Is the orthodontic fringe quackery?
My recent post on the airway and orthodontics at the 2023 AAO Congress resulted in a lively discussion. This has led me to revisit a post that I wrote in 2015 on orthodontic quackery. There have been many developments since then. Here is my update.
Accepted orthodontic practice
An excellent place to start this discussion is to consider the definition of evidence-based medicine. This is the classic definition.
” EBM is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients”
However, this is rather basic and does not always align with the contemporary concept of evidence-based care. As a result, I would like to add that we may include the views of practising physicians and the recommendations of learned societies, but only when high-level research evidence is absent.
Furthermore, it is essential that when this evidence is not available, we must not make claims for treatment that we cannot substantiate.
Importantly, these definitions enable clinicians to develop new ideas and treatments that can be tested using appropriate research methods. In orthodontics, this is usually RCTs but does not exclude other approaches where randomisation is impossible.
We now need to consider what a clinician should do if they develop a new treatment method or philosophy. Importantly, there is nothing wrong with them sharing preliminary findings. Nevertheless, they should not make claims for the treatment without more robust scientific evidence. It, therefore, follows that they should carry out further research. This is an ethical way to practice.
It is patently wrong to make claims in the absence of evidence.
The fringe and quackery.
Undoubtedly, orthodontists have developed treatment methods using empirical knowledge and research methods over an extended period. However, we are now in an era in which we should study the effects of most treatments using high-level research. But if this is not done and the promoters of the treatment make extreme claims, can we consider this to be quackery?
We can define a quack as someone who
- Promises benefits from treatment that cannot be reasonably expected to occur.
- Recommends against conventional therapies that are helpful.
- Promotes potentially harmful therapies
- Promotes magical thinking.
- Empties patients’ bank accounts.
It is also essential to consider that the quackery practitioner promotes techniques knowing that they are misrepresenting the risks and benefits of their treatment.
So what is orthodontic quackery?
At this point, defining orthodontic quackery is complex. This is because many treatments have developed over time as standard clinical practice. This includes using pre-adjusted fixed appliances, the extraction/non-extraction debate and the definitions of the need for orthodontic treatment. Examples of innovations honed by research are TADS, the effects and indications for functional appliances and the early treatment of Class II and III malocclusions.
I would now like to consider what we can classify as orthodontic quackery. This ever-lengthening list must include
- orthodontic treatment for TMD,
- our old friend self-ligating brackets that develop bone and avoid extractions.,
- any method of increasing the rate of tooth movement, particularly vibration, magic lights and MOPs,
- extreme claims about the effects of functional appliances and myofunctional orthodontic treatment in growing mandibles.
- The use of the Carriere appliance to change the skeletal pattern and modify airways.
- The orthodontists who claim to treat a high percentage of cases non-extraction.
- Orthodontic treatment to cure breathing disorders.
Conclusion
Now I have revisited orthodontic quackery; my original conclusion is still valid.
“The lack of evidence for some treatments and the blurred lines between others make it difficult to differentiate between accepted and fringe/quackery treatments. As a result, we can only classify quacks as those who know they are making claims contrary to our evidence”.
This means that those who ignore published high-level research findings or recommendations made by our specialist societies on treatments are simply orthodontic quacks.
Emeritus Professor of Orthodontics, University of Manchester, UK.
I think that some dentists who are promoting 3d direct aligners without clinical evidence and with evidence that advises against their use due to excess monomer should also be included.
That post should generate a large response from…….orthodontic quacks!
Hi Kevin,
So how can you be so wrong?
There is a type of evidence called clinical observation, which cannot be denied.
I have a series of 130 CBCT pre and post slow expansion.( similar to mew s) Dr manuel lagrave had used them for a study which did not get published.( due to lack of controls) .
It works ! Even though it was not published!
Mostly non extraction treatment? …yes, that too works. Its not quackery.
Some things are not easy to publish ,especially philosophies.
It’s a nicely penned scientifically supported article and observations. Definitely there are people who promote such procedures. However, when I see at a grass root level, the quackery has deeper roots in dentistry. So much that everyone is an orthodontist nowadays. They learn from YouTube and project themselves as qualified orthodontist. Since the availability of niti wires and straight wire appliances, even a dental technician is doing orthodontics. So quackery started so called since 1970s in orthodontics. I know my comments are not relevant to present blog, but in larger sense, are damaging for patients.
As ever you speak very wise words.
After nearly 39 years in orthodontics, I have today completed my final case and put the pliers on the rack. Whilst there have been many huge improvements in orthodontics over the years,I believe the rise of quackery is a reflection of the post factual, self-centred world which we inhabit. This has enabled the unprincipled to thrive, by preying on the fears of the unknowing.
Quite what the answer is I know not, but it is essential and invaluable that people such as yourself are prepared to put their heads above the parapet and call these people out.
Gareth, I agree there seems to be less and less space in the middle ground. Best wishes on a long and happy retirement.
I would include those who promises better and faster results using Invisalign or similar when comparing to those treatments with fixed appliances. For me its part of the job explaining to the patients that the information they saw about a faster treatment in some Invisalign ad is fake. Thank you for your valuable contribution with this blog Dr. Kevin.
Since there is no oversight of claims from either a legal or even ethical perspective expect this to continue and likely worsen. In medicine placing breast implants the size of volleyballs or doing facial plastic surgery until the person no longer looks human is obviously almost ubiquitous with obviously no repercussions ,should we expect better in our profession ? Doctor Google is neither honest or ethical an uphill battle with a very few Don Quixotes.
Art
Generally speaking, I agree with Kevin, but a few other factors have to be taken into account. First, by nature, the scientific approach is skeptical, and I have no problem with that. The issue is when skepticism changes to cynicism and any novel development is rejected like a knee-jerk reaction. This sometimes happens when a new (often technologically-based) technique disrupts the status quo, which more often than not is based on historic/outdated research/techniques. Worse still, our orthodontic residents are taught a rather narrow curriculum and pick up the biases of their professors, which leads to a vicious cycle of calling out “quacks”. Here, we have to think about quackery vs mockery. It’s OK to point out a lack of evidence, unsupported claims, etc. but it has to be done dispassionately. The use of emotive terms/graphics (such ‘snake-oil salesman’) have no place in a professional, scientific discission. On the other hand, I completely agree that claims based on “imagination” (for example, forward growth using anterior growth guidance appliances or orthotropics) that fail to provide a viable underlying biologic mechanism(s) when tested, need to be identified and avoided, bearing in mind the three rules of medicine: 1. Do no harm; 2. Make no assumptions; 3. Be better than placebo.