The sorry tale of micro-osteoperforation?
Micro-osteoperforation (MOPS) is a method of causing localised trauma to the alveolar bone. This is supposed to increase the rate of tooth movement. A few weeks ago another systematic review suggested that there is no evidence that suggests this treatment is effective. As a result, I thought that I should look at the story of micro osteoperforation to see what we can learn. This is a sorry tale.
I have posted about micro osteoperforation before. The inventors of MOPs did not appreciate these posts. As a result, they posted this comment about my criticism of their invention in this blog.
“We will not enter into a debate on science with you as this is clearly not a suitable platform, but you walk a precarious path when you fail to acknowledge the commendable work and efforts of your fellow scientists, researchers and academics. When you stand behind your electronic bully pulpit to conveniently denigrate scientists and their work – without sufficient data to back your accusations – you are taking the low road”.
At the time I was very concerned by these comments. As a result, I stood back from discussing this form of treatment. Since then several authors have published systematic reviews on micro osteoperforation. The most recent one was in the highly ranked Journal of Dental Research.
Fu et al
JDR: advance access: https://doi.org/10.1177/00220345198784
I will not go into this review in detail because their findings agree with other reviews.
What did I think?
I thought that it was an excellent clear review that was carried out to a high standard. The authors wanted to look at the effects of techniques that involved minimally invasive surgery on the rate of tooth movement. They divided the methods into MOPS and piezocision. I shall only look at the evidence they found on MOPS.
They found 8 studies that evaluated MOPS. Most of these assessed the effect of MOPS on the rate of canine retraction. When they did a meta-analysis of these trials, they showed that the single use of a MOP did not accelerate canine tooth movement. They also pointed out that there was high heterogeneity in the data because of differences between the studies. The major ones concerning the diameter of the archwires, amount of force and methods of measurement. Their overall conclusion about MOPS was:
“There is not sufficient evidence to determine whether a single use of MOP can accelerate tooth movement”.
Earlier this year, I posted about another systematic review into MOPS. The EJO published this paper. These investigators came to similar conclusions
“MOPS increased the rate of canine retraction over four weeks. However, clinically, this effect was not substantial”.
I wondered why the two reports came to slightly different conclusions. When I looked closely, I found that the EJO review included two more trials than the JDR paper, that was published at a later date. I am not sure why the two studies included different articles. However, I wonder if this is a reflection of too many systematic reviews about the same subjects, with limited editorial control? Anyway moving on….
In summary, it appears that MOPS does not increase the rate of tooth movement. But let’s have a look at the history of this “treatment”.
History of MOPS
MOPS was first developed by a team at NYU who published several animal studies into this treatment, most notably, in 2010. They then did a small trial that the AJO published in 2013. Unfortunately, this study had several problems, and I summarised these as:
“I really had problems understanding this study. I found their methods confusing because they used a combination of a 1:1 parallel trial and a split-mouth study. Furthermore, I felt that the lack of clarity in the methods meant that this study is at high risk of bias”.
My comment was borne out by subsequent systematic reviews. There was even a letter to the AJO that pointed out some of the significant flaws in this study.
NYU also took out the patent on this technique in 2010. This was then licensed from NYU by Propel. As a result, there was a considerable conflict of interest for NYU and the investigators.
NYU even published this press release extolling the effects of MOPS. They claimed that MOPS reduced orthodontic treatment time by more than half!
Evidence?
So all we had was some animal studies and, in my opinion, a low-quality trial. Yet, this treatment became widely promoted and advertised. When you look at the Propel website, there are a substantial number of KOLs. Interestingly, they include several of the “usual suspects” who seem to be KOLs for several companies.
I know that I may be sounding like a stuck record. Indeed, you may feel that I am preaching from the “electronic bully pulpit”. However, I feel strongly about what happened. This was an example of a treatment being developed, advertised and adopted with low-quality evidence. There were conflicts of interest everywhere. Yet, the orthodontic speciality widely adopted this form of treatment and promoted it extensively on websites. For example, just type Propel orthodontics into google and you will see the claims that some of our clinical colleagues are making.
