July 06, 2017

Quo Vadis Orthodontia – Are we in the midst of a perfect storm?

Quo Vadis Orthodontia – Are we in the midst of a perfect storm?

This is a guest post by Dr Mark Wertheimer from South Africa. This is about his feelings about potential issues with professionalism, new treatments and advertising.

Mark is the WFO Council member for South Africa and past president of the South African Society of Orthodontists. He has been in private practice for 21 years.


A perfect storm is “an expression that describes an event where a rare combination of circumstances will aggravate a situation drastically”. However, it is also used to describe “an actual phenomenon where circumstances occur in such a confluence, that they result in an event of unusual magnitude.”

Orthodontics and the perfect storm

You may inquire how this relates to orthodontics. Let us first consider the combination of issues that confront us at present. Simplistically, let us think of it in terms of:

  1. Motive
  2. Means
  3. Opportunity

The motive in this case is easy to determine as there is a massive network standing to financially benefit from orthodontic treatment delivery.

The means is through the provision of treatment and includes all in the chain of treatment provision who may benefit.

Opportunity includes the fact that there are patients who desire treatment. It also includes the opportunity provided by a rich media network to discuss all aspects of orthodontics, particularly on social media.

Social media

There are many social media groups advertising products and philosophies. Some of these may be useful. For example, those where practitioners present cases seeking advice on how to treat, or showing treatment progress and results.

However, we also have self-proclaimed experts who use social media to promote their philosophies. They frequently use platforms created by themselves or companies that stand to benefit from the philosophies presented. They also use a technique that points out that we should embrace the changing times or fall behind, or even treat patients according to their wishes despite the approach being illogical, possibly detrimental, and possibly bordering on malpractice.

The mainstream literature provides much information on a multitude of pertinent aspects regarding the practice of the specialty. However, the sometimes-inconvenient truths therein are the subject of cognitive dissonance amongst many in our discipline.

In addition, we have treatment modalities promoted by companies via marketing with huge budgets.

The effect of advertising

The primary aim of orthodontic companies is to keep shareholders happy with a healthy bottom line. To sell their products they, of course, advertise. A current advertising approach is to convince practitioners that it is easy to use their product. The target is not only the specialist but the general dental practitioner. Importantly the GDP does does not have the orthodontic knowledge of a specialist, and is may be easily influenced. Various forms of customized setup and aligner therapy are examples of this.

These treatment modalities are also attractive to the public who are interested in orthodontic treatment. They are also attractive to many in the profession since they provide a source of income, sometimes without the expenditure of huge effort or resources.

What is there not to find attractive with this? We have graduates of orthodontic residency programs with huge accumulated debt that they need to service, who are anxiously seeking their slice of the pie. In some instances,  key opinion leaders who have their ear and credibility merely because they have loud voices, influence them. Furthermore, the KOLs are given a podium to preach their message from, have a presence on social media or even publish their own orthodontic magazine!

Social media based treatment planning

Social media has provided a platform for communication of treatment approaches. Importantly, diagnosis and treatment planning are often reached by consensus on these platforms. As a result, the final plan is possibly influenced by the forceful nature of the persona who advocates it.

Ponder a recent example of a case posted by a general practitioner wishing to carry out her first case of treatment with the admission that she had never done it before. She asked for fellow members of the Facebook group to help with the treatment plan.

My question is as follows….

“How would you feel as a parent knowing that your child’s treatment plan was hatched on Facebook by people who’d never seen her and examined her and themselves weren’t specialists”?

They were suggesting a treatment approach to the treating practitioner who didn’t know where to start and would be continuing to manage the treatment which she’d never done before and didn’t know where she was going to end up. This is hardly comforting, in my opinion.

Learning from the past?

We went through the years following the Brimm case which led to TMJ being investigated in relation to orthodontics. Then came the effect on facial aesthetics, and now, it’s all about sleep apnea. The question is whether orthodontic treatment, especially that involving extraction, is related to any of these three issues. But, is that the correct question? I believe that the correct question is rather – Is it possible with inappropriate treatment to influence the TMJ, facial aesthetics and sleep apnea? My answer to that would be ……. certainly!

