Orthodontic Outrage
 
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Orthodontic Outrage
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PRESS RELEASE

ORTHODONTIC CONCERNS
this is our case against suppression and oppression


The issue: Professional Suppression in Orthodontics

For over a hundred years the orthodontic specialty has been split in two. One group favours straightening teeth by mechanics and surgery and the other by trying to guide growth before the child has finished growing. At different times in the past each group has held ascendancy almost to the exclusion of the other. At the moment the mechanical group has established control and almost all children in this country with overcrowding are treated with the extraction of four or eight permanent teeth, following which the remaining teeth are moved into line with ‘train tracks’. Currently the ‘natural growth’ group that favours non-extraction and growth guidance methods is seen as unorthodox in the UK although opinions vary around the world.

Recent scientific evidence, that questions the merits of extractions, is sparking debate elsewhere, but not in the UK where the establishment is closing ranks to suppress any form of debate. There are five resulting issues that are of concern to all:

  1. Conventional orthodontics, as practiced by the majority of orthodontists in the UK, could well be causing as much harm as it does good.
  2. Patients are not being informed of the risks or alternatives to orthodox treatment and are therefore not able to provide fully informed consent.
  3. The ‘orthodox’ group is so sure that it is right that it feels justified in suppressing the views of those who use non-extraction methods.
  4. Monopolisation of education over the last three decades has lead to a severe shortage of clinicians with non-extraction skills
  5. Many orthodontists are engaging in ‘Supervised Neglect’ by delaying treatment until puberty when it is often too late to use growth guidance to avoid jaw surgery and the extraction of teeth.

This is a topic that would be of real interest to your viewers because orthodontic treatment is required by over half of UK families and for many of them this represents the largest health expense they will ever make. In addition the conflicting views from the different parties involved would make excellent copy or viewing.

 

1. Conventional orthodontics, as practiced by the majority of orthodontists in the UK, could well be causing as much harm as it does good.

Viewpoint of the group favouring straightening teeth by mechanics and surgery:
This group’s approach is in the ascendance at present and has been for at least three decades. This means that, at least in this country, all those in any position in the governing bodies or in education are of one mind on this – they are right and there is no need for debate. This group claims that there is no evidence to show that alternative unorthodox methods work although they accept that there is no evidence to show that they don’t. This is in spite of the fact that there is little evidence to support their own methods and considerable evidence to show that they could be flawed.

Viewpoint of the group favouring non-extraction and growth guidance methods:
Some of the most experienced practitioners have lived through three complete reverses in the orthodox approach to extractions – each held with equal conviction. When challenged in the past, each group has responded, as scientists usually do, with long lists of evidence showing that they are correct (very poor reading/viewing unfortunately). However, there is increasing evidence that extractions can damage faces and that the number of extractions in the UK is alarmingly high by international comparison. The ‘natural growth’ group feels that patients should be told about this.

2. Patients are not being informed of the risks or alternatives to orthodox treatment and are therefore not able to provide really informed consent.

Viewpoint of the group favouring straightening teeth by mechanics and surgery:
They are so convinced that they are right that they do not see any need to even consider alternatives. This is despite the fact that patients are entitled to be fully informed of the risks and alternatives, and despite the fact that these risks and alternatives are the subject of increasing debate, albeit outside the UK. Recent research has showed that over 90% of patients in the UK felt that they had not been adequately warned about the risks and over 95% had not been told about alternative methods – indeed consultants at some hospitals are refusing to tell patients about alternative treatments that they do not practice personally (see brochure “Informed Consent Prior to Facial Surgery”) – and yet the establishment does not see that there is any problem with informed consent.

Viewpoint of the group favouring non-extraction and growth guidance methods:
These practitioners are being swamped by parents who want to avoid extractions and surgery but can not find an orthodontist who is willing to provide treatment without extractions. There are plenty of stories of desperate patients and angry parents who were given no alternative by their orthodontist, but who were subsequently treated or re-treated by ‘natural growth’ practitioners without extractions or surgery with as good, if not better, results. Parents often have to travel long distances to see these practitioners because they can’t find anyone in their area who will treat without extractions.

3. The ‘orthodox’ group is so sure that it is right that it feels justified in suppressing the views of those who use non-extraction methods.

Viewpoint of the group favouring straightening teeth by mechanics and surgery:
This group not only dominates the governing bodies and education establishments, but also the UK’s key professional journals. In the UK, the peer review bodies, which decide which articles are worthy of publication, are drawn exclusively from the group favouring straightening teeth by mechanics and surgery. They see all differing perspectives as wrong and unworthy of publication – this has resulted in near monopoly of coverage for the establishment and wide censorship of non-extraction views. Currently there is a concerted effort by established orthodontists to discredit non-extraction practitioners by disciplining them before the General Dental Council. These moves are clearly motivated by their disapproval of the method of treatment rather than the result. In one such instance the patient was re-treated by the established orthodontist who had instigated the attack only to be unsatisfied and seek treatment from a third expertreturn to the original ‘discredited’ practitioner.