Summary
In summary, in my opinion, micro osteoperforation is a sorry tale of:
- Academic innovation followed by ambition
- Institutional self-promotion and income generation
- Flawed research and poor refereeing.
- Key Opinion Leaders making unsubstantiated claims
- Practitioners not evaluating the evidence
- Exploited patients
In effect, this is similar to self-ligation and vibration. All that has happened is that our patients have been charged for a treatment with no evidence that it works. When will we ever learn? I hope that all those involved can sleep at night…
Emeritus Professor of Orthodontics, University of Manchester, UK.
Hallelujah! As an early adopter of new technology and occasional KOL, I was reluctant to jump all in and join the MOP bandwagon. I thank you Kevin for looking into manufacturer’s claims not supported or proven by ADEQUATE evidence.
Hi Kevin
It appears to me as you have stepped on someone’s tail. The screams can be heard from the moon and back. 😂
thanks for the article
two comments here:
1
It’s not exactly like self ligating brackets or vibration treatment – in the first instance, the patient probably isn’t aware there’s anything special about the brackets unless you tell them, and there’s really no morbidity or any downside to using them (except they cost the orthodontist a bit more)
the vibration thingie may be no use, but it does not demonstrable harm and isn’t really an inconvenience to the patient as long as they aren’t expected to pay extra money for it.
doing MOP is invasive and much more likely to distress the patient than either of the above, and unlikely to be included in the normal pricing of ortho treatment
2
I don’t think it’s that widely used. Maybe if you read adverts and websites a lot and seek out innovation for its own sake you’ll find this stuff, but in reality, not only do I not know any orthodontists who do this, I don’t know any orthodontists who would want to do this.
I suspect after this, I don’t know any orthodontists who would want to know any orthodontists who do this.
Stephen Murray
Swords Orthodontics
Such an invasive procedure was ‘advocated’, just to fulfil the greed of name fame and wealth of some of our colleagues, is in bad taste for the profession.
This does not reflect well on NYU!
I need to know how much KOL,s are paid for each product validation before I rate their opinion.
The same faces pop up everywhere !
Andrew, That information is available online….check out https://www.policymed.com/2011/10/physician-payment-sunshine-act-key-opinion-leader-paradigm-shift.html.
Thanks.Appreciate it.This KOL situation is getting out of control.
I have been sucked in in past yrs by KOL,s so I feel particularly strongly.!
Congratulations. Rather than a self-aggrandising popularity contest your admirable work continues to encourage clinical decisions based on science rather than emotion. Rock on.
Dr. O’Brien, thanks for your great effort to always look for the good of our profession and give us relevant information to make good choices to treat our patients. In that order I want you to led us know what are your thoughts on “low level laser therapy” to accelerate tooth movement and decrease treatment time.
Thank you for your efforts to restore scientific rigor back to our specialty.
Thank you for continuing to share with us the truth without bias. It is very disappointing and concerning that a manufacturer would speak to you in that manner and accuse you of bullying. It speaks of their ethics and character. I appreciate you still having the courage to write about this topic.
Thanks, but it was not the company that made the comments. These were made by the University academics who developed MOPS and carried out the research that I criticised in my blog…
Thank you Kevin for your honest and considered assessment of the EVIDENCE. You have again exposed another air guitar of rapid tooth movement, like vibration and self-ligation.
The public are deceived by proponents of these treatments and they need to be made aware, before more patients are harmed physically and financially.
The KOLs use their bully pulpit to deceive for their financial gain without any regard for research or evidence, and disregard their ethical duty to their patients.
Keep going. The profession needs to be redirected before we are regarded merely as beauticians with perfumed potions.
Thank you again Kevin. You are making a difference.
I always thought universities are lead by scientists?Congratulations for the post, Professor.
Dear Ioannidis
I am afraid your assumption is not correctly , at least in many cases. There are university course for homeopathy, osteopathy etc etc . Universities have turn into financial institution in many case. Alas and alack ….
Thank you again, Dr O’Brien for another clear assessment. A clinical trial, with all the appropriate informed consent procedures is appropriate but a long way from clinicians selling an unproven treatment modality.
