. When a myriad of courses arise, I wonder whether the new generation of clinicians should be trained to understand advanced statistical methods and models that easily mask to the “uninitiated” the intended and misleading methodological flaws. This is about acknowledging our own preferences in career choice, and our strengths and limitations as clinicians. This is about the circular business of academies linked to professional dental associations that ask us to pay their fees while trusting their self-proclaimed experts to enlighten us in our journey. Solutions? Speak up and help holding accountable dishonest individuals and the institutions that support them. As suggested by Prof. Em. O’Brien, you might re-discover the pleasure of making yourself knowledgeable again.
Parabéns pelo post, eu me vi representado de corpo e alma nesta reflexão, concordo com seu dilema e vou além, creio que muitos estão agem com ignorância, e outros tantos pela má fé, mas acrescento outra categoria, daqueles que estão sendo muito criativos, mirando apenas o dinheiro que porventura venham de pacientes iludidos com tratamentos milagrosos sem nenhuma evidência. Trristes dias de nossa nobre especialidade.
Translation with google
Congratulations on the post, I saw myself represented body and soul in this reflection, I agree with your dilemma and I will go further, I believe that many are acting with ignorance, and many others with bad faith, but I add another category, those who are being very creative, aiming only for the money that may come from patients deluded by miraculous treatments without any evidence. Sad days of our noble specialty.
Is orthodontic misinformation lies, mistakes or ignorance? Simplistically, I think the answer lies in what lens it is being viewed through and by whom. I share your concerns on this and so much more
Thank you Kevin for looking out for all of us. I say that with respect and skepticism. When anyone professes they will show us what is true or not true, my thoughts immediately turn to Ignaz Semmelweis, the father of modern infection control, who was laughed off the stage by his fellow physicians for promoting hand washing which he discovered empirically. They couldn’t SEE germs at that time.
Quantum Physics is demonstrating what we don’t yet know. In the 1980’s, our profession was scrambling, in reaction to a lawsuit, to literally anything to disassociate tooth movement from TMD, even one Journal article that claimed the teeth and TMJ weren’t connected. Later studies concluded we don’t grow jaws, but that the jaws move because orthopedic repositioning caused the physiology of the body caused apposition of bone on the condylar head and on the inferior part of the inner surface of tm fossa.??? So, we were “growing” jaws, just not the way we thought.
We have seen the shame and sham of “evidence based” material, even to the point of seeing our journal articles that quote one “evidence based” article, and later quoting a different EBA, that claims the Exact opposite.
We are aware that many EB articles are written to justify a bias or promote sales. Shameful, but that exists.
So, my best wishes for you in assuming to be the watchdog of our profession, but please be careful with your own biases. Even true watch dogs sometimes bite innocent people.
Your post was excellent…having practiced for 44 years and teaching for 25 years I questioned some of my solutions to common problems
Was I making the patient better or were the solutions following a KOL without evidence
I tried to have the residents look into peer reviewed journals to see if the treatments proposed were sound with good outcomes. I can only hope that I made some residents consider proper treatment
This topic is very close to my heart because, at the beginning of my career, I believed in many orthodontic lies. Later, I became part of the system and, in some ways, contributed to spreading them.
Sometimes, I wish I could be more ignorant—because ignorance can be bliss when you don’t fully realize the impact of your actions. But over the years, I have continuously reflected on this, questioning why misinformation persists in orthodontics.
Beyond character flaws, unfair behavior, or the temptations of money, I believe one major factor is the lack of professional education on how to handle truth and misinformation responsibly—both the good and the bad. Are we truly taught how to navigate truth in our profession? 🤔
But now, I’ve learned that truth is not painful—so why tell stories or hide? The real story of orthodontics is truth itself, and sharing it is easy, interesting, and necessary. Collective dishonesty holds back progress, keeping us in a cycle of stagnation. We’re not evolving—we’re just circling in a crisis.
So, let’s all try to be a bit more honest—it starts with education, professors, authors, researchers, and lecturers. At least, I try to be more truthful every day and protect the next generation. Because truth isn’t painful—it’s powerful, and it’s the coolest thing we have. 🔥💡
This is a great post and one that needs attention from many. Based on what we have seen thus far and the evidence produced, it is safe to conclude a few things. Anyone making claims re: expansion to cure Airway issues, extractions causing Airway issues, Myofunctional therapy to prevent relapse, Aligners for Expansion and Customized brackets leading to faster/better etc. is indulging in deception and lies. It is time to call things what they are. The proponents not only do not have the data, they DO NOT want these claims evaluated with clinical trials. For then the truth will be revealed, and that will affect the bottom-line.
exactly!!!!
So black and white, so willing to dismiss thousands of patients and parents who have had remarkable improvements in their child’s health with airway expansion and myofunctional therapy. I understand that this is not your approach and therefore you cant understand how an airway approach could work. All these dentist must be out to take advantage of their patients. There is not enough data to support it so just dismiss it right? And better yet call them all liars and claim that everything done with-in standard of care is the “only” good medicine. I have been working with dentists for a decade now and the one thing that is safe to conclude is that you all love to tear each other down instead of collaborate. You can’t disprove it and they haven’t proven it yet. Perhaps both sides of this argument are too dug in at the heels. As a medical doctor I wish both sides of this argument would put the ego aside and come together to work whats best for the patient and have less concern about promoting their dogma.
