Through a glass darkly: Orthodontics in the 21st century

Joseph de Maistre (1753-1821) said that every country has the government [and the criminals?] it deserves. So it is with orthodontics. Today, many suspect that our specialty is in decline. We think that a lack of “teachers” is the source of this malaise. Unfortunately, this shortage is merely a symptom of a much greater problem—the idea that the basic trappings of a learned scientific calling really do not apply to day-to-day chairside treatment. In short, we are where we are by dint of wishful thinking and the gradual, unspoken realization that everything and anything work well enough to support a practice. When everything works, nothing matters. It was not always so.

Our sustaining mythology that orthodontics is a true medical science was popularized by Angle and his acolytes, many of whom were people of real substance and achievement. Orthodontics was commonly seen as “a thinking man’s calling.” The first orthodontic courses, however, were offered by proprietary schools, all of which were tarred by the brush of the Flexner report in 1910 and the Gies report in 1926. Parenthetically, as viewed from a remove of about a century, one is forced to conclude that Marx may have been right when he said that history repeats itself—first as tragedy, and then as farce. In any event, our leaders were forced to the conclusion that both dentistry and orthodontics needed a more prestigious home: hence our ongoing relationship with academia. In passing, it should be noted that we came to them, rather than vice versa. We said we were interested in playing higher education’s game of creating and husbanding knowledge. But were we really? How did it work out?

At the outset, Angle’s view of orthodontic science proved faulty. Creating a normal occlusion didn’t grow faces, a realization that Allan G. Brodie likened to learning that there is no Santa Claus. After World War II, orthodontics tried once again to grow faces, both with shiny braces and with eponymous “functional” appliances; biologic science (as opposed to materials science) had little to do with these endeavors. To this day, we pretend to be “scientific.” We pay lip service to such mumbo jumbo as the “functional matrix hypothesis” (as long as understanding its terminology isn’t a requisite) and have replaced extraction with a host of popular but largely ineffective substitutes, each with a labored, after-the-fact “scientific” rationale. As long as nobody dies from anchorage loss and permanent retention, this clear violation of the tenets of science may seem to have little practical significance; however, it imposes a penalty that threatens the status of the specialty: it argues that there is little in the way of a market for evidence, the work product of “the schools.”

From day 1, residents see that any given treatment plan depends more on the day of the week than on the details of the malocclusion. The literature rarely intrudes on the orderly flow of activity in the clinic, and the various “didactic” courses are tolerated, but only just barely. Without the gift of faith, who would become a priest? Without a belief in Angle’s sustaining mythology about orthodontics as a true medical science, who today would opt to become an orthodontic academic? It thus should come as no surprise that, as a symptom of the new order, few are interested in a teaching career. Can anything be done?

Many think that organized orthodontics and dentistry ought to “do something” to get the specialty back on track. But what? Support the education of potential academics? Given the promise of financial support, everybody says that they want to “teach and do research,” an urge that commonly subsides when their residency ends. Occasionally, well-meaning alchemists-to-be will try to create bona fide scientists by pushing them through some sort of PhD program, a strategy that is only slightly more plausible than the notion that a medal can make a hero out of the Cowardly Lion. Pay for travel, dues, or salary augmentation? Largely a waste of money, as are most of the financial inducements that have been trotted out in the hope of luring folks into the groves of academe. But even if we had a surplus of educators, would that solve our problems? I doubt it.

Crazy treatments proliferate at an amazing rate. Is it reasonable to expect our academics to spend their lives playing what amounts to an endless game of orthodontic “whack-a-mole”? You might think that perhaps they can “educate” both the specialty and the public about the methods that jostle for attention on the Internet. Unfortunately for our version of the truth, the First Amendment protects other versions as well. In the absence of data and legal support, criticism is dangerous, especially when directed toward commercial enterprises. The companies may pay for many of our speakers and are responsible for much of our armamentarium, but, in the end, their fiduciary responsibility is to their stockholders, not to us and our patients. There is a solution. Its implementation, however, cannot be farmed out to “someone.” As noted by Cassius (Shakespeare: Julius Caesar , Act I, Scene II), “The fault, dear Brutus, is not in our stars, but in ourselves ….”

Both our problem and its solution can be inferred from a simple Zen riddle. Rational, evidence-based treatment, at least in the short run, probably has a negative impact on the bottom line. At the same time, it presumably has considerable benefit to the patient, who, in any event, will rarely, if ever, know the difference, one way or the other. The way we respond in anonymous isolation will determine the future of our calling.

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Apr 6, 2017 | Posted by in Orthodontics | Comments Off on Through a glass darkly: Orthodontics in the 21st century
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