In all three instances, we have had fringe champions promoting an all or nothing argument and throwing out a challenge to everyone to disprove them. Researchers have used considerable resources to discover little of this matters when sound logic could’ve come to the same conclusion. Some have read too far into these conclusions and veered off in the opposite direction…and then, depending on where their personal interests and beliefs fell on the spectrum, we ended up just arguing in circles instead of progressing. Does the real answer not lie in learning as much as possible about the topic, with objective assessment, and individualized treatment based on the patient’s needs and treatment goals. In addition to an evidence based approach that leads us to the ultimate treatment plan?

The plastic “revolution”.

We have been through the era of examining the proposed advantages of self-ligation and more specifically, the creation of bone. Lysle Johnston referred to this as the appliance “speaking the language of the cellular environment”.

Today we have the “Fantastic Plastic Revolution’’. Whilst aligner therapy has its place.  The question that needs to be asked is whether the boundaries are being pushed unrealistically, and if so, by whom and for what reason.

Two major methods of creating space to accommodate crowded teeth include expansion and IPR. There is much evidence to suggest that there are limits to expansion and the belief that this may be more stable purely because one is using “Fantastic Magic Plastic” seems somewhat lacking in foundation. We have little long term data on the effects and stability of aligner treatment as well as that of aggressive IPR. What will the future hold? Are we to believe that “Fantastic Magic Plastic” has the ability again to communicate via some “special communication” with the biological environment?

Various media bombard practitioners  expounding the advantages of various treatment modalities.

Paradoxically, when “things don’t work out” the practitioners forget their scientific training. They do not query the gurus on why the appliance/philosophy is not working. They simply accept the guru’s message which is to persevere and have faith or you must’ve done something wrong, because it doesn’t suit them to admit the truth.

The perfect storm

In summary, I fear that we have a cascade of events with multiple influences in the direction that drives financial gains. Not only a cascade of events but a combination of influences promoting the approach. Whilst some may consider this to be over dramatic or maybe even melodramatic. I wonder if it lays the foundation to a “perfect storm”?

Where will this leave our specialty? If the research is one day forthcoming that refutes much of this treatment, will orthodontics have been reduced to quackery? If that is the case then all in the profession are likely to be tarred with the same brush. Importantly, the specialty as a whole will be tainted.

Who will have been the architect of this catastrophic event? Will we have given the various detractors ammunition to use against us? Have we been complicit in allowing this to go so far that we now have a runaway train?

Is this a time for introspection by the members of the specialty. Or should we merely march forwards without giving it any thought whatsoever and contemplate the epitaph on the tombstone of orthodontia?


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Have your say!

  1. Thanks for a very good position piece : IMHO the bottom line is that we are failing in undergraduate schools in failing to teach students the necessary critical analysis and reading skills and failing to empower students to question. Too many teachers in dental schools begin the ‘guru’ mindset training by refusing to engage students in questioning and challenging their teachers and the evidence for clinical decisions. This allow the KOL gurus to propagate the do not question in postgraduate ‘education’

    To often at dental school students are told ‘well, it works for me’ or similar cr***, rather than explaining the evidence based reasoning for their decision. This obviously means teachers need to be self confident in their own clinical skills and knowledge of the evidence – something that is reducing as dental schools rush to be the best at research and ignoring the importance of teaching

    • You’re correct Ross. I can’t talk for other countries but we’ve noticed that the calibre of the residents had changed and many just want an easy way out, a cookbook approach to treatment and the opportunity to delegate. Customized setups facilitate this approach too

  2. Add to this home treatment kits made available by mainstream manufacturers under the guise of alter ego agents.
    Never fails to amaze me how unaware many of us orthodontists are about some new ortho revolutionary technique out there that many of our dental colleagues have been introduced to by “their” journals. They are genuinely surprised we have not heard of it. Parallel universe. Fake news indeed.
    We cannot solve this individually. We need “organized” dentistry and orthodontics as in AAO, ADA and other national associations to take this threat seriously. If not we will cede control to entities that don’t have the public’s best interests in mind!

  3. Right on target. I am afraid the specialty is going back to a small room up over the barber shop!! Dr. Behrents, AJO/DO Editor in Chief, allowed me to do a guest editorial for AJO/DO. It was entitled” Our perfect storm:One orthodontist’s opinion and was in the May 2016(vol149, #6) issue.
    Jimmy Vaden

  4. It is funny that patients are happy to pay more for Fantastic Plastic even though it takes longer and isnt as good a job as braces. I just cant fathom that thought. In saying this we do it in our practice. I refuse to and give it to the younger dentists in the practice.
    And how does a general dentist refer to an Orthodontist now a days. Some are Damon only ( and we know all about them). Some are restricted to invisalign. Some believe in early intervention. Others don’t. Going to an ortho conferance the orthodontists fight with each other as they all bring out research backing what they have to say. So which Orthodontist do you pick to send you patients. Or do what 1000s are now doing and doing their own Ortho. I always believe that a good relationship with a good friendly orthodontist that has the same philosopy as you is very important. Just harder to find now a days. ( I am a senior lecturer for Progressive Orthodontics by the way)

    • “even though it takes longer and isnt as good a job as brace”?

