I have a dream

The current pandemic, while causing much apprehension in these tumultuous and uncertain times, has allowed for reflection with respect to our personal lives, values, as well the specialty, and the route it is pursuing into the future. In a guest blog entitled “Quo Vadis Orthodontia: Are we in the midst of a perfect storm”, for Kevin O'Brien in June 2017, I elaborated upon various concerns with respect to the specialty. An article in the APOS Trends in Orthodontics journal entitled “Pursuit of Excellence: A forgotten Quest”, explored the issues further.¹ Although some of the initial concerns remain, the landscape has been complicated by further issues. I wish to express my dreams for the future of the specialty, and have thus entitled this article, “I Have a Dream”. This is in no way intended to diminish the immense importance of the issues addressed by Martin Luther King in 1962, but rather to voice deep concerns about the future, and my dreams for how I'd like it to be.

While the Coronavirus pandemic was escalating, I noticed a Facebook post from Ross Hobson, a UK based orthodontist and educator, pleading for evidence-based behavior from clinicians, rather than the irresponsible utterings witnessed on social media. This mirrored part of my “dream”.

The specialty is currently in the midst of a variety of storms. Haruki Murakami stated, “When you come out of the storm, you won't be the same person who walked in. That's what this storm is all about”.

William Shakespeare (The Tempest) wrote, “What's past is prologue”.

We cannot alter the past but, in going forward, we can restore order in the specialty. There is an urgency to do so. Strong leadership is needed to shape the “new normal” and determine realistic boundaries based on contemporary evidence?

The current lack of leadership in the specialty is leaving a vacuum which is being exploited in the prevailing stormy times. The Dalai Lama aptly stated, “A tree with strong roots can withstand the most violent storm, but the tree can't grow roots just as the storm appears on the horizon”.

Perhaps those assuming de facto leadership roles should bear in mind Douglas MacArthur's description of a true leader. “He does not set out to be a leader, but becomes one by the equality of his actions and the integrity of his intent.”

Jim Rohn's words are appropriate when contemplating today's self-proclaimed icons: “The challenge of leadership is to be strong, but not rude; be kind, but not weak; be bold, but not a bully; be thoughtful, but not lazy; be humble, but not timid; be proud, but not arrogant; have humor, but without folly.”

Companies are opportunistically expounding upon the virtues of products which enjoy little scientific support. We should be profoundly aware that the primary responsibility of companies is to their shareholders, with scant respect for the orthodontist. Eliades (2020) ² referred to the various media for the dissemination of such material as industry associated conferences, technology boosted blogs or bulletins managed by industry. In some instances, contrary to unequivocal evidence, there are still a multitude of attempts to find support for the efficacy of various approaches, including continued research trying to find relevance for “pet” protocols. Various approaches aimed at accelerating treatment are a notable example.

Key opinion leaders (KOL's), the paid company voices, are promoting concepts and products, some benefitting very handsomely for doing so, despite the fact that what they are promoting enjoys little validation. Eliades described KOL's as follows: “the typical presenter in these groups has the profile of a “clinician,'' with the term defining a spectrum of engagement limited to a subjectively defined, untested experience confined within his/her practice and presenting a selection of patients' data. Orthodontics has had a number of cases in which heavily-advertised and speaker-promoted products fell short of the claims made by the industry and its associated circles of speakers.”

Dr Hans Wellens commented in a recent blog, “I cannot seem to shake the impression that the voice of the KOL's remains disproportionately amplified on the lecture circuit, and that the orthodontic community remains receptive to alternative facts”. (Kevin O' Brien's blog, June 2020).

The orthodontic spectrum still includes some endeavoring to provide high quality evidence-based treatment. At the other extreme are those more concerned with being popular, using modalities they believe are advantageous often because they have been promoted by an enthusiastic speaker (KOL) given a platform by a company with vested interests, despite little supporting evidence. Significant contradicting evidence is ignored since the uncomfortable truths associated with such evidence are the subject of cognitive dissonance. This also appears to be reflected in conference programs which feature speakers that one might consider questionable. Meetings are held to promote specific appliances. The attendance at these meetings interestingly shows that the “FOMO” (fear of missing out) crowd are unwavering in their support for congresses having popular speakers, often promoting baseless approaches, while the evidence-based events suffer from lack of support. Perhaps a balance would be optimal, with scientific convenors carefully vetting speakers and their proposed material to ensure quality presentations that contribute positively to the future of the specialty. I ponder the proud fathers of the specialty shaking their heads in dismay with respect to how orthodontics has evolved.