Dr. O’Brien. I subscribed to your blog a couple months ago. I appreciate the work you are doing. I noticed in the studies cited above that there was only one MOP performed. Is there any evidence that multiple MOPs would be effective at accelerating tooth movement? Or are there any studies about retracting cuspids into fresh extraction sites rather than mature alveolar ridges? The RAP effect induced by extractions or MOPs seems to make good physiological sense to me based on my understanding of how teeth move, so I’m wondering why the studies conclude otherwise.
I am so sick to death with snake-oilers!
Rock on indeed Prof and thank you for your courage.
For years various attempts to accelerate treatment times have been made.
It seems reasonable that MOPS has been tried to accelerate orthodontic tooth movement as a less invasive approach than flapped corticotomies ala Wilkodontics. The paper you reference mentions “There is not sufficient evidence to support that the single use of micro-osteoperforation could accelerate tooth movement..” What about multiple use? What about studying use in other areas?
Mesial movement of lower second molars where first molars had to be extracted is difficult and slow at best. Why not study this area with multiple use ? Or do we just throw out the baby with the bathwater ??
If it’s my baby daughter, then yes.
It is a sad state of affairs when bullying and threats come into play, especially when you are just sharing a point of view and interpretation of evidence. They tend to get personal, usually as a response to either threatening their potential income or bruising their ego (or both). I have had a legal threat in 2014 following on from a Blog about fast braces and a Messenger threat in 2016 from one of the KOL’s on your linked page when I posted a link on a FB Page to a Blog on Passive Self-ligating Braces not being any better! It’s about evidence and not about a person, yet they spin it personally, perhaps out of feeling insecure? To paraphrase Joe Friday out of Dragnet – it is ‘Just the facts ma’am/man’.
Yes, simply replace the name Damon where it says Propel and you see a pattern develop!!
Dr O’Brien …thanks for giving a clearer perspective on a series of treatment modalities… What’s your take on piezocision.is it an effective method of reducing treatment time?
Sorry, but I see zero ctor members or authors of the basic science study and clinical trial that are on propel’s board..
lets think about it another way
I invent a technique that could revolutionise orthodontic treatment. I do a small study and it shows some promise.
I would then want to do a study of the highest quality to see if it really works. Results from such a high quality study could not be argued with and it could be possible that the study proved the technique was so outstanding that the study had to be stopped to prevent the control group being disadvantaged. Who would not want to demonstrate without the possibility of argument that a new technique worked.
Provide the evidence and we will use the technique
Kevin you are too kind. I hope they cannot sleep at night!
Dear sir,
Your thorough screening of reviews is commendable and we’ve always been benefitted from your knowledge in various forms(publications, blogs, lectures..) I thank you for all. I beg to slightly differ from your post and would like to present that MOP does help (as per my clinical experience; the lowest form of EBD) in the cases wherein there’s inadequate medullary bone and the tooth needs to transgress the path. Shall further update if I get through studies in this support.
Prof. Kevin, I appreciate your efforts. So please reconsider my points about this meta analysis:
I thought this paper has a lot of limitations. The authors have missed the following papers in their meta analysis:
For MOPs:
Attri 2018
Kundi 2018
Sirvajaran 2019
Feibakhsh 2018
For Piezocision
Wu 2015
In the Figure 2 they pooled 2weeks movement canine rate in Abbas study with 4 weeks movement rate in other studies
In figure 4 they combine the total time treatment studies with the alignment time studies (Gibreal 2018 and Uribe 2017)
Interestingly the studies were heterogenous in methodology( study designs), clinically( at least, interventions are different here), and statistically .
Best regards
Thank you for defending the scientific method and thank you for defending evidence-based orthodontic practice. In these times of KOLs shaping clinical practice using un-validated techniques, Orthodontics can seem like a demon-haunted world. Your blog is a candle in the dark. Thank you for holding the light high.
In my neck of the woods the current vogue treatment is MSE (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5398849/) out of UCLA with Great Lakes the supplier of the magical gadget. I can’t find 1 trial that supports long-term benefit verses anything. Sprinkled in with the attributed benefits that are “obvious” with palatal shelve displacement are the polysomnography stuff and OSA mitigation. MOP or MSE if there’s a 3 letter acronym, it must be evidence-based.