January 23, 2020

KOL claim of the month!

I have decided to write a new monthly series of posts called the “KOL of the month”.   I will look at some recent claims made by a KOL,  and contrast these with scientific evidence.  Our first KOL claim of the month is by Dr Bill Dischinger.

Dr Dischinger got his specialist training at Tufts in Boston in 1999.  I want to discuss his recent article in a magazine called Orthotown.

BuzzingThrough Treatment

Orthotown November 2019.

Orthotown is a magazine that includes articles on practice management and case reports.  As a result, it is not a scientific journal. However, we still need to look critically at the claims made in these magazines as they are intended to inform clinical practice.

This article is a clinical case report about the treatment of one patient treatment using Damon brackets. As part of the therapy, Dr Dischinger also used PropelV Pro High-frequency device.

What are the claims?

In the article, he outlined a simple non-extraction treatment of a mild malocclusion in an adult. This treatment took 37 weeks.  He made several statements about Propel and Damon brackets.

“I often recommend this device (Propel) for an improved orthodontic experience, whether bracket or aligner therapy, because high-frequency vibration (HFV) breaks down the bone during treatment, builds bone in retention, can get a retainer vibrated back into place (retention guarantee), and it works very well in increasing predictability and aiding discomfort, particularly in adults”.

 

“Because I had confidence that the patient’s movements would express quickly and predictably, I decided to shorten his appointment intervals from my normal eight weeks down to six weeks, and eventually five weeks”.

 

and…

 

“Increased competition and pressure from corporate orthodontics to control our fees force orthodontists to be as efficient as possible. By incorporating high-frequency vibration and passive self-ligation in my braces cases, I can be far more efficient, and patients are very grateful to have a quality, orthodontist-delivered finish in a shorter period of time with reduced discomfort, as well as a bit of an insurance policy for retention”.

His final summary comments were:

“I believe with advancements such as passive self-ligation and high-frequency vibration, the future of orthodontics is bright for both patients and orthodontists”.

What does scientific research tell us?

The evidence is clear, and I have posted about this before.  We know that there is an absence of evidence for the acceleration and reduction of discomfort by vibration. There is also no evidence that self-ligating brackets increase the speed of treatment or reduce pain.

Dr Dischinger does not mention this research in the article.

Dr Dischinger is a KOL for Propel and listed on the speaker’s bureau for  Ormco.

He has received just over $600K from Ormco from 2016-2018 according to Open Payments.  There is no record of payment from Propel. 

He did not declare a conflict of interest in the Orthotown article.

Finally, I would like to emphasise that there is nothing wrong with being a Key Opinion Leader for a company, as long as a potential conflict is declared.

 

 

 

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Have your say!

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    And 37 months!!??? For a simple case ???

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    Dr. O’Brien, Unfortunately, I think you could write one of these every day.
    Thank you.

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    Ormco KOL is a family thing. Dad, Terry Dischinger, was a big Edgewise Herbst guru for Ormco years ago.

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    Orthodontics is not dying, it’s dead

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    Dear Professor O’Brrien,
    This is a tough blog to host as it might put you at odd with many Gurus and KOLs. However the ortho community is better off because of it. Thank you very much for creating this blog. Looking for to reading it monthly.

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    Thank God there are people like you to question the exaggerated claims of manufacturers and their lecturers (promoters)…sadly the harm to unsuspecting patients related to corruption of the dentist education system has been horrific for decades with full mouths drilled to stumps for instant ortho, then to restore mild wear, to headaches, migraine cures and even wrinkles. Fortunately the harm from quicker ortho claims has been more to the pocketbook of the victims- provider and patient- than to the teeth themselves. It will be good to eventually learn what really helps reduce orthodontic treatment time besides a shorter payment schedule.

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    The Holy Grail of “shorter treatment times” may be within our reach if we will all stop being bamboozled by claims by manufacturers of X Y and Z new gadget (which is really just a re-purposed gadget from years past in a shiny new box) that is supposed to make teeth move faster.

    KOL’s who are still promoting self-ligating brackets and vibrators should be put out to pasture. We need some new KOL’s.

    Osteoclasts and osteoblasts have a molecular relationship with the pdl. We can’t change the fundamental laws of the universe as described by Isaac Newton in the 17th century. We don’t really have a nuclear option. Quantum mechanics are not readily applicable to moving teeth.

    The way to get to the end faster is by planning and using logical steps in our treatments. Applying the right tool for the job also helps.

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    Dear Prof. O’Brien

    For too long have the minds of young orthodontists and dentists been swayed by unfounded claims of better, faster and even magical orthodontic treatment. It’s about time the academic community “called them out”. You have our full support!

    Prof. Ahmad M. Hamdan
    Dean and Professor of Orthodontics
    School of Dentistry
    University of Jordan

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    Great response John Wise! Your wordsmith talents are quotable (and if I do quote you), I WILL give you credit as the kol of Ortho wordsmithery!

