July 18, 2019

The end of orthodontics, or is it?

A few weeks ago, I returned from the AAO congress in a dystopian mood and published a post called “are these the early days of the self-destruction of orthodontics”. In retrospect, this was a particularly bleak personal viewpoint.  A young Russian Orthodontist, Alex Ditmarov, who translates my blog posts, has politely disagreed with me. He has written a more uplifting post on his own blog. He has kindly allowed me to publish this on my blog. I thought that this was great.

The end of orthodontics, or is it?

A month ago, Kevin O’Brien published in his popular orthodontic blog a post titled ‘Are these the early days of the self-destruction of orthodontics?’ The text was inspired by his visit to the annual AAO meeting where he has been giving a lecture on Bill Proffit’s legacy.

The situation around orthodontics was presented in a desperate tonality: key opinion leaders maliciously misguide young specialists, the American market is plagued with teledentistry, Europe is full of myofunctional charlatans, etc. As a result, we are awaiting the end of the speciality.

After reading the post, I felt a bit disappointed. Firstly, I have just started practising orthodontics less than 5 years ago and do not admire the perspective of its nearing death. Secondly, even though I admit the presence of all the issues listed, I don’t think they are fatal. Paradoxically, they might be even beneficial.

At the moment I am waiting for a connection flight to Moscow at Amsterdam airport. I have been visiting another orthodontic event in the USA, the Tweed Study Course.

In contrast to the AAO meeting, this event has no advertising part, no presence of companies or key opinion leaders and is known as the most popular hands-on orthodontic course in the world held with little changes since 1941.

I first learned about it through an article by James Vaden published four years ago in the AJO-DO. A year later, I filmed an interview with the course director Herbert Klontz. By now, it has been watched on YouTube more than 3,600 times. You can find it here.

Last week, I finally fulfilled my long-awaited goal and completed the course myself. This was an absolutely invigorating experience. I have not just learned some wire-bending tricks and cephalometric nuances, but have been completely reassured that fundamental orthodontic knowledge has not been lost and continues being transmitted to the young generation with love and passion.

What about KOL, teledentistry and myofunctional charlatans then?

Of course, our perception of the overall situation is dependent on what we focus our vision on. Let’s focus for a while on orthodontic fringes mentioned by Kevin. 

Myofunctional Charlatans

Myofunctionalists have been around for many decades. From Alfred Paul Rogers, who considered to be the father of myofunctional therapy to his present-day followers they were stating the same mantra: 1. muscles influence hard tissues 2. through myofunctional exercises we can correct hard tissue pattern. Interestingly, there is still no single case in the literature that would prove the second point. However, the first point is with no doubt correct. Muscles influence hard tissues, that is it! And the most sophisticated myofunctional therapy can’t help that!

Can myofunctionalists be the threat to orthodontics? I doubt so. They, of course, can harm a patient’s bank account, but they definitely can neither worsen nor cure a malocclusion. Therefore, they will just stimulate a patient to be pickier in finding a reliable orthodontist next time.

Key Opinion Leaders

Back in the days, they were called representatives or reps. Marketing strategies were less aggressive, and magic brackets were not yet invented. Nowadays, the situation with opinion leaders has become more complicated due to the advance of technologies. Social media delivers unproven data straight to our smartphones, huge theatralized events in support of new, untested appliances are held around the globe, and impressive sums of money are paid for lip service.

Can this be a threat to orthodontics? This could be a potential threat to some indiscriminate orthodontists. However, thanks again to new technologies we already have an antidote: https://openpaymentsdata.cms.gov Here you can simply put the name of a medical practitioner and check the amount of money one received from a supply company. I think it should be a necessary check for any orthodontist or patient who has doubts in the sincerity of strong statements.

Again, I don’t think this is the end of orthodontics. This situation just makes us more vigilant.

Teledentistry

This is a very new movement. The most popular teledentistry procedure relating to teeth straightening is sending clear aligners straight to a patient letting him, or her treat a malocclusion on one’s own. Obviously, it can be hazardous. It can lead to soft tissue loss, severe bite problems, root resorption, etc.

