May 14, 2018

The Uberisation of Orthodontics.

This is a guest post about the “Uberisation of orthodontics”. The author is Martin Kelleher who is a specialist in restorative dentistry from London. It is great to read a non-orthodontists view of the “recent developments” in orthodontics.

The new orthodontics?

The race to the bottom for the quickest, allegedly ‘great’ or bargain deal in orthodontics has reached a place that few would have thought possible even five years ago. This gradual ‘uberization’ of orthodontics
 has produced a raft of new and largely unproven claims for treatments. These are promoted with gushing enthusiasm and superficial short-term evidence of their supposed long-term benefits for patients.

The thrust of the promotional ballyhoo, which appears on various websites, or in trade-sponsored dental comics, usually involves some pretty case report pictures. These are usually part of advertorial articles that sometimes seem to have been written by someone with strong commercial interests.

The fanciful claims are not only targeted 
at interested and enthusiastic dentists, but 
also increasingly aimed directly at consumers potentially interested in changing their dental appearance.

The claims

Importantly, the direct accessibility and apparent simplicity of the treatment are promoted on the internet with breathtakingly superficial marketing straplines as being quicker, cheaper and more acceptable. Little seems to be mentioned about potential risks, or that such rapid results are probably a newer version of the sadly well known term ‘relapsodontics’, while potentially being biologically even more dangerous for the vulnerable roots and the soft tissues of some unsuspecting patients’ teeth.

The claims by some new hyperventilating marketer for ‘quicker, quicker, faster, faster’ branded techniques (possibly soon to be named ‘two and a half month smiles and “no one can see the appliances at all at all’ or some other nonsense) need to be treated with considerable caution by conscientious and
 caring dentists. Bitter experience shows that when something appears to be too good to be true there is usually a very good reason for that.

The role of the professions.

Professions are established within society to help protect the vulnerable from an asymmetry of knowledge, skills or experience being exploited by unscrupulous people to advantage themselves unfairly at the expense
of others less fortunate than them. Most ethical dental professionals are careful and relatively modest in their proposals about what they can deliver with dentistry and do not make outlandish claims. That approach is wise because many things are outside the direct control of dentists. For example, the patient’s genetics, compliance, oral hygiene, diet, smoking habits or smile aspirations.

Indeed, many experienced dentists are uncomfortable with the recent proliferation of self-aggrandizing advertisements and claims for egotistical, narcissistic dentistry, often promoted by younger, or apparently non-specialist, dentists. These less than altruistic approaches, replete with their vacuous advertising straplines but rather tenuous grasp on ethics, have recently been crowding out established morals, ethics and patient care in dentistry.

Snake oil and ethics

Theoretically, people are protected from bad dentists and dentistry, but what happens in the grey areas when it is not a named registered dentist, or dentists, supplying these orthodontic human-experimentation-without- licence treatments, perhaps via a website or facility based in a foreign country?

Unfortunately, every generation produces its own version of the ‘snake oil salesman’. A charlatan in full flow can be a fascinating and often amusing sight − always provided one can recognize one early on and maintain a safe distance from the spectacle, while watching others being entranced by the smooth sales patter and the clever manipulation in order to make the susceptible observers believe that they are getting something wonderful for supposed ‘peanut$’.

In the latest selfish demonstration of some business-focused guru’s pursuit of his own agenda, the normal protective concerns
 for the patient’s long-term wellbeing appear to have been blissfully ignored. Into this vanity driven casino some new entrepreneur, possibly complete with Stetson hat and jangling spurs, has entered, having decided, apparently that, prior to offering to straighten someone’s teeth, no detailed history or serious clinical examination of that patient is now required. Instead, some digital photographs and some impressions to be taken by that untrained ‘consumer-narcissist’ will suffice for a piece of software to be run by someone, somewhere, which will be able to make a full diagnosis, discuss treatment options, their risks and benefits and also be able to obtain valid consent. In addition, these magical remotely produced models can be used to make devices
 to produce biologically dubious movements of teeth which have unknown bone support, root length, or periapical status to some new unstable positions in order for them to become a desirable fashion accessory and all in someone of unknown mental or dental health.

“Uberisation of orthodontics”

This allegedly consumer friendly development is apparently being lauded by some visionaries targeting human vanity and being promoted with panting marketing enthusiasm
as ‘disruptive technology like Uber’. However, moving teeth around is risky and unpredictable 
at the best of times and it is not like taking a cheaper cab ride, nor is it what most sensible dentists would recognize as the practice of responsible dentistry. Neither is it what many experienced dentists would be willing to have done either to themselves, or to a child of theirs, or to someone about whom they genuinely cared.

Is this further drift to be left unchallenged, perhaps as just another case of ‘let the buyer beware’, or ‘Caveat emptor’, as my old Latin master used to warn? If so, what about the probability that in the future some less 
than totally satisfied Facebooking, Twittering, Instagramming, narcissistic ‘entitled consumers’, or their ever helpful lawyers will seek to cast all the blame on dentistry for not warning them about the problems of their desired cheaper and quicker ‘Uberized’ treatment approaches?

This is a shorter version of an article published in Dental Update in September 2016.

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Have your say!

  1. Avatar

    Great article outlining the issues. I love some of the phrases in here which so explicitly describe the landscape without even mentioning the persons involved but leaving the informed reader with no doubt as to whom is being alluded to

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    Best thing I have read since Edward Angle !

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    Very nice post and indeed a breath of fresh air coming from a non-orthodontic specialist. It is however easy to blame GDPs and companies for the current environment in Orthodontics, where in reality they are only filling a demand. It’s a demand arisen by the fact that Orthodontics has lost its way. At a time where even many of the specialists out there provide little more than superficial diagnosis with rudimentary treatment delivery à la ‘throwing in a niti’ or a piece of plastic and see what happens, we as Orthodontists have nobody but ourselves to blame. All is not lost though if we as a specialty find our way back to our high standards of proper diagnosis and individualized treatment planning, precise treatment delivery, and treatment results that are both esthetically pleasing and functionally sound. However the time to do that is now!