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    Unfortunately, orthodontists have been inadvertently conducting clinical research for orthodontic manufacturers for a long time. Remember, ceramic brackets? Did anyone place Md ceramic brackets only to see the patient’s Mx incisors be worn down at the next adjustments. Yikes! Then there is the MBA venture capital initial concept of clear aligners. First for the orthodontist, then for for anyone when a dental license, then on to today and any patient perform their own aligned therapy. What’s next? Orthodontics is a wonderful opportunity to help so many people in a life changing way, but it is not easy, in fact orthodontics is a very challenging art and science. I’m thinking that perhaps Larry Andrews needs to remind Every orthodontist to raise the bar and continue to aim for great occlusion and beautiful esthetics. Don’t settle for quick and easy.

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    It is disappointing that organized dentistry has chosen to be part of this problem. For many years the American Dental Association has certified corporately sponsored courses through “ADA CERP”. Quoting directly from ADA CERP “Standard V.1 requires that educational objectives, content development, and selection of educational methods and instructors must be conducted independently of commercial interest.” Many major corporations highlight their ADA CERP credit status. After decades of allowing violations of their own standards, ADA CERP now claims that effective July 1, 2023 they will no longer certify “commercial interest” events. After this lengthy compromise of their own standards, it is easy to question why ADA CERP is not willing to correct their own behavior and immediately retract certifying corporately sponsored events.

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    For at least 15 years I cannot think of a single dental study, in general, or orthodontic study, in particular, that has lead to clinical innovation used in practice. There have been many new products but they have been entirely derived from capitalistic companies or from individual clinicians trying to solve problems.

    It’s entirely fair and appropriate to criticize so much of the KOL junk science. But the orthodontic research community has not exactly been doing anything brilliant to justify as suitable jurors to said deplorables.

    KOL garbage is balanced by academic hubris leaving the science or ortho to essentially being: “it works in my hands.”

    Both sides are pathetic.

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    Prof.O,Brien,excellent work .
    I fell for all this KOL stuff earlier in my career.I have a shelf full of useless gizmos.
    Keep the science flowing !

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    I just read an article in the NY Times which refers to these claims as JUNK SCIENCE. This is an appropriate term to be applied to these corporate claims and their paid so called “Key Opinion Leaders”

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    Ha ha – brilliant, waiting for more!

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    Dr. O’Brien. Thank you for taking the time to review the treatment summary I submitted to The OrthoTown Journal. I do want to apologize for not listing myself as a KOL for Propel. Having never received any free product or payment from the company I had never considered myself to be one, but given they consider me one as listed on their website, I apologize for not disclosing that fact.

    Orthodontic research is a funny thing. It is not difficult to find research to support or dispute virtually any claim. As a clinical orthodontist, I try new techniques and evaluate if they work in my hands. As mentioned above regarding research, we have seen articles that show this decrease in time and confirm the biology effects of vibration (there are in fact quite a number of compelling published research articles on the positive effects of vibration), and as you mentioned, we have seen articles dispute that as well. Which research is correct? When confronted by conflicting research I rely on the experience within my own practice. Based on the first hand results in my practice, these modalities have been a positive, both for myself and reported to me by my patients.

    I believe the future of orthodontics can be and will be bright. We have a wonderful specialty that I know you and I both love and want to protect. We have such a positive impact on people’s lives every day. I know you may disagree in how I show my support for the profession, and that is ok. I respect all you have done for our profession and I hope you continue the great work you do in helping to preserve our specialty.

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      Thanks very much for your honest comments. However, I am a little confused when you say that there are studies that support the concept of vibration. I assume that you are meaning some of the early retrospective work. These have now been superseded by randomised trials that have shown that there is no evidence that vibration has an effect. As a result, I (and many others) do not feel that the research is conflicting. In this respect, there is no need for orthodontists to rely on their clinical experience, the research has given us the answer. Again, thanks for your comments.

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        Thank you for responding to my comments Dr. O’Brien. I am actually referring to some of the more recent research. I certainly do not claim to have full answers, but I do see positive implications from it. I have included some links to some of the more recent research here.

        https://www.ncbi.nlm.nih.gov/pubmed/30397398 (Judex)
        https://www.jwfo.org/article/S2212-4438(18)30164-4/fulltext (Alansari)
        https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5937741/ (Alikhani – paradox)
        https://www.ncbi.nlm.nih.gov/pubmed/26672126 (Alikhani – preservation)
        https://www.ncbi.nlm.nih.gov/pubmed/30547016 (El-Bialy, Shipley – OTM)
        https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6702681/ (El-Bialy – Retention)
        https://www.ncbi.nlm.nih.gov/pubmed/30002296 (Shipley)

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          Thanks for your comments and the list of studies that you feel support the claims that you are making. I have had a look at them and I have the following comments to make:

          Judex: This was a study on an vitro device, which was essentially a plastic box with tissue cultures.
          Alansari, this was a poor overcomplex trial with multiple drop outs and protocol deviations, the differences that they detected were not clinically significant. I have not come across this before and I shall review it on my blog.

          Alikhani x 2. These were animal studies. Importantly, the results of animal studies do not translate to the human clinical field and they cannot be relied upon to support a change or recommendations for practice.

