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
RCT
· 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
Specialists
· Clinical appraisal
· Greater engagement with research
Solutions
· Dental schools should revisit the curriculum
· Specialist societies should be proactive in social media
· Promote evidence to counter KOLs and fringe orthodontics