      Evidence supporting that assumption please?
      The previous KO’B blog reviewed some literature that contradicts that point of view, did it not?

  5. Mark, I agree 100% with your ‘essay’ on some serious issues facing our specialty. I am amazed how some highly educated professionals fall prey to self professed ‘gurus’ who only want to sell their appliance, and courses . Sometimes I wonder if we educators have missed instilling the value of evidence based life long learning. Blame can be passed all around, orthodontic product manufacturers come up with all kinds of claims with no supporting data. It falls on academic researchers to conduct clinical trials and RCTs to show that manufacturer claims are questionable or absurd. It is quite contrary to medical world where a product goes through 3 or 4 phase trials to get an approval. In orthodontic world product is introduced first and then we try to find out if it works. We can see now this phenomenon with products sold to ‘accelerate ‘ orthodontic treatment ‘. We should not give up and continue to point out issues you have raised where ever and whenever we can. I commend Kevin for his analysis of contemporary issues and articles. Again kudos my friend Mark!

    • Thanks Ravi. All your comments here are true. A question I’d pose to you is whether you have seen a change in the calibre of residents over the years. Of course, once they graduate you have little influence in what they do or what path they follow in most cases. Many just want to go out there and have it easy with a cookbook approach that allows easy delegating and a whole lot of other things too

      • Mark, there is no simple answer to your query. All our graduates choose a path they think suits them. But we know we have taught them how to distinguish good from bad. Rest is on them.

  6. Congratulations for the relevant post Dr. Mark. Your comments seem dramatic, but they are very realistic. Unfortunately, several post graduate programs also have a role in this scenario. Maybe we should spend more energy in teaching the scientific basis of our specialty, instead of looking for new technologies with questionable applications.

  7. Thanks all for the comments. Much appreciated

  8. I enjoyed your essay and could not agree more. Highly trained professionals sell snake oil like fantastic plastic, slippery brackets and mouth vibrators. They base their treatments on those that provide the greatest financial gain regardless of the volumes of evidence that fail to support their ideas.

    No wonder general dentists are confused and believe the nonsense promoted by their gurus. The specialty is to blame. It is too easy to point a finger at universities and commercial courses.

    I saw an 8 year old with one anterior tooth in an atraumatic crossbite. A specialist (orthodontist) had offered fantastic plastic for $9,000. This of course was to be followed by treatment in the permanent dentition and another significant fee. I see patients like this every week from specialists . What should referring GDP’s think? Some no doubt think that the other practitioners are out of touch if they do not provide such modern and aggressive treatments.

    As Lysle has said, all treatments work to a degree and everyone stays in business. I also wonder what the epitaph will say? Perhaps, “Greed conquered all”.

    • I think that this article will resonate with many of the practitioners who take the time to read the Kevin’s website.

      As someone who did several GP ortho courses before entering the speciality, including the one mentioned in an above comment, I agree that the marketing strategy of these courses is principally to make orthodontics sound predictable and straightforward. It is easy to take this sentiment to heart when it’s being delivered by a charismatic speaker and you have no standard to weigh it against. After a year or so of doing cases, the reality of what I was getting myself and these patients into became clear as things didn’t always go according to plan and I began to appreciate the difference between ‘unknown unknowns’ and ‘known unknowns’. The reality is that when you’re out there as a GP doing ortho, you are truly on your own and I know of colleagues who have lost a lot of sleep over this.

      I would suggest to readers attending GP ortho courses to approach them with a degree of circumspection (as you would in all things when taking a scientific approach). Do not trust any instructor unless they can show you examples of what they are teaching on their own patients done with their own hands. Anyone can present anothers work and give a lecture. Anyone can cite literature to support a viewpoint. The proof is in the pudding my friends – if they can’t show you their results with consistency then there’s probably none to speak off.

  9. Great essay Mark. Spot on

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