Viewpoint of the group favouring non-extraction and growth guidance methods:
These practitioners have found it almost impossible to get even quietly worded articles published in the UK and have had to use overseas journals -- there are examples of articles that have been published in the top overseas journals that had been turned down repeatedly by the professional journals in the UK. This group has had to appeal directly to the broader body of dentists in a call for open debate about treatment alternatives. They say that they have been pressing for better standards in orthodontic research for thirty years only to be ignored (see following section - simple overview of the evidence).

4. Monopolisation of education over the last three decades has lead to a severe shortage of clinicians with non-extraction skills.

Viewpoint of the group favouring straightening teeth by mechanics and surgery:
The dental colleges say that they have the right to teach whatever methods that they consider are best supported by the evidence. The colleges are quick to quote evidence showing that the orthodox treatment, with ‘train tracks’ and extractions, is the best way of straightening the teeth. However they don’t mention the research that shows that these methods cause damage and offer only a short-term solution – crooked teeth usually return later. Whereas when criticising the unorthodox methods the colleges quote ‘clinical’ studies despite the fact that ‘clinical’ orthodontic studies of this type have been heavily criticised by orthodontic researchers (see next section) as being unreliable. At the same time basic research on tooth and jaw growth strongly suggests that unorthodox methods, such as growth guidance, can be effective provided that the treatment is carried out correctly. Unfortunately very few of the students that have qualified over the last three decades have been taught non-extraction skills. Instead they have been educated to believe that crooked teeth are an inherited problem and trying to influence growth is a waste of time.

Viewpoint of the group favouring non-extraction and growth guidance methods:
These practitioners have lobbied the General Dental Council, which is appointed by the government to look after the public interest. However the public representatives on the council have been swayed by the orthodox orthodontists on the professional bodies and in the educational establishments that claim that they have science on their side. As a result the GDC has made no effort to redress the balance despite evidence from independent scientists showing that much of the so-called ‘science’ supporting orthodox treatment is flawed (see below).

5. Many orthodontists are engaging in ‘Supervised Neglect’.

Viewpoint of the group favouring straightening teeth by mechanics and surgery:
This group is mainly interested in straightening the teeth and is less interested in the growth of the bones. They quote clinical evidence showing that early ‘Growth Guidance’ treatment is no more effective at straightening teeth but as they routinely use mechanical methods to finish their cases this is hardly surprising. Orthodox orthodontists find that early treatment merely means that the patient is likely to need a longer course of treatment in order to finish with much the same result; they therefore tend to prefer leaving it until the patient reaches puberty.

Viewpoint of the group favouring non-extraction and growth guidance methods:
There is clear evidence that it becomes difficult to change the bones after the age of eight. Growth Guidance practitioners seek to guide the growth of the jaw before this age in order to create room for the teeth and eliminate the need for extractions. However patients are usually advised by the profession to wait until puberty by which time it is frequently too late to avoid extractions or even worse to avoid major surgery because the jaw may well have already grown incorrectly (as was the case with the parent quoted in the press release). The Growth Guidance practitioners believe that the clinical evidence relating to early treatment is both unreliable and conflicting, and in any case fails to show that early treatment is less effective. It merely shows that conventional orthodontists have difficulty in achieving results when starting around puberty – probably because the advantages of early treatment are negated by the use of mechanical methods (i.e. train tracks) to finish the treatment.

Should we be worried?

Overcrowding, orthodontic treatment and extractions are all on the increase:
Our modern diet and lifestyle is leading to an increase in the number of cases of overcrowding. And UK orthodontists are increasingly using extractions and surgery to treat it. Not only are these extractions and this surgery unnecessary, but it is also becoming increasingly expensive for families as treatment fees increase. Rarely has unnecessary harm cost so much.

The UK is out of line with the rest of the world:
In the UK probably 80% of orthodontic patients receive extractions or surgery, while in the USA the figure is believed to be about 40% (no exact figures exist).

Conclusion:
Whatever the merits of either form of treatment, ignoring scientific research and suppressing debate hardly serves the interests of the patients or indeed the long term interest of the profession. It only really serves those with a vested interest in the status quo.

Enforcing Professional Standards or Ideological Witch-hunt
There have been several recent cases where orthodontists with extreme ideological views in favour of the mechanical approach have advised the General Dental Council to enforce sanctions against a dentist that favoured non-extraction and growth guidance methods.

Example one: Lindsay Winchester, a consultant at East Grinstead Hospital and a leading advocate of the mechanical approach, advised a patient to sue a dentist from East Grinstead who favours non-extraction and growth guidance methods. The case brought against him by the GDC failed and the patient, who then went to Lindsay Winchester for treatment, later had to seek the opinion of a third expert who said that Richard had done an excellent job all along. The patient wrote and apologised to Richard for the distress that had been caused, saying that “quote here from letter”.

