Article
The race to the bottom for the quickest, allegedly ‘great’ or bargain deal in orthodontics has reached a place that few would have thought possible even five years ago. The gradual ‘uberization’ of dentistry in general, but of orthodontics in particular, has produced a raft of new and largely unproven claims for treatments, which are promoted with gushing enthusiasm and superficial short-term evidence of their supposed long-term benefits for patients.
The thrust of the promotional ballyhoo, which appears on various websites, or in trade-sponsored dental comics, usually involves some pretty case report pictures as part of quietly advertorial articles that sometimes seem to have been written by someone with strong commercial interests. A convenient amnesia can allow such possible conflicts to remain undeclared, but the fanciful claims, which are not usually supported by worthwhile long-term independent scientific studies, seem to be targeted not only at interested and enthusiastic dentists, but also increasingly aimed directly at consumers potentially interested in some change in their dental appearance. These alleged panaceas for suboptimal smiles sometimes seem to encourage dentists to eschew the tedious detailed assessment of patients prior to offering them treatment and some appear to question, if not actually dismiss, other peer reviewed, accredited specialist orthodontic training and techniques. It is an inconvenient truth that, even with prolonged orthodontic training and education, and even with the tooth movements being done with care and skill in carefully selected cases, some relapse and/or resorption and/or gingival recession are commoner longer-term complications of elective orthodontics than some would care to admit.
To be fair, some of these newer techniques do make a lot of sense in some well chosen cases and a number of those people behind some of these developments appear to have spent considerable time and effort in developing their own orthodontic diagnostic and technical skills. Some have also produced proper training and education for general dentists, especially in relationship to which cases to treat and which to avoid, along with putting some decent supportive mentoring systems in place to ensure reasonable quality assurance.
However, that is not universal and there are some frankly daft websites with systems purveying dubious and scientifically unprovable claims. One recent new website has suggested minimal patient contact for proper clinical evaluation and instead suggested that patients should take their own photographs and impressions with a view to producing digitally derived models in order for someone, somewhere, to produce devices direct to the consumer, presumably outside of any GDC jurisdiction.
The direct accessibility and apparent simplicity of the treatment are promoted on the internet with breathtakingly superficial marketing straplines as being quicker, cheaper and more acceptable. Little seems to be mentioned about potential risks, or that such rapid results are probably a newer version of the sadly well known term ‘relapsodontics’, while potentially being biologically even more dangerous for the vulnerable roots and the soft tissues of some unsuspecting patients' teeth.
Many years ago I gave up believing in Santa Claus, or other fairy tales, such as that one can routinely con ‘the lovely ladies in the ligaments’, ie the periodontal ligament mechanoreceptors – or consistently fool the osteoblasts or osteoclasts or their various complex messenger systems with wishful thinking marketing jargon about ‘speed of tooth movement’, ‘invisibility of appliances’ and/or the subsequent stability of any such rapidly achieved results. The longer-term outcomes of such ‘wham, bam, thank you, ma'am’ cavalier straighter teeth treatments are highly likely to be unstable, especially without compliance with the oxymoronic ‘permanent’ retention, and some of these elective interventions have been disastrous for some patients' roots and/or their soft tissues.
The claims by some new hyperventilating marketer for ‘quicker, quicker, faster, faster’ branded techniques (possibly soon to be named ‘two and a half month smiles and no one can see the appliances at all at all’ or some other nonsense) need to be treated with considerable caution by conscientious and caring dentists, but increasingly also by some potentially narcissistic and/or naïve consumers. Bitter experience shows that when something appears to be too good to be true there is usually a very good reason for that.
The sensible advice for any ethical dentist, who is rightly concerned about the potential long-term dental health consequences of possibly treating a malocclusion in his/her trusting patient, is to be cautious. Personally, I find it helpful to spray myself liberally with the most potent version of anti–male bovine excrement that I can find before listening to some slick orthodontic evangelist at some conference, or reading some puerile ‘botty water’ marketing speak in some commercially driven dental rag.
Over recent years, as the Advertising Standards Authority and/or the GDC and/or the dental profession generally appear to have failed to challenge inappropriate claims effectively, there has been a proliferation of selfish promotions of unproven dental materials, dubious antiseptic chemicals for periodontal problems and many frankly daft techniques in various branches of dentistry. Fundamental flaws are sometimes not that easy to spot until one gives some serious thought to the probably flawed basis for some of these, possibly financially driven, promotions.
Professions are established within society to help protect the vulnerable from an asymmetry of knowledge, skills or experience being exploited by unscrupulous people to advantage themselves unfairly at the expense of others less fortunate than them. Professions are given rights and privileges in return for undergoing rigorous education and training, as well as exhibiting good behaviour, often fulfilled in accordance with a code of ethics. Most ethical dental professionals are careful and relatively modest in their proposals about what they can deliver with dentistry of different types and most do not make outlandish claims. That approach is wise because many things are outside the direct control of dentists or their teams – such as the patient's genetics, the patient's compliance, their daily oral hygiene, or their diet, smoking habits or smile aspirations.
Many experienced dentists are uncomfortable with the recent proliferation of self-aggrandizing advertisements and claims for egotistical, narcissistic dentistry, often promoted by younger, or apparently non-specialist, dentists. These less than altruistic approaches, replete with their vacuous advertising straplines but rather tenuous grasp on ethics, have recently been crowding out established morals, ethics and patient care in dentistry.
