Orthodontic quackery. What is it, and how does it relate to the history and the future of our specialty? The place to start is to define both conventional orthodontic treatment and what we might consider to be “quackery.”
Perhaps the most logical definition of “accepted orthodontic practice” is that it encompasses the treatments and concepts that most orthodontists should be practicing or teaching. These can easily be defined as “treatment based on credible scientific evidence published in peer-reviewed journals.” It is also pertinent to consider that without evidence, accepted orthodontic practices can include the views of experienced clinicians practicing in the relevant area or the recommendations of “learned societies.”
Defining “quackery,” on the other hand, is more difficult because of the great diversity of orthodontic practice. I looked for definitions; according to Wikipedia, we can consider that the quack:
Promises benefits from treatment that cannot be reasonably expected to occur.
Recommends against conventional therapies that are helpful.
Promotes potentially harmful therapies.
Promotes magical thinking.
The Oxford English Dictionary defines a quack as “a person who advertises false or fake remedies.”
Although these definitions appear reasonable, we must also consider that there are most certainly blurred lines between these 2 concepts. This could be because the definitions do not reflect the full breadth of contemporary health care. Perhaps a further way to consider this is to suggest that a quack is a person who knowingly does not practice evidence-based health care.
At this point, I fear that I am entering dangerous ground. If we look back at the history of our specialty, it appears that many of the great advances that have been made are the result of an innovator’s proposing and developing a treatment method that is then adopted by the mainstream. Examples of this include Edward H. Angle, who developed his appliances and treatments by experimentation and trial and error; Calvin Case, who argued against Angle’s nonextraction approach on the basis of a few case reports; and Rolf Fränkel, who, in relative isolation, developed a functional appliance that changed the way we treated many of our patients.
As a result, we must be able to differentiate between the great innovators of the past and the quacks. There is no doubt that these innovators were not quacks; however, it is clear that they did not practice the “evidence-based care” to which we aspire.
Contemporary evidence-based care
The evidence-based care movement has changed the delivery and effectiveness of all health care, including orthodontic treatment. We now have plenty of sound scientific evidence that underpins a reasonable proportion of our treatments. But there are still variations in the care that we provide; examples of this are the extraction-nonextraction debate, different functional appliance philosophies, and differences in bracket designs. I suggest that these may be considered the usual differences in clinical opinion that occur when there is clinical uncertainty.
However, there are also treatments that some might consider quackery because they are promoted widely and fly in the face of clear evidence to the contrary. This could, arguably, include some self-ligation claims, “new” appliances that promise ultrafast treatment, or extraordinary claims of growth modification, such as changing the position of the bones deep in the cranium with a removable orthodontic appliance.
Although it is easy to be flippant or critical of these claims, I would like to be open-minded and therefore suggest a further definition of a quack: the promoter of a technique or a product who knowingly misrepresents the risks and benefits.
We then need to critically evaluate the evidence for both conventional and fringe treatments. When we look at the evidence for what we might think of as fringe or quackery-based treatment, it is well established that the level of evidence is weak. Although we have evidence underpinning some aspects of “acceptable” orthodontic treatment, in many areas the level of this evidence also is weak. In some areas, the levels of evidence are similar!
This confusing situation is compounded further when we remember that there are also highly respected practitioners who follow philosophies and make claims that are contrary to the evidence. A good example of this is self-ligation, which continues to be promoted by key opinion leaders, in the face of research evidence that contradicts the claims. Yet, these opinion leaders are not criticized to the same degree as some who are considered to be on the fringe.