How Did We Get Here ?

This article is about “How did we get here?” and “Where are we going?”. It is based upon an address I gave at the Asian Pacific Orthodontic Conference (APOC) meeting earlier this year.

That address was inspired by an article written by Dr Nikhilesh Vaid (President Elect of the WFO) in APOS Trends in Orthodontics.^[1] He was considering how big ideas had changed lives and cited, among others, double glazing, the microwave and the Internet. Yes all big ideas. As orthodontists-as clinicians – as innovators – we are always on the lookout for big ideas. It is easy to become excited about new ideas and particularly technology – often optimism bias.^[2]

We are constantly informed by manufacturing companies there are new ideas that we must have. Marketing in a competitive environment is their job. Profit is their objective. Our job as responsible clinicians is to filter out what is appropriate and cost-effective for our patients. What facts do were know about some big ideas? Self-ligation means faster treatment – no evidence. Vibration enhances tooth movement – no evidence. Lasers aid tooth movement – no evidence. Designer brackets with special names move teeth faster and with less force – no evidence. What is necessary is proven technology – not being invited to fly on a magic carpet rather than the proven technology of an airplane.

Nicky Stanford in a Guest Editorial AJO 2017 looked at orthodontic advertising in the UK.^[3] The exaggerated claims of faster, less pain, less root resorption. No evidence. In the UK, three companies were sanctioned by the Advertising Authority, Fast Braces, Damon and Acceledent. All had to withdraw their advertisements and misleading claims. Some will say OK we can see through all that what is the problem? The problem is hidden behind a shroud of untruths. Advertising is now aimed at the general public and especially untrained [orthodontic] practitioners. Many of whom cannot quantify the claims made. They only see the supposed benefits – back to optimism bias. Specialists, with their training, can identify the “flip side” – the risks, the alternatives and advise patients what may or may not be in their best interests.

Sometimes in a commercial competitive marketplace this needs courage. Courage which comes from training, experience and professionalism.

And it is training, experience and professionalism that forms an important part of this lecture. As President of WFO I listen to and recognize the constant theme, in all regions, about the quality of orthodontic care being provided and by whom. I am not talking about care provided from appropriately educated practitioners. I am talking about care – or lack of – from practitioners who do not possess what the WFO would regard as appropriate training. These practitioners are being supported and encouraged by commercial enterprises – with vast sums at their disposal – where profit not care is the objective. Why would they bother to do it otherwise?

Professor Jonathan Sandler (EC member) wrote a superb article in the JWFO looking at how profit is so often put before patient care and I recommend the article to you.^[4] The overpromise which under delivers-that is the “slippery slope.” Commercial advertising to the public has distorted the marketplace where anyone without specialist education can set up their stall. Professions are running the danger of becoming trades. The third party “virtual orthodontist” at the other end of the computer providing diagnosis, treatment planning, and appliance construction. This is take away McDonald orthodontics. Virtual reality will improve until a distinction between the attainable and unattainable becomes blurred. Our regulatory bodies and governments have encouraged the downgrading of professions. Professions which I define by training, experience, ethics, and morals-putting the patients’ interests first.

As L Jerrold said in an AJO article. More money to be made in the business of orthodontics than the practice of orthodontics.^[5] That is how we got where we are now.

So what for the future? I think we must expect the unexpected.

We are in a competition. Not with each other, but with commercial enterprises selling to untrained colleagues and susceptible general public. As professionals it is now no longer enough to understand and apply our training of science and technology – we have to understand how consumerism, social media and marketing work. Globalism has opened another window on the world.

If we choose to protect and preserve our profession, for the future generations of trainees and patients, we not only have to understand these phenomena we have to be able to predict these changes. Computer scientist Alan Kay said “The best way to predict the future is to invent it.” Unfortunately, the future is being invented before our eyes by commercial enterprises. Wearing the shroud of new, best and must have.

What is the answer? We cannot and should not fight marketing with marketing. Do not be tempted by take away MacOrtho. We are not a regulatory body we cannot police. We cannot, under current legislation, advocate restrictive practices – orthodontics only by orthodontists. As educated orthodontists we are open to criticism when, in all honesty we comment that certain treatment methods may be futile and invariably harmful. We would be hitting our head against a brick wall and trying to swim against the tide of commercial advertising and the tsunami wave of profit motives. No mileage in criticizing those, with limited or no experience in orthodontics, who attempt treatment. The results speak for themselves and in my opinion the ever increasing mal-practice claims should be a touchstone not only to individuals but Regulatory bodies who in my opinion have woefully failed to live up to their responsibilities of protecting the public.

We should be positive-whilst drawing attention to failure-demonstrate and publicize the advantages of appropriate training and education.

So where are our strengths? What professional stamp do we have that cannot be bought in a MacOrtho take away? Training – training which demonstrates reliability, validity, and professionalism. This is the unwritten contract we have with our patients.

1. Professionalism, quality assurance. Which the WFO does through encouraging and supporting orthodontic boards. It is these boards which are able to provide the professional passport to the next generation. A passport that cannot be taken away that can only be gained by dedication and hard work. That is our unique selling point – and within the marketplace it is a “best seller”

2. To be open and brave about our toolbox. One tool does not fit all. You, as a patient have your individual characterizes. Not every shirt in the shop will fit you. You as an individual should choose. But I, as an orthodontist, know how to offer you a choice from my toolbox which I know works and comes from scientific backing. It has taken me years to safely know which appliance to use – and even more years to know when not to use it

3. Initiatives such as WOHD (World Orthodontic Health Day) – an innovation and promotion by the WFO (World Federation of Orthodontists). Opening up awareness and choices. The clear advantages of treatment by appropriately educated practitioners. And choices that are made on evidence and not veiled apparent benefits from commercialism.

The WFO Executive has taken these matters into consideration and is exploring logical and legal ways of supporting our Fellows, avoiding alienating generalist colleagues when we know that a patient’s best interest are served by professionals working together and ensuring that patients have access to the best evidenced-based advice for their particular malocclusion.

I have not provided answers. I have recognized the problem and difficulties and attempted to set out a responsible, non-confrontational ethical pathway which, I hope, will lead to both present and future patients best outcomes in the hands of those appropriately orthodontically educated.