This might become a severe threat to a patient’s health. I feel really sorry for those who already have harmed themselves with this. However, I don’t think this is a threat to orthodontic speciality. Sadly, but this is even a beneficial phenomenon since, in the long run, it creates lots of patients who are urgently in need of regular orthodontic care.

Summary

To summarise, we have plenty of disagreeable orthodontic movements going around. But having a closer look, we see that most of them represent changes in the modern-day economy, but not orthodontics. These are just new ways of making money.

As a result, more and more patients become involved in the teeth-straightening industry. Even though demand and supply are growing, the number of reliable orthodontists is staying more or less the same. In this condition, the role of filtering mechanisms such as board certification becomes crucial. I think the creation of an international orthodontic board is inevitable. It is only a question of how and when.

From the present point in time, we can see ahead both the death and the golden decades of orthodontics. It is the fork of the river. And it is we who are in charge.

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Have your say!

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    Optimism of the new generation ! But I think he is right .

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    Yes, yes and yes!! I wholeheartedly agree!
    (Sent from Greece 🇬🇷)

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    I agree with your statement about Direct To Consumer orthodontics . To repeat a point of another colleague , “not everybody can afford to be seen by us” . DTC company try to tap into this market . Sadly young and naive people would be ripped offed. Bad for them .
    Myofunctional dentists : Big companies have been trying hard to sell their myofunctional plastics to GPs for many years. Once they use to claim ” No braces , better faces”. After they have been repeatedly experienced backlash from dissatisfied patients , now they have become more slick in claiming and selling their products : They don’t promise that their plastics make teeth straight . They claim they “create ” beautiful faces or help patient to grow naturally, breathe better etc. They are so blatantly ignorant and uneducated that one of them keeps claiming to find “cure ” for TMD .Surely there are some percentage of society who love mumbo jumbo and would be attracted to ” natural” way but for majority science is still attractive. I don’t personally feel threaten by this cult.

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    Orthodontic Truth #1
    Orthodontist Authenticity is under attack.

    Orthodontic Truth #2
    There is no Intelligence in plastic.

    Orthodontic Truth #3
    Orthodontic Doctor Intelligence is still needed!
    Orthodontic Truth #4
    Orthodontic Retail didn’t Work.

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    Kevin,

    So true…long last somebody ids playing my tune……
    Top half of the pyramid is going to gain immensely, thanks to the ‘Tinsel town drama’
    Cheers …Its so good to be old, experienced and well endowed in the art of traditional Orthodontics….
    Regards
    Mani Prakash

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    I was interviewed by Alex a couple of years ago not knowing what his agenda was. This piece helps me put that into context now. I have only one additional comment: The notion that “muscles influence hard tissues, that is it” is deeply flawed. The two other tissues that need to taken into account to appreciate craniofacial homeostasis are teeth and functional spaces. For example, a lack of homeostasis can precipitate orthodontic relapse, and one could argue that the airway trumps everything when it comes to functional and spatial regulation of the craniofacial system.

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      Hi Dave Singh, the interview that you mentioned took place three years ago in 2016. At that time I’ve been travelling the USA collecting material for my video series about American orthodontics. Sorry to tell you, but I didn’t include this interview in the final project since I found your position a little bit too extreme. Nevertheless, I respect your point of view and will be happy to have a constructive discussion on any orthodontic issue. Apart from extraction/non-extraction debate, of course.

      Best wishes, Alex

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    OSTRICHAPHOBIA. A condition where the head is buried deep in the sand exposing a very sensitive rear end.

    In 2018 the Clear Aligner industry earned US$11 billion, much of that out of the pockets of orthodontists – and this will continue to grow.
    I personally am dead against any process where the emphasis is on ‘how quickly and how cheaply can I do this?’ I have no doubt that many people will regret the day that they got their online ‘straight teeth’ when the other chickens come home to roost. Unfortunately they will probably not be able to afford to come to see you as they didn’t have the money in the first place.
    Criticising and disparaging this industry will not make it go away, and the projected CAGR in the Clear Aligner industry is $27 billion by 2022. Out of whose pockets do you think this will come?

    In the US, in addition to what you can order or buy online, you can now get your teeth straightened at Macys, Walgreens, CVS Pharmacy and it won’t be long before every Supermarket and Big Box Store that has a Pharmacy, Optical Division and Hearing Aid Division will have a Straight Teeth Division. That is 40,000 supermarkets and close to 2000 Big Box Stores.

