Orthodontic uncertainty. Research, core outcomes and snake oil. Salzmann Lecture Kevin O’Brien. AAO June 2021. Episode 122

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Orthodontic uncertainty. Research, core outcomes and snake oil. Salzmann Lecture Kevin O’Brien


Uncertainty in Orthodontics

·      Present in all clinicians

·      Claims – can increase uncertainty

·      Research – reduces certainty

o   How much more research is required to reduce uncertainty


Case reports / control

·      Should not change clinical practice but give more information



·      The level of evidence which can result in clinical changes



Modern definition of evidence based practice

·      Clinical experience, Clinical research

o   Clinical research should outweigh clinical experience

·      Patient opinion

o   Inform patients based in clinical experience and clinical research



What do we know about orthodontics

·      No method of speeding up treatment works

·      Bracket and the wire does not matter

·      Easy to straighten teeth

·      TADs increase anchorage by 2mm

·      We cannot change skeletal growth

·      Extractions can be required

·      Generally maintain archform

·      Don’t know much of relapse

·      Operator effects


Oral health definition : Comfortable and functional dentition which allows individuals to continue in their desired social role

·      No mention of cephalograms / occlusal indices

o   Do we measure the right thing?


What do we measure Tsichlaki & O’Brien systematic review of RCTs study

·      60% Morphological outcomes not relevant measures to patients

·      25% Cost of treatment

·      25% Adverse effects

·      10% Quality of life

·      2-3% consequences

o   Conclusion = Studies focus on orthodontists outcomes, not patient outcomes


Core outcome set – COMET

·      Standardise outcomes Tsichlaki / Fleming

·      4 stage approach

1.     Identify previous outcomes

2.     Qualitative interviews with patients

3.     Delphi consensus – agreement international orthodontists

4.     Final meeting

·      Findings

·      Breakages

·      Adverse effects

·      Skeletal relationship – not cephalometric

·      Occlusion

·      Stability

·      Co-operation

·      Impact of self-perceived aesthetics


Why is research rejected?

·      Denial of research: incorrect research, patients are different

·      Quackery – promotion of unsubstantiated methods that lack scientific rationale

o   Develop new disease, new method of diagnosis, new name, course and criticise others

o   Examples: expansion, orthotropics, self ligation, orthodontic airway, speed up orthodontics


Key opinion leader

·      Doctor who influences their peers practice

·      Paid – Kevin suggested changing title to paid clinical salesman

o   Speak at conferences

·      Substantial social media presence


Facebook based orthodontics

·      Clinical case presented by KOL, followed by comments from others with conflict of interest = subtle advertising


Is orthodontics getting lost

1.     KOLs

2.     Fringe orthodontic practice


Why does the social media approach work? Wider understanding of uncertainty, human psychology

·      People like to hear certainty

·      People struggle to think statistically

·      Understanding is based on a small number of observations

·      We have an aversion to loss

·      Problem of science is it is based on uncertainty in precise terms

·      The cunning of uncertainty Nowotny, Thinking fast and slow Kahneman


General Dentist

·      Not taught competence in undergraduate programme

·      Black hole of orthodontics,, can be influenced by fringe thoughts



·      Clinical appraisal

·      Greater engagement with research



·      Dental schools should revisit the curriculum

·      Specialist societies should be proactive in social media

·      Promote evidence to counter KOLs and fringe orthodontics

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