Kevin
Keep up the good work. I well recall those days when we thought that if we designed the correct functional appliance then we could grow mandibles. We have since learned that we must live with the biology as it is and not as we would like it to be.
Regards from retirement
Our profession needs more truth tellers and less charlatans!!!!!
The adverse outcome if resulted from mistake then it can be Malpractice…
In case of Malpractice Ignorance is not a Valid Defense…
Misinformation happens everyday and everywhere…
As long as it does not cause damage then the dentist gets away clean….
Hi Kevin:
So where is the evidence for your opinion? I say that facetiously as a joke 🙂 However, Dr Spencer hit the nail on the head. The mandibular growth issue cannot be explained on the basis of 2D cephalometric data – but the mechanism he postulates regarding TMJ remodeling is encompassed by the Spatial matrix hypothesis, using statistical shape-space as a tool.
Regarding lies, more lies and statistics, orthodontists might need to do a little more introspection since they are the readers of orthodontic literature. In other words, when an article is submitted for peer-review prior to publication, it’s the duty of the Reviewers to sort the corn from the chaff. If poor papers end up being published, then the authors cannot be ‘blamed’ if the Reviewers failed to point out the deficiencies. However, peer-review is a rather nuanced procedure. Sometimes, the Editor overrules the Reviewers and decides to accept the manuscript even tho’ not all Reviewers hold the same opinion. Some Journals/Editors have a very low-quality threshold and simply want to publish the next issue. So, let’s say a poor study is published – the story does not end there. It’s the duty of orthodontic readers to address the issues. This is most often done by writing a Comment or Response where the authors have a chance to offer a rebuttal. This is an accepted scientific procedure (instead of taking to social media and berating the piece). Retractions have been made in other journals, so why not in orthodontic journals?
so
1 “without deviation from the norm, progress is not possible”
2 “all progress depends on the unreasonable man”
Now you can argue the merits of either quote, but getting better results requires doing something differently. What I think is needed is an idea for how long you can keep doing something different, and how different it can safely be, before you have to objectively analyse it and offer it to analysis by peers to see if it stands up.
Stephen Murray
Swords Ortho
Great post Kevin.
I think the drivers towards critical appraisal, both in terms of science and biomechanics, are subdued by 2:
1/ ‘game changers’ – a solution without drawbacks. The appeal of an easy fix draws people in (especially inadequate orthodontists like myself), however there is rarely a discussion of risk, limitations, and cost
2/ Lack of availability of critical appraisal – most orthodontic programmes include critical appraisal, however post qualification there is little availability of this approach (with the notable exception of your blog Kevin). Contrary to this there are experts who continue to educate in terms of clinical techniques which is widely available. Although publication reporting tools and peer review journals uphold the notion of critical appraisal, their readership may not be as popular as once was. Which leaves conferences and social media as a non-peer review process with varying and an optional approach to ‘critical appraisal’
It would be great to have more critical appraisal, such as your last post Kevin, exploring a systematic review with weaknesses in the papers they included
Thanks for your blog post. I often ask myself the same questions.
I have reached the conclusion that what starts as ignorance can become lying once individuals or organizations are pushed for information that supports their claims.
Said otherwise, what starts as ignorance becomes evil once money is flowing into provider’s hands…that’s usually the source of ongoing misinformation. What started as a lack of education becomes evil once they get used to the cash flow. At that point, choosing the lie over loss of money becomes easy, and likely seems necessary.
Keep writing, Dr. O’Brien.
Dear Kevin and other respondents,
Thank you for raising this important topic and your input of opinions and ideas.
The state of the literature shows us that we still have along way to go to solving our problems.
There are many sources of how to conduct better research but it seems that they are for other people to use and we know that the profession’s knowledge of statistics and critical thinking skills is lamentable.
I very much enjoyed Bjorn Ludwig’s contribution _ it is alright for to not know the answers, but be honest and self critical, retain a curious mind and leave your ego at the door as it does not benefit our patients when we , their interpreters of the evidence based research ,don’t do our jobs.
Quality research is a tough gig with many disappointments ,painfully slow and rarely many moments in the spotlight.
I often wonder if we had to pay our patients to treat them, how many of these fringe treatments would be undertaken.
Finally, I am reminded of a few of Lysle Johnston’s “one liners”:
-In God we trust – all others bring data.
-Those with the passion, don’t have the data & unfortunately those with the data, have lost the passion.
-Be skeptical not cynical !
The current state of knowledge is always changing so we should be open to the challenge of new ways of looking at old problems but it is up to the salesman to provide the proof not for the buyer to prove that something does not work which is where we find ourselves all to often in this time of KOL and influencers.
To those who do the drudge work of quality research, I thank you because you are the only way forward.
Thank you for your sage words for so many years. I view your blog as one of the last bastions of reason in orthodontics. Far too many of the young among us rely on online groups for help and information which nearly always have not so obvious financial goals.