          El Bialiy x2. These were retrospective studies and are a low level of scientific evidence.

          Shipley. This was a low powered pilot study characterised by large deviations and high uncertainty. The authors acknowledge this.

          All these papers were published in small journals that would not be considered to be mainstream.

          When we look at the trials that have been published in the orthodontic literature they all suggest that there is an absence of evidence for the effects of vibration. I have blogged about them and these are the relevant posts. I hope that you have read them and can see the differences in the methodology and conclusions.

          Vibration and invisalign, AJO 2018 https://kevinobrienorthoblog.com/acceledent-invisalign-treatment/

          Duration of treatment with fixed appliances AJO 2018 https://kevinobrienorthoblog.com/new-trial-on-acceledent/

          Space closure AJO Jan 2018 https://kevinobrienorthoblog.com/no-evidence-that-acceledent-increases-the-rate-of-space-closure/

          UK advertising standards ruling on vibration https://kevinobrienorthoblog.com/acceledent-advertising-breach-uk-advertising-code/

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            Dr. O’Brien,
            I guess now I”m a little confused. The papers you have referenced are all studies done on low frequency vibration. Not one study you referenced was looking at high frequency vibration. There is quite a difference between the two. So, at this point, I guess you are correct, there really is no conflicting research as all the papers you have referenced refer to Acceledent and low frequency vibration not to Propel VPro and high frequency vibration. Of the posts in this blog, I am the only person that supplied research regarding high frequency vibration. I am not trying to be argumentative, but to see my name on a blog, never having been contacted to ask me any questions about the referenced article, felt a little bit like a slander. As we have currently been doing, open discussion is the best way to talk about differing opinions in any aspect of life, and most certainly in our specialty. I saw my dad’s name slandered for years, despite some very good research published in the AJO multiple times supporting his claims. That has always been my biggest disappointment in the orthodontic profession. The tendency for colleagues to tear down one another, usually from afar (and now with social media it is even easier now, case in point this blog) just does not serve our profession in a positive way. As I have stated, I respect the work you do, but it’s apparent you don’t have that same respect for the work I do, but differing as we are, we both love our profession and want the best for it. Now for myself to be going through what my dad went through is yet again, disappointing. I know that putting my thoughts and cases out there will lead to criticism and critique by some people. That’s part of the game, and I know you have dealt with that too. But then, to see that all the research that is being used to slander my name publicly isn’t even applicable to the technology I am writing about just is not right in any way.
            We have choices to make in our life. We can have fair, honest, open debate about differing opinions, or we can sling arrows at colleagues from a safe distance. I choose to be open to the former rather than the latter. I encourage you to consider the role you can play in our profession. You can influence it in such a positive way without hurting people within it. You have done such great work for so many years. So many research projects. Educated so many students. I ask you to be a light of positive debate and set an example of open dialogue that is healthy and helps build our profession upon an ethical foundation.

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            Hi and thanks for your comments. I would like to point out that I stated that there is a lack of evidence for the effects of vibration in accelerating tooth movement. This applies to both low and high-frequency vibration. To my knowledge, there are no good trials on high-frequency vibration. As a result, my feeling is that we cannot promote this treatment to patients when we do not know if it is effective. There is nothing slanderous about this statement, as it is true.

            I decided to do this new series on the KOL claim of the week to highlight claims that are not being supported by evidence. I did this to suggest that perhaps KOLs should be more cautious about the claims that they make, as they have a responsibility to colleagues and patients. As a result, I am practising ethically. I am happy to let you have a blog post to outline your position as a KOL, just let me know if you want to take up this offer. I think that this would be the best forum for you to raise your points rather than the comments section here?

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    The only reason to suggest that the research is conflicting, is if there is a conflict of interest. The nail on the Propel coffin has been nailed shut. Making unsubstantiated or blatantly false claims, is no longer acceptable.

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    I wonder if the faster treatment was caused by the shortened appointment intervals as opposed to the use of Propel.

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      Justin, a very valid question, one in which I ask as well. With aligner treatment, utilizing vibration, I change the aligners 2/week as opposed to 1/week. My cases track very nicely. I am not able to transition that fast without vibration. I have tried, and it has not worked. Many will say it is because the vibration acts like a super chewy, (and if anyone took the time to read my first article on vibration and aligners, I fully admit to that being possible). With cases I treat with brackets and use vibration, I do shorten my appointment interval. Could I do that without vibration? Certainly on some cases I believe you can and I have. For a case like this where I had to gain a lot of mandibular canine torque, I find that to be a difficult, slow movement, and I haven’t seen in my practice the ability typically to do that normally. This was a simple case study submission, not a research paper, so, this is a case study of one.

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    Dr O’Brien, thank you for covering such interesting and relevant issues on your blog; I look forward to reading your posts, and the comments they generate, every week. To all of the Drs who have commented on this post and others: I applaud you all for maintaining civil discourse. I have tuned out of many ortho groups on social media because of the negative spiral seen in the comments section. Respectful and vigorous debate is good for our profession.

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