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      Concordo plenamente!

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      And what about the orthodontists that have limited their practice to invisalign.. and those that dont take lateral cephs any more.. I even know specialists that have stopped taking models. Many specialists have joined the uberisation as well. Making it even bigger. And all the spokes people for these companies are specialists getting paid really really well to talk about the products.

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    I remember reading the dental update article back in 2016 and thinking “finally someone who thinks a bit like me”, hopefully I wasn’t the only one. The whole thing is difficult to condense down but I think we need better undergrad training in ortho together with a greater appreciation of what will NOT work (instead of showing nice cases). I can’t remember any article or discussion of what is not worth treating and therefore best avoided (I have one waiting to go if anyone interested). Instead it’s all about treating every single little thing. This leads to a culture where the patient can get whatever they want and the orthodontist can just turn off brain and stick on a brace since there are no apparent negative consequences to doing so. I can’t help feeling that as a profession we reap what we sow. We need to be more honest and realistic and be prepared to advise the patient appropriately and not just do what the patient wants every time.

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    always in a right way!! Extremely precise!!

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    Here! Here! In an age where the exam chair and a physical diagnosis has been replaced by photos and intraoral scans, this is a siren call for our profession to return to the fundamentals which, unfortunately, seem to be less important than in years past. Well done!

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    Another interesting and thought provoking post!

    Whilst I’m not entirely convinced that referring to fee paying patients as ‘narcissistic entitled consumers’ is the most endearing term that could have been used, I agree with some of the sentiments in your article. Patients may very well view the race to the bottom as simply an opportunity for greater choice and increased affordability and accessibility, but with that comes the issues of exploitation you have highlighted. The line between an orthodontist and a dentist providing orthodontics is at best blurred and patients will make a dental buying decision the same way they make any other consumer decision. The range of options now available presents the patient with choice and an element of control and this is something the group of ‘younger and non-specialist dentists’ you refer to understand well, much to their commercial advantage.

    The appearance of DIY orthodontics is worrying and it is easy to see why consumers may wish to explore this option. It will just take a few well-placed micro-influencers and bloggers to promote their own miracle treatments for this to gain traction to the detriment of both clinician and patient. Much can be done to tackle this situation and that of the misleading claims you refer to but at what level? When a patient is looking for information about orthodontic treatment, are they seeing a balanced and cohesive position from the profession to counter the consumer focussed marketing? Do practices widely share agreed position statements on their websites and social media channels to help tip the balance? I would suggest this is not the case potentially leading to the situation you describe.

    The provision of orthodontics is changing rapidly and with it the need to evolve. There is, and hopefully always will be, a place for expert advice, proper treatment planning and excellent patient care. The challenge is to clear the way for the patient to make an informed decision based on facts and not misleading claims.

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    I think it’s interesting that a specialist in an area other than ortho has got so exercised about this. It sort of does a dis-service to uber because at least there are regulations to make sure their drivers have proper driving licences and roadworthy cars. The policing of many new ortho treatments is going to be very vague.

    People are supposed to thin Industry Disruption is a good thing. I think it’s not a good thing unless everyone is satisfied the important aspects of the outcome is the same and the risks and downsides are no worse. I don’t mind flying on Ryanair because I don’t believe I am any more likely to have a plane crash or delayed flight than on any other short haul flight. It never bothered me to turn up on time for my flight or accept that I might not get in-flight meals or free luggage check in. And now other airlines are the same.

    The idea that some company can provide mail order ortho using patient-generated records and no radiographs isn’t a good one.

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      I agree that this analogy is unfair to Uber.

      When I book an Uber (rather than black cab) to take me from the train station to the office, then I arrive at the office. The very same office that the black cab would have delivered me, in a similar length of time.

      STO is the equivalent of a partially trained Uber driver demanding I leave the car at a location that was not the requested office. In some cases, the driver would have taken me a considerable distance in the wrong direction. They would then explain that: had I wanted to get to my office then I should have taken a black cab; it would have taken longer to get to the office had I opted for the cab in the first place; and that I should have known the difference between the two, even though this was not covered in the small print of the website (consent process).

      DIY orthodontics is the equivalent of an Uber driver making me drive the car and then kicking me out at the first street corner. On occasions this would work well, some people take a cab for these short journeys, but the likelihood of your office being so close is low. Worse still, should you crash the car, then you are unlikely to be insured for personal injury.

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    Dr. Kelleher and I have both spoken out about concerns with ‘instant orthodontics’ using veneers. I’ve been sanctioned for suggesting ortho is often a better choice for correcting healthy crooked teeth. Apparently lawyers know better? We may disagree on the idea that shorter term orthodontic treatment options can be included in an ABC list. Sadly there seems to be loads of fluff with claims from manufacturers allowed to persist for years, but some new technologies like ultrasound orthodontics may provide meaningful improvements. I enjoy reading anything Dr. MK says!

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    It is noteworthy as well that both myself and Jonathan Sandler cited your original article whilst writing our own and that another article by Jay Bowman in the Angle Orthodontist discussed similar sentiments

    http://www.apospublications.com/article.asp?issn=2321-1407;year=2018;volume=8;issue=1;spage=10;epage=13;aulast=Wertheimer

    http://www.angle.org/doi/full/10.2319/0003-3219-88.3.370 by Jay Bowman in the Angle Orthodontist Journal

    https://www.jwfo.org/article/S2212-4438(18)30011-0/fulltext
    Jonathan Sandler in the WFO journal

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