An aggregated sample of orthodontic records could be used to improve care.
It would help clinicians to understand and assess their own performance.
It could facilitate the establishment of standards of care for various problems.
A registry could help clinicians provide more predictable care.
A registry would demonstrate the specialty’s commitment to excellent care.
The specialty of orthodontics was recently recognized by U.S. News & World Report as the number 1 profession in the United States. The editor of the American Journal of Orthodontics and Dentofacial Orthopedics , Rolf Behrents, gave a thoughtful and provocative commentary of this ranking in the April 2016 issue. Perhaps orthodontists have been singled out because each clinician has the ability to deliver excellent care, since each can obtain and analyze diagnostic records.
Where are we as a specialty? Fourteen years ago, Lysle Johnston’s editorial in the World Journal of Orthodontics entitled “When everything works and nothing matters” got to the heart of the problem. Add to that Sheldon Peck’s excellent treatise in the June 2012 issue of Seminars in Orthodontics in which he stated, “Today, conscientious orthodontists are being challenged by commercially marketed appliance systems that promise easy solutions and are based on non-extraction dental arch expansion. This is a throwback to orthodontic methods advocated a century ago, long before the evidence-based era of orthodontics, radiography, and periodontology.” Dr Peck addressed these same issues in his Sheldon Friel Memorial Lecture, which was published in the European Journal of Orthodontics . The summary of his talk is that conscientious clinicians should try to develop individualized treatment plans for their patients and not be influenced by treatment “philosophies” with untested claims. Orthodontics must address these issues so that the specialty can be preserved for the bright and energetic young people who are being taught in our graduate programs. All students—and all clinicians—deserve a road map for success. Society must know that orthodontists have the patient’s best interest at heart and that the results achieved for each patient are the best that current science and art can provide. Treatment must be about service and commitment to the patient’s well-being. The benefit of treatment must outweigh its burdens for each patient.
There are many different kinds of appliances and many treatment philosophies. This is well and good because everyone does not think in the same manner. Varied appliances are not the issue. The issue is that orthodontic treatment plans must be based on evidence, not anecdote. Our specialty has ample evidence in raw form. What can the specialty do that will help it evaluate the evidence it has and arrive at some common denominators for what a particular malocclusion should resemble when its correction is completed? The solution is relatively simple. We need an “orthodontic registry”—a tool that will allow the specialty to gather and disperse information to optimize treatment outcomes for all patients. A registry would eliminate the problem of “everything works but nothing matters.” In medicine, treatment techniques are not generally accepted or used in hospitals unless there is evidence to support their clinical efficacy. The Federal Drug Administration does not allow drugs to be used unless these drugs have been tested and proven to have a predictable value for the patient. Why are there not similar safeguards in orthodontics? A registry would help the specialty to improve its performance on 2 fundamental levels. (1) On an individual level, a registry will enhance each clinician’s understanding of his or her performance. (2) On the population level, a registry will facilitate the establishment of a standard of care for the many problems being treated.
Orthodontics is not magic. If orthodontics had a registry, it would give everyone who is practicing the specialty valuable evidence about “what works.” A registry would yield “big data” to our specialty. It will help clinicians to deliver a high quality of service to every patient routinely.
At present, there is no way to demonstrate whether 1 treatment approach is better than another. The specialty needs answers so that patients are better served. The evidence that exists in the specialty could be used better with a registry. It would be invaluable to be able to compare a particular patient’s problem with other patients in the registry with a similar problem to see how the problem was most successfully treated. For example, different treatment plans for the correction of the same type of malocclusion will probably yield a different distribution of results. A registry can answer the question: what is the distribution of possible treatment results that a practicing orthodontist can expect when using various treatment tactics?
Currently, much of the specialty’s education comes in the form of case reports or case series that demonstrate what is possible when treating a patient with a particular approach. The current educational paradigm entails a “show and tell” approach; this approach has limited usefulness and can be quite misleading. A registry could help define not only what is possible, but also what is probable with respect to treatment outcomes. Clinicians need treatment modalities that are predictable, not possible. “Predictable” means predictability approaching 99%. Consider a 90% success rate; it would mean that there is a 10% failure rate. Does any clinician want 1 of 10 patients to be a failure? Therefore, if a certain treatment will afford a greater frequency of success than another, clinicians should use it. If some treatment approaches afford a lower frequency of negative sequela and frank failure, they should be embraced.
Simply stated, a registry would provide a way to evaluate treatment. It would give the specialty a basis for calculating the efficiency or the efficacy of various treatment techniques and approaches. Participation in a registry will enhance treatment planning as well as treatment tactics before and during treatment. A registry will allow practitioners to evaluate treatment outcome with respect to peers.
A registry could also yield information that will help our specialty and individual clinicians decide when it is time to terminate treatment, because the continuation of treatment beyond a certain point is more likely to result in net harm to the patient, even though the intention of the orthodontic provider is good. When the optimal treatment outcome is unknown for a patient, it can be difficult to determine when it is appropriate to end treatment. Big data will allow practitioners to better understand what kind of outcome is reasonable to expect, given an initial malocclusion and a particular treatment approach. Arriving at a treatment outcome sooner rather than later is a good thing. The less intervention (the less you touch a patient) on the way to a particular treatment end point, the better off the patient (less is more).
As an incentive, a registry could have continuing education ramifications. One would hope that continuing education credits could be granted for participating and learning how to improve individual clinical performance through participation in a registry. HIPAA concerns for registry participants should be easily solved. A comprehensive orthodontic medical-style registry will afford an opportunity for every educationally qualified orthodontist to participate. A registry would lead the way for the rest of the dental profession with respect to evidence-based dentistry.
A starting point
Whereas a registry may serve a wide variety of uses, there are many problems associated with its establishment and maintenance. Foremost among these is the expense of operating a registry. Quite probably, practitioners who participate would be happy to pay a participation fee. The American Association of Orthodontists and the American Board of Orthodontics would have to give an orthodontic registry credence and financial support. By supporting a registry, these entities would be demonstrating to the public that the specialty is continuously working to improve the care provided by our membership: care of a quality that can only be provided by our members—orthodontists! It would be worth spending resources to educate the public about our commitment to their orthodontic care quality.
There are 2 types of data that a registry might collect: (1) complete pretreatment and posttreatment data, and (2) annotated treatment data—ie, treatment records accompanied by case management and patient compliance information. The second type of data could be collected on a representative subset of patients or retrospectively by an investigator on a patient-by-patient basis. An example that represents the second type of data required for the registry is data collected at each certification examination by the American Board of Orthodontics.
Ten years ago an orthodontic registry would have been a difficult endeavor, if not an impossible data-management issue. With the technology available today, the process, although politically challenging, would be highly manageable. The specialty should expect these problems and solve them. As with many other things, ongoing continuous evaluation of the registry process from data quality to sharing the results with participating orthodontists, educational institutions, and other research organizations will require continuous supervision to ensure optimal usefulness of the data.
There are many ways to make a registry work for patients and our specialty. A registry must be brought to fruition. Once all agree that it is important and appropriate to have a registry, it is a matter of making a start. The establishment of an orthodontic registry will enable the specialty to provide a better and more predictable quality of care to all patients.
All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.