The much lauded ‘market’ has its place in society, but it is not perfect by any stretch of the imagination. Major problems do occur with markets, as witnessed by the 2008 catastrophic banking crisis, when the uncontrolled greed of some bankers (and yes, I have spelt that word correctly) required society at large to pick up the huge consequential bills, while the supposedly Mensa level perpetrators of these scams and financial gambles waltzed off with their bonuses largely intact because ‘the banks were too big to fail’.
In healthcare generally there is a tacit acceptance that ethics and ethical behaviour will fill in the cracks around the actual letter of the laws. An unregulated direct access model runs the risk of reducing vulnerable human beings to mere profit centres and treating them as ‘perfect smile punters’ to be sold whatever they wish to have, regardless of what the possible consequences might be for them in the longer term. Theoretically, people are protected from bad dentists and dentistry in the UK, but what happens in the grey areas when it is not a named registered dentist, or dentists, supplying these orthodontic human-experimentation-without-licence treatments, perhaps via a website or facility based in a foreign country?
Every generation produces its own version of the ‘snake oil salesman’. A charlatan in full flow can be a fascinating and often amusing sight – always provided one can recognize one early on and maintain a safe distance from the spectacle, while watching others being entranced by the smooth sales patter and the clever manipulation in order to make the susceptible observers believe that they are getting something wonderful for supposed ‘peanut$’.
America, as a country, has some good characteristics but perhaps, given its vast population, seems to produce lots of slick sales-driven people. The expression that Americans prefer the word ‘guru’ because they cannot spell the word ‘charlatan’ has been attributed to Peter Drucker. He was a founding member of the management consultancy gang, but the gag could apply just as much to some famous bankers, or to some cosmetic dentistry ‘veneer-ologists’, or other slick purveyors of short-term ‘quicker, prettier looking, teeth now’ orthodontic opportunists.
In the latest selfish demonstration of some business focused guru's pursuit of his own agenda, the normal protective concerns for the patient's long-term wellbeing appear to have been blissfully ignored. Into this healthcare, or increasingly vanity driven, casino some new entrepreneur, possibly complete with Stetson hat and jangling spurs, has entered, having decided, apparently that, prior to offering to straighten someone's teeth, no detailed history or serious clinical examination of that patient is now required. Instead, some digital photographs and some impressions to be taken by that untrained ‘consumer-narcissist’ will suffice for a piece of software to be run by someone, somewhere, which will be able to make a full diagnosis, discuss treatment options, their risks and benefits and also be able to obtain valid consent. In addition to all of that, these magical remotely produced models can be used to make devices to produce biologically dubious movements of teeth which have unknown bone support, root length, or periapical status to some new unstable positions in order for them to become a desirable fashion accessory and all in someone of unknown mental or dental health.
I guess that one term that might describe this approach could be ‘One night stand orthodontics’. In other words, ‘they want it and you can do it’ and JFDI and stuff the long-term consequences of those superficially attractive impulsive actions. One further tawdry justification that has been offered for this crassly shallow thinking is that ‘if you don't do it, then someone else will and at least it will be cheap’. There is a term for that in Dublin…
This allegedly consumer friendly development is apparently being lauded by some visionaries targeting human vanity and being promoted with panting marketing enthusiasm as ‘disruptive technology like Uber’. However, moving teeth around is risky and unpredictable at the best of times and it is not like taking a cheaper cab ride, nor is it what most sensible dentists would recognize as the practice of responsible dentistry. Neither is it what many experienced dentists would be willing to have done either to themselves, or to a child of theirs, or to someone about whom they genuinely cared.
King's College Hospital is located in deepest ‘Saff London’ and some of it overlooks Ruskin Park. It was John Ruskin who said that ‘It is unwise to pay too much but it is worse to pay too little. When you pay too much you lose a little money – that's all. If you pay too little you sometimes lose everything because the thing you bought is incapable of doing the thing it was bought to do. The common law of business balance prevents paying a little and getting a lot – it can't be done. If you deal with the lowest bidder it is well to add on something for the risk you run and if you do that you will have enough to pay for something better.’
These wise words are still relevant to various aspects of dentistry today, including, sadly, the state sponsored dental terrorism called the UDA system.
Finally, if this emerging problem is not obviously within the jurisdiction of the GDC, possibly because of geographical or internet reasons, or is not a particular concern for their semi-informed consumer champion – as the current GDC chairman appears to be, based on his Pendlebury address – where do the responsibilities of the Advertising Standards Authority or Consumer Rights Act 2015, or the dental profession at large fit in with this worrying and complex charade?
Is this further drift to be left unchallenged, perhaps as just another case of ‘let the buyer beware’, or ‘Caveat emptor’, as my old Latin master used to warn? If so, what about the probability that in the future some less than totally satisfied Facebooking, Twittering, Instagramming, narcissistic ‘entitled consumers’, or their ever helpful lawyers will seek to cast all the blame on to dentists, or dentistry at large, for somehow not warning them adequately, or at all, about the problems of their desired cheaper and quicker ‘Uberized’ treatment approaches?