    Now to my point. There are two things that I believe a large number of orthodontists forget, or have never even bothered to consider.
    1. There is a difference between an orthodontist and the practice of moving teeth (orthodontics).
    2. It is extremely short sighted and poor business practice to have a single source of income, because when that is threatened, where do you stand?

    To amplify. Orthodontists are highly trained specialists in the field of dentofacial and craniofacial orthopedics, which to my very limited knowledge, not being an orthodontist, does not only mean straightening teeth. It means working with the craniofacial complex to arrive at the optimal balance and structure for that individual – not just dragging recalcitrant teeth to an unstable position and then ‘fixing them there with permanent retention’.
    How would you feel if you took your 8 year old, who had fallen out of a tree and broken his arm, to a specialist who said “No problem. We’ll put the bones back into place, pin them and then put him into a cast”. When you ask when the cast will be removed you get a strange look and the reply. “Removed? Oh no. We can’t remove the cast or the bone will break again”. I doubt that any of the passionate and vocal supporters of a process that is proudly hailed as ‘not having changed in 100 years’ would be satisfied at that outcome.

    Seriously – it is time to stop the ridiculous rhetoric which is parroted by single-minded individuals, hell-bent on retaining a status-quo that WILL change, and is changing faster than the general belief or understanding. Wishing something away isn’t going to stem the tide.

    Whistling in the dark and pretending that there is no threat will keep your heads in the sand and your sensitive rear end will surely be dealt a swift and possibly cataclysmic blow which could dramatically reduce your income and your privileged status in the community.

    The writing is on the wall – believe it or accept it, or not. If you want to save your practices and profession, open your minds to what else is possible for you, with a brilliant education in orthopedics, that will not be threatened by commercial interests. Use your skills where they are needed most – and that is in the remodeling and restructuring of compromised airways – that is what you are actually trained to do.

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    Dear Kevin and Alex,

    Thank you for another thought-provoking post.

    I agree that the face of orthodontics changing. We are, for example, increasingly referred to as an ‘industry’. Undeniably, an industry may be blossoming around us but we are the professionals within it. Much of what happens in industry is of course beyond the control of the key players and orthodontics is, alas, no different. Against this backdrop, we must continue to advocate for what is right and call out what is wrong (with DIY Orthodontics a glaring example).

    So where do we fit within this brave new world?
    Just as modern politicians trivialise complex arguments for their own ends, industry aims to replicate this within healthcare. One of the challenges and attractions of our great speciality is the importance of non-binary decision-making. Surely, as specialists we need to continue to apply the knowledge for which there is not yet a substitute? Specifically, we should continue to advocate for predictable and considered treatments for our patients. We should be there to counsel on what we can, cannot, should not and ultimately should do for them. Isn’t that what should set us apart? A knowledge of the options, and which one to choose based on awareness of the merits and demerits, realistic objectives and limitations?

    It might sound timely and alluring to panic and join a race to the bottom by espousing a range of extra-curricular ‘benefits’ of treatment. Perhaps it would be more opportune to focus on doing what works, on not ignoring evidence on the benefits and constraints of growth modification, on the predictably of getting excellent occlusal results and the associated imperative of retaining them?

    Your point-counterpoint suggests a stark choice between winning the wrong way or losing the right way. The happy middle-ground is increasingly unpopular these days. However, I’m sure it is out there somewhere and we should look to inhabit it with pride and great satisfaction.

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    Myofunctional charlatans:

    If the main task of the orthodontist is to treat the patient after the change of teeth, this can be left as it is. Unfortunately, he completely misses the problem and does not make a meaningful contribution to public health. Myofunctioninelle therapy is most effective at the age of approximately six months up to the mature milk dentition, there one can speak of restituierender treatment. Pictures that impressively confirm this can be found in the net (Fuhlbrück / Codoni).

    Translated with http://www.DeepL.com/Translator

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    I would love to see the creation of an international orthodontic board. And recertification. This could solve some of the problems facing our profession.
    Treatment by a Board Certified orthodontist should give confidence to the patient.
    KOL – board certified??

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