August 29, 2017

Orthodontic marketing: Are researchers behind the times?

I have written several times about the poor evidence base of heavily marketed new orthodontic materials and techniques. This post is about a recently published paper that takes an interesting look at this problem.

Over the past few years, there have been several developments that companies have heavily promoted in the absence of clinical evidence. For example, self-ligating brackets, micro-osteoperforation and application of vibration. When independent researchers have studied these developments, they have concluded that they have few advantages over conventional methods. I have posted about this before and I have been accused of being over critical, bullying or preaching from an electronic pulpit. Therefore, I was  very interested to see this new paper published in Progress in Orthodontics. This was a systematic review to assess the prevalence of clinical trials in orthodontics that evaluated commercially promoted products after their release.

A team from the East End of London and Bern, Switzerland did this study.


Seehra et al. Progress in Orthodontics (2017) 18:14 DOI 10.1186/s40510-017-0168-y

What did they do?

They did a standard, well-carried out, systematic review that included all the orthodontic randomised trials done between 2012-2016. They recorded data on the following:

  • Region of authorship
  • The marketed intervention and comparator
  • The direction of the treatment effect (positive/negative)
  • Declaration of sponsorship/funding/conflict of interest
What did they find?

They found 84 RCTs. Europeans did most of these (48%), non-American and Europeans published 33% and only 17% were done in the USA.

Interestingly, 45 % of the trials involved an analysis of marketed products after their introduction. The remaining trials assessed non-clinical interventions and non-marketed interventions, for example, growth modification, closing loops etc.

They found a positive effect of the treatment in over 50% of the total number of trials.

Their overall conclusion was:

“Half of orthodontic trials involved marketed products and almost 44% report no improvement related to the product”.

What did I think?

I thought that this was a well carried piece of research. I particularly liked the discussion and the authors raised the following important points.

Firstly, we need to have adequate research as part of the development of  new products.

Secondly,they found that a third of trials focused on speeding up treatment and they showed little meaningful difference in the rate of tooth movement.

They pointed out that the licensing of new products does not require supporting clinical data. Nevertheless, people should not make claims about speeding up treatment, or reducing extractions, when clinical evidence is absent.

Finally, I thought that they made a really important point. This was that academic based research comes at a price in terms of financial and opportunity cost. Importantly, if the companies had done the research before the release of the product, then the Universities could have spent their time and funds on other useful research. This has resulted in a waste in research.

My last comment is a plea to the Key Opinion Leaders, and it may fall on deaf ears? Please think carefully about (taking the money) promoting developments  that lack an evidence base. Remember, you have a responsibility to our patients, fellow orthodontists and academic researchers.


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Have your say!

  1. Lately We published a paper in the Israeli dental journal that discuss this exact issue. Here we did not have a room do discuss the changes made in the profession by the SLB. We called the recent time in orthodontics Post Orthodontics like Post Modernism and other posts period. We have to understand that we are in a post era. Attaced is the paper. Enjoy.
    Post Orthodontics and Alternative Facts
    Dr. Naphtali Brezniak and Agate Krauss
    Post-orthodontics is a new term. It describes the field of orthodontics after the change that has taken place in recent decades. The entry of the Aligners, as an integrated part of orthodontic treatment, (the transparent plates design and made by Align Technology announced the beginning of the change. This article follows the conceptual changes the profession experiences in the last 20 years, from Zia Chisty who invented the commercial design of the Aligners to Amos Dudley who took it a step ahead away from the Orthodontists’ hands, into the Do It Yourself world . (1,2).
    And what about alternative facts? In orthodontics as a medical-scientific field, it is not enough just to introduce a new product to the market. It needs to be scientifically certified through publications of studies in high graded referee journals etc. As we cannot simply take the decision to omit the second power of the central formula in Einstein’s theory of relativity (E=MC2), without proving the change, we cannot change the definition of the physical term Torque, an essential movement in Orthodontics. We believe that lately it was done, and even published in an excellent accepted orthodontic journal. Thus, by probably rephrasing a basic physical definition, and publish it, this alternative “fact” will be quoted again and again in order to convince the profession that the transparent plates are also capable of carrying out Torque (3,4,5). The question arises whether we are at the beginning or at the end of this post-orthodontics period. Only time will tell.
    1. Rolf G. Behrents. Do-it-yourself impressions and clear retainers: A fairy tale. Am J Orthod Dentofacial Orthop. 2016 Aug;150 (2): 205–207
    2. Milton B. Asbell. A brief history of orthodontics. 1990 Sep 98;(3):206–213.
    3. Brezniak N. The clear plastic appliance: a biomechanical point of view. Angle Orthod. 2008 Mar;78(2):381-2
    4. Simon M, Keilig L, Schwarze J, Jung BA, Bourauel C. Forces and moments generated by removable thermoplastic aligners: incisor torque, premolar derotation, and molar distalization. Am J Orthod Dentofacial Orthop. 2014 Jun;145(6):728-36. Erratum in: Am J Orthod Dentofacial Orthop. 2014 Oct;146(4):411.
    5. Brezniak N. It is all about definitions. Am J Orthod Dentofacial Orthop. 2014 Nov;146(5):548-9.

    Naphtali Brezniak MD, DMD, MSD in private clinic in Tel-Aviv and serves as a Consultant in Orthodontics to Clalit Smile.
    Agate Krauss is a PhD candidate in Medical-Sociology, in Ben-Gurion University, Beer-Sheba

  2. A well made point about research being done on behalf, as it were, of the companies that bring new stuff out. Obviously there is money to be made and some companies that produce unproven gizmos will make money from selling the idea before it eventually falls out of favour, so why bother testing it?
    You should see some of the ideas that get pushed around the cosmetic industry, many of them costing 10s of thousands of pounds to buy. The cosmetic industry is full of unproven ideas and I’m afraid we’re part of it. Remember we are the customers for these ideas that we then have to sell to the patient. The patient’s are not the customers for these things, we are, all the companies have to do is sell the stuff to us.
    In an ideal world companies should test their ideas and, if they don’t, then we shouldn’t buy them and probably not do their research for them either. Is any of that ever going to happen? I’m afraid selling useless stuff to the gullible is an idea as old as the hills.

  3. Love that this blog has an app now. Congratulations Prof!

  4. Most of us have attended courses which have the primary intention of selling a new product. A partner returned from one with a $90,000 order for a ‘special bracket’ and continues to believe it is the better choice because he attends courses geared to that brand. I followed another path, but again the other brand claimed to be better so we use different ones in the same office.

    The ‘faster treatment’ concept certainly interested me and I am disappointed to read studies that question the gizmo of the year’s true effect, but on occasion they may help and it means progress. The dental authority needs to be educated to the fact that dental professionals are occasionally being fed misinformation and are not intentionally misleading patients by repeating manufacturer’s claims. None of us want to be guilty of promoting something that is not effective, so it is important to have people such as yourselves speaking out on this problem even when we hate to hear the truth.

    Some of the toughest things to admit must be the false beliefs taught by a professional’s most trusted mentors. We must all be ready to accept the results from properly conducted studies and be more suspicious than we have been. Being ready to admit being wrong at any stage in a professional career can be helpful.

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