21st century orthodontics: When everything works, can anything matter?

At age 12, I had orthodontic treatment, during the course of which, I decided to become an orthodontist. $125 for two molar bands and some elastics seemed like a magical way to print money and thus, a clear pathway to my future. I always had good grades, so there was nothing to stand in the way of this trivial career plan. Further, in dental education and in many graduate programs, there are few choices to be made, so my plan had the soothing benefit of letting me go 15 years without any more career decisions. As time went on, however, I developed a more mature (or at least different) attitude toward my relationship with dentistry and orthodontics. I decided that it would be challenging, and fun to become an academic in what was called “a thinking man’s specialty.” Ultimately, I found myself part of an enterprise that our sustaining mythology to be a true medical specialty. I found that there is more to orthodontics than two molar bands and a bill for $125.

A society, a journal, and schools constitute the tripod upon which a learned calling is built. The development of the legs of the orthodontic tripod thus was an expected stage in the evolution of an exciting new calling promoted by a coterie of exceptional clinicians. How has the specialty’s first century turned out? Has the re-emergence of large, scientifically barren proprietary schools been a positive event? Given the excoriation of proprietary schools that drove us into the universities, we have apparently come full circle. In other words, there is nothing to be learned from the second kick of a mule. Were our early leaders (the so-called “Fathers of Orthodontics”) correct in their optimism? Did their science stand the test of time? Did things turn out the way that Angle and his colleagues expected? Based on 60 years of experience wandering about in the world of orthodontics, I feel obliged to comment on these questions.

Firstly, it must be noted that nobody dies from lost anchorage or, indeed, from the impact of any popular treatment, no matter how “crazy.” (Aside: Sleep disordered breathing probably could be lethal; however, as with TMD, an orthodontic proximate cause seems merely to be a life preserver thrown to those seeking an extra arrow in their clinical quiver.) Given this ability to practice free from the dark cloud of biological reality, our leaders went on to produce a century of “science” that was a triumph of wishful thinking that usually involved some sort of scheme to grow bone. For example, Angle thought that the achievement of a Normal (“Class I”) occlusion would cause the face to grow properly and, in the case of Class IIs, the resulting mandibular augmentation would correct the malocclusion. Further, the first appliances that could control bodily tooth-movement were used to produce labial root-torque in the hopes of growing bone over the roots of grossly flared incisors. In the same vein, the so-called “functional” appliances that have littered our history share one important detail (in addition to the fact that they seem to have little impact on facial growth): all produce an anterior mandibular displacement that many think/hope will produce extra mandibular growth. Given that success in practice is unrelated to the truth of these untutored claims, the status of our calling is in question. As asked in this short communication’s title, does anything matter?

When I was a resident, I viewed our sustaining mythology as a Platonic ideal toward which we had not yet made much progress. I thought that, if I got a Ph.D. (a scientific union card), I could clear things up and thus craft an interesting and valued career. It would be an orthodontic age of enlightenment; my papers would be on everyone’s bracket tables. As things turned out, research is fun and my work is genedrally respected; however, the elastic intellectual nature of our specialty meant that most clinicians feel no need to pay attention to academe — “It works in my hands.” Gradually it dawned on me that I would have to view my research career as a personal game, a game that would be challenging and in which I would be the scorekeeper. Although I generated data that I thought should be of use clinically, I never could convince myself that it had much of an impact on treatment. Plus ça change, plus c’est la même chose.

If, in our second century, treatment still is conducted largely in the absence of a rational, evidence-based foundation, our future merits serious consideration. From the standpoint of our colleagues, a lack of “teachers” is thought to be the specialty’s major problem. Is the concern based on a decline in the significance of our research or is it a concern for orderly “practice transition”? Either way, given an apparent need for teachers, where are they to come from? We have recruited widely and thus have run out of foreign sources; can we look to our own schools? Is there anything in our educational system that would cause smart young residents to consider a life in academia?

Today’s residents are different from those of earlier generations. They are more sophisticated, less technically adept, and much less likely to believe in our classic professional mythology. Things that are quicker, easier, and cheaper are probably more enticing than, say, “anchorage preparation” or Bonwill-Hawley archwires. Indeed, there seems to be little understanding of the nature of an academic career. “Teachers” hold seminars and patrol the clinic; academics, in contrast, create and husband knowledge, often in the wee hours of the night. Given our drift toward cosmetology, there is little enthusiasm for a life spent generating data for which there seems to be little market. Whip sockets used to be important to horse-drawn carriages. Today, however, there is no need for whips in our autos. Absent a need, there is no market. Lest these comments be considered an overstatement, it may be noted that I have never received any kind of answer to a simple, oft-repeated question: “Is there any answer to any question that would cause you to change the way you practice?” Silence. O.K., given this attitude toward evidence what can be done to attract teachers and academics

How about money? Retirement of student debt, professional memberships, travel help, and the like are commonly suggested strategies designed to recruit teachers and researchers. Write a check and the problem is over. Would that it could be so easy. I have always wondered whether we should want to attract “researchers” for whom a few thousand dollars are important enough to determine the nature of their careers. Similarly, consider the Catholic Church: is there a move to attract more priests and nuns with trivial sums of money? For both the Church and orthodontic academics, the problem is the same—a loss of faith. We no longer believe in the specialty’s sustaining mythology. When everything “works” and nobody dies, evidence-based practice is for many an unnecessary elaboration that serves only to interfere with the orderly flow of commerce. No matter how bizarre the treatments advanced on YouTube or in motels, they are popular with those in constant search of something to sell. It is the uncritical selling the unlikely to the unknowing. In the end, monetary contributions are important to the day-to-day workings of a department; however, they do little to attract residents to a career in academe. Is there nothing that can be done? If you build it, they will come.

There is a solution, but it will have to come from the rank and file toiling anonymously at chair side: If you practice evidence-based orthodontics and if you seek evidence, then there are always those who will emerge, not from a corn field in Iowa, but from the various schools. Not every resident has crippling debt; not every resident thinks only of money; not every resident think “theory” is a waste of time. In the absence of demand, however, none of this will come to pass. The specialty probably will respond like water seeking its own level.

In the future, I suspect that orthodontics will become a multi-level calling, a pyramidal array ranging from cosmetology at the bottom to skilled, evidence-based practice at the peak. It remains to be seen whether the few at the top will be enough to constitute a medical specialty that can attract teachers and researchers. I hate to say it, but I doubt that our prestige can emerge unscathed. We will have to feed much farther down the trough.

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Jan 9, 2020 | Posted by in Orthodontics | Comments Off on 21st century orthodontics: When everything works, can anything matter?
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