Social media is a playground for promotion, where those with the loudest voices, often having large groups of supporters, batter any opposition into submission. In some instances, administrators of groups favor certain members for various reasons, even to the extent of offering them protection from any perceived challenge. Jay Bowman summarized it well in a recent Facebook comment: “No evidence will be presented, just cranky, controversial claims accompanied by inflammatory statements; based on absurd anecdotes with the real intent of eliciting more responses, thereby promoting their names, beliefs, courses and “professional organizations” without any conclusions. When actual evidence is provided, it's quickly countered with squawks of personal attacks as smokescreen excuses for not providing any actual alternative evidence, while twisting the subject around to deflect, like a prevaricating, cheap magician. This is a scientifically dishonest game that has sadly been successful for many self-proclaimed “maverick” or “pioneering” comrades. These folks continue to flog the same dog, claiming they're in it for the “science” and for the good of their patients (while just trying to get others to “follow” them down their rabbit hole to give them some sort of justification and self-perceived credibility). Unfortunately, most are unable to conceive that they might be incorrect in their assumptions.”

Fundamentally, we require honesty. Saying that, “we are using this technique although there is little evidence to support it, but anecdotally we are achieving some favorable outcomes”, is very different from engaging in vitriolic attacks or defensiveness, when one is criticized for unwavering promotion of an as yet unsupported approach, or even one that has been disproven.

Various appliances and concepts have been promoted. An example is “The Airway Movement”. Catch phrases such as “Airway friendly orthodontics” are ubiquitous. Despite the magnum opus “White Paper” published by a group assembled by the AAO, many are still unwilling to accept its conclusions, because it is just too inconvenient for them and doesn't fit their narrative.

Being involved in over a hundred webinars during the lockdown exposed me to various disturbing trends in the specialty, many of which were highlighted by questions from the attendees. Many were seeking validity for a technique or protocol, prompting questions seeking support for their approach despite overwhelming evidence to the contrary. For example: “expandodontics beyond biological boundaries”. Diagnostic logic has been supplanted by the desire to carry out quick, easy, delegable and profitable treatment.

Reflection on times before the advent of social media reminds us of an era when clinical excellence and evidence-based practice were more prevalent. The nature of orthodontics allows treatment modalities to be used prior to them being validated. This is both an advantage and a curse, a double-edged sword that, in some cases, allows clinicians to put “cutting-edge principles” into practice while, at the same time, allowing unscrupulous endeavours to prosper, often with great financial rewards for those promoting them. Patients are often guinea pigs in the hands of early adopters.

It appears that it is more important nowadays to be able to display an extraordinary level of busyness with lesser regard for the planning of treatment and management of patients undergoing treatment. Production and financial success are the primary motivators. A quality orientated and patient-centered approach is of lesser importance.

Computerized approaches abound for the purposes of:

• Diagnosis and planning. The initiation of treatment as quickly as possible is of primary importance.

• Having third party companies generate treatment appliances, whether it be aligners or customised setups, which include all the components for treatment and instructions on how and in what order to use them. This allows for delegation and decreased contact between the practitioner and the patient. A cookbook sequence is followed by staff.

• Virtual appointments proposed to save patients traveling to the office, thus allowing them the luxury of treatment from home. While this approach may be possible in certain instances and with respect to specific appointments, is it a panacea for quality outcomes?

There is certainly a place for the use of technology. However, practitioners still need to remain the masters rather than becoming subservient to such technology. Will specialists become slaves to computer technology and the companies that drive this?

Sydney J. Harris's warning that “The real danger is not that computers will begin to think like men, but that men will begin to think like computers”, is very appropriate for the current orthodontic landscape.

Virtual appointments have been proposed especially during the pandemic, together with some promoting certain appliances they believe to be advantageous in facilitating treating patients “from a distance”. This opportunistic marketing ploy during these unprecedented times is certainly concerning. Some are boasting about signing up patients for starting treatment without examination or diagnostic records, based purely on a virtual examination. It is my considered opinion such an approach leads to suspicion, amongst other things, in the eyes of the public, and does not bode well for the future of the specialty. This will affect the specialty assuming its rightful place in the eyes of the public as well as “rising to the majestic heights” (Martin Luther King – “I have a dream” speech), and regaining the respected position it once held. However, it appears that the desire for instant gratification and swift remuneration is uppermost in the minds of many practitioners.

The use of virtual means to address issues for existing patients during the pandemic is certainly understandable. The big danger is that these practices prevail when we continue practice within the confines of a “new normal”. This might play into the hands of direct-to-consumer companies, viewing it as validation for their approach, and using it as ammunition in their fight against mainstream orthodontics. It would be short-sighted and foolhardy of the orthodontic specialty not to realize these dangerous sequelae.

My dream is that order will be restored and that true leaders will emerge and guide the specialty on an evidence-based path into the future.

“This is no time to engage in the luxury of cooling off or to take the tranquilizing drug of gradualism”. (Martin Luther King)

To paraphrase King further, “It would be fatal for the specialty to overlook the urgency of the moment”. “I say to you today, my friends, so even though we face the difficulties of today and tomorrow, I still have a dream.”

“I have a dream that one day this specialty will rise up, live out the true meaning of its creed”.

“You may say I'm a dreamer, but I'm not the only one”. (John Lennon)