Example two: Robert Lee, who was head of Orthodontics at London Hospital and also a leading advocate of the mechanical approach, advised the General Dental Council to take action against a dentist who favoured non-extraction and growth guidance methods. The case has dragged on for over three months so far and has become the most expensive one that the GDC has ever heard. The outcome is far from clear, but is likely to be heavily influenced by the ideologies of many of the witnesses. The clinician in question fears that the GDC may be tempted to find him guilty – if only on a technicality – in order to seek to justify the expense of the trial.

Simple overview of the evidence

John Mew – a leading advocate of the non-extraction and growth guidance approach, an internationally recognised lecturer and the author of innumerable scientific papers on this subject (most of which have been published abroad) has prepared the following simple guide to the evidence. To avoid sterile or one-sided argument, the evidence quoted below is broadly accepted by both sides.

Introduction:
Orthodontists in the UK are trying to defend the indefensible and are only succeeding because they currently hold the position of power. They are making very large incomes for achieving uncertain long term results gained at the real risk of damage to the face and teeth (almost all their patients in the UK finish up with four or eight extractions). They ruthlessly suppress those who advocate non-extraction treatment; even encouraging the General Dental Council to discipline them. They accept that the evidence is inconclusive but for some reason feel justified in imposing their own mechanical and surgical methods on others.

Orthodontic research has one of the worst records of any science in the world; this is largely because the clinicians do not listen to the scientists (see list of quotes by orthodontic scientists). For example, in a recent edition of the British Dental Journal Dr Sandler (the publicity officer of the British Orthodontic Society) faced criticism that he twice used negative evidence to justify positive statements (a major crime in science). Enclose a list of widely accepted evidence that the current establishment ignores because it does not suit their pattern of practice.

Some History - how views have changed over the years:

Calvin Case 1890 Extraction
Edward Angle 1911 Must never extract
Tweed / Begg 1938 Must always extract
Witzig/ Truit/ Mew 1973 Non-extraction
Current establishment 2005 Mostly extraction

John Mew has proved a controversial character within the orthodontic specialty While he has been applauded by many national and international bodies, the main orthodontic body in the UK sees him very differently:

Viewpoint of the group favouring straightening teeth by mechanics and surgery:
Most of this group (which includes the UK’s main orthodontic body) view him as an eccentric who has had some influence on current methods of treatment, but some view him as a dangerous maverick or even a heretic.

Viewpoint of the group favouring non-extraction and growth guidance methods:
This group views him as a leading practitioner and scientist and even as something of a whistleblower.

Orthodontic Science

  • Sackett, D. Professor of Evidenced Based Research at Oxford. 1985 “Orthodontics is behind such treatment modalities as acupuncture, hypnosis, homeopathy, and on a par with scientology”.
  • Johnston L.E. Professor at Ann Arbour Michigan. 1990 “Clinical practice …is at bottom largely an empirical process that is little influenced by theory inferred from any of the life sciences”.
  • Richards Derek. Director of Evidenced Based Dentistry 2000 “The current focus of dental schools leans toward the teaching of technical skills rather than scientific thinking”.
  • Shaw, W C, 2000. Dean Manchester Dental School. “Sadly it is hard to see this situation change unless the inadequacy of current (orthodontic) knowledge is acknowledged by its practitioners”.
  • Frankel Rolf. 2001 “A mechanical approach treats a symptom, not the cause”.

Faces

  • We know that forward growing faces look more attractive. (Peck and Peck 1970)
  • We know that people with forward growing faces have straight teeth. (Platou & Zachrisson 1983).
  • Orthodontic treatment is “accompanied by exaggerated vertical facial growth". This “contributes to the poorer aesthetic result". (Battagel 1996)
  • ‘Longer faces look less attractive’. (Lundstrom et al 1987)
  • Orthodontic treatment cases faces to lengthen and “facial aesthetics deteriorate” (Lundstrom &Woodside 1980)
Vertical Growth
Damages Faces
Horizontal Growth
Improves Faces
Picture showing how vertical growth damages faces Picture showing horizontal growth

This child’s face was damaged by vertical growth following orthodontic treatment. Vertical growth is associated with thick lips, receding chins, protruding noses, sloping foreheads and tired eyes.

Although this boy's teeth stuck out both jaws were encouraged to grow forward. Most other techniques pull the teeth back. No extraction method could achieve this result.

Other Iatrogenic Damage.

  • Over 90% of the roots of the teeth show signs of damage following treatment with fixed appliances. (Kurol, et al 1996). 40% of patients show root shortening of more than 2.5mm. (Mirabella and Artun 1995)
  • Enamel damage, with fixed appliances, is rapid, widespread and long-term. (Ogaard et al 1988) (Ogaard 1989) (Alexander 1993).
  • ‘Unacceptable’ relapse occurs in 91% of patients twenty years after treatment. (Little et al 1988). A highly respected study but some clinicians have challenged it.
  • “The majority of results were unsatisfactory”. Suppressed results of a ten year study by Professor Richmond in Cardiff 2002