The “Orthodontic World” is flat!

The past few years have seen me travel to almost a new country every month, most often on account of orthodontic meetings. This has been a great opportunity to get a first-hand glimpse of the changing global landscape in general and orthodontic landscape in particular. My travels have taken me to every continent except for Antarctica (will surely happen soon!), and I can sum up most of what I have seen by the title of Thomas Friedman’s exceptional book called “The World is Flat.” Simply speaking, the urban landscape in most parts of the world is almost identical. The skyline from a hotel room in Manhattan, London, Bangkok, Mumbai, Cape Town, Shanghai, or Dubai is almost the same and the likewise the orthodontic landscape – both literally and metaphorically!

Tom Friedman describes this phenomenon by the phrase “The World is Flat.” He states that “the global competitive playing field is being leveled. It is now possible for more people than ever to collaborate and compete in real time with other people, on different kinds of work, from different corners of the planet, and on a more equal footing than at any previous time in the history of the world.”

The book outlines 10 flatteners that have been instrumental in this paradigm shift. The author^[1] enumerates them as:

1. Flattener #1: The New Age of Creativity.

2. Flattener #2: The New Age of Connectivity.

3. Flattener #3: Work Flow Softwares.

4. Flattener #4: Uploading.

5. Flattener #5: Outsourcing.

6. Flattener #6: Offshoring.

7. Flattener #7: Supply Chaining.

8. Flattener #8: Insourcing.

9. Flattener #9: In-forming.

10. Flattener #10: Digital steroids.

Have these flatteners flattened the orthodontic terrain? Not only in the developed world but also in the “fast aspiring to be developed world,” we are unequivocally witnessing a convergence of trends in orthodontic knowledge, markets, and care protocols! The impact of digital technology has been discussed threadbare on various forums and it accounts for the first four “flatteners” influencing orthodontics. Digital treatment plans and outsourced fabrication of appliances are trends around the world. The Flattener’s 5-9 have ensured that an office in Mumbai can get an appliance that was fabricated in Europe or China, with almost the same turnaround time, as a laboratory in the same city!

The knowledge gap between what we know, what we do not, and how we can bridge this gap to instantly apply it to a clinical scenario is becoming smaller or almost non-existent, due to the 10^th flattener – Digital steroids. Friedman defines “the steroids” as a combination of small factors that amplify the effects of outsourcing, offshoring, uploading, supply chaining, insourcing, and in-forming. The digital steroid puts all text, sound, photo, and video media into a common standard – digital (0’s and 1’s in a computer) – that can be easily shared, stored, searched, and manipulated. Today, Facebook or WhatsApp/WeChat Groups allow us to collaborate with colleagues, literature, and patients as if we were all in the same room! I have personally learnt so much from these interactive groups and blogs, and the best part is whatever I have seen a colleague do, thousands of miles away, can be implemented chairside in an instant! An existent digital flattener is VoIP (“Voice over Internet Protocol”), which allows people to make phone calls using a broadband Internet connection. This is a flattener because all VoIP calls cost the same, regardless of how far you are calling – next door or to another continent. The mobile steroid consists of technologies that let you work away from your office. Chief among these is the spread of wireless Internet access, which allows people to work online from their portable computers in airports, hotel lobbies, libraries, and even coffee shops. Facebook posts and Instagram images of colleagues viewing and approving treatment simulations from exotic beach locales and ski resorts are realities of our times! Needless to say, we do not even need a conventional computer to do most of this. Tablets and mobile phones enable us to track most of our professional workspace. Our world has shrunk, flattened, and can be carried in pockets and handbags, almost anywhere!

It is this triple convergence – of technologies, business practices, and new players, on a new playing field, developing new processes and habits for horizontal collaboration – which I believe is the most important force shaping our profession in this era. Giving so many people access to all these tools of collaboration, along with the ability through search engines and the Web to access billions of pages of raw information, ensures that the next generation of innovations will come from all over “Planet Flat.” If you see the demographics of published orthodontic literature or at podium spaces on major international orthodontic events, “Planet Flat” expresses itself vociferously!

The Orthodontic Journey toward “Planet Flat” should also have an excerpt from history! My travels took me to St. Louis, Missouri, USA, in May 2019 and Prof. Ki Beom Kim, a distinguished colleague at SLU, invited me to speak at his school. Being the gracious host that he is, he picked me up from my hotel and drove me to the school. The morning was well spent, lecturing to the residents and the faculty. Now was the time for a treat that he had promised me (an enticement that made me make the trip, travelling for hours!) He drove me to the place that was Dr. E. H. Angle’s house and orthodontic office, the first orthodontic office on the face of this planet! It was an overwhelming moment for me, and I am sure would be for any orthodontist! No technology or interface in orthodontics could have espoused this emotion! [Figures 1 and 2]. This was like a visit to Bethlehem for a Christian, Mecca for a Muslim, or Ayodhya for a Hindu. I felt blessed to be there and was ruminating how lucky I was to be at the cradle of orthodontic civilization and more so to be in this wonderful profession! The euphoria came a full circle, as we drove off, and not less than a mile away, we drove past a mall that had huge billboards displaying brands of consumer products, and ….an orthodontic service provider that “directly” provides aligners to patients in the mall by offering a scanning service. No orthodontist or dentists are involved at the chair/mall side! We know this is happening (and that’s a discussion for another day), but these two moments were too close (geographically and emotionally) for comfort!

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Figure 1

(a) The building that was Dr. Angle’s orthodontic office. (b) The street on which Dr. Angle’s office was located.

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Figure 2

The house down the street from the office where Dr. E. H. Angle lived.

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George Ritzer’s voices some concerns about the flattening world,^[2] in “The McDonaldization of Society.” He states “This phenomenon may also pose a threat to the distinctive places and communities that give us our bearings that locate us in the world. From the first stirrings of capitalism, people have imagined the possibility of the world as a perfect market – unimpeded by protectionist pressures, disparate legal systems, cultural and linguistic differences, or ideological disagreement. But this vision has always bumped up against the world as it actually is – full of sources of friction and inefficiency. Some obstacles to a frictionless global market are truly sources of waste and lost opportunities.”

Some of these perceived inefficiencies are institutions, habits, cultures, and traditions that people cherish precisely because they reflect nonmarket values such as social cohesion, faith, and pride. If the global markets and new communications technologies flatten those differences, we may lose something important. That is why the debate about this phenomenon has always been, from the very beginning, about which frictions, barriers, and boundaries are mere sources of waste and inefficiency, and which are sources of identity and belonging that we should try to protect! I am holding “specialty orthodontic care” very close to my chest! Your thoughts, please?