We received a typical bulk e-mail from the American Association of Orthodontists this week that makes for an interesting thought experiment. The e-mail announced that the AAO plans to have a consensus conference in 2018-19 regarding the relationship between sleep apnea and the practice of orthodontics. Their goal is to “produce a white paper including evidence-based guidance that can be used in the practice of orthodontics”. This isn’t the first time that the AAO has commissioned a group of experts to assess evidence and develop clinical guidelines in a specific area of orthodontic practice.
The last example of this was the joint task force of the AAO and AAOMR which developed an “evidence-based” white paper titled “Clinical Recommendations for the Appropriate Use of Cone Beam Computed Tomography (CBCT) in Orthodontics” (see below). One of us discussed this episode in a blog this past spring. When the draft of the findings of the task force were given to the AAO rank and file, there was a hostile response by those that had a vested interest in the use of CBCT, e.g. owners of CBCT machines and key opinion leaders aligned with the makers of CBCT machines. In turn, the AAO Board of Trustees voted not to accept the report of the joint task force and to communicate their decision post haste to the membership via the AAO e-bulletin (see below, p.8). So, in the end and despite the evidence, the orthodontist is still free to use their own judgement regarding the use of CBCT in orthodontics.
Evidence-based practice relies on big data. That is to say, randomized clinical trials with robust data from powered samples are considered more reliable in the hierarchy of evidence than the beliefs of a room filled with experts. Orthodontics doesn’t really do big data and for the most part what we do is governed by uncertainty and the precept of “that’s just the way you should do it”. With that being said, have we changed any warmly held clinical orthodontic practice from the results of evidence-based study? No. Most seasoned orthodontists would say that everything works in orthodontics at least some of the time. The absence of reliable evidence is not evidence of reliable absence. However, the burden of proof for any clinical practice is always on those who advocate for it and if those who advocate for it are in charge of the consensus conference, confirmation bias will loom large. We think that this is similar to the white papers presented by the cigarette companies regarding the health effects of their products.
So, here’s the thought experiment.
- What is driving this proposed evidence-seeking conference?
- Is the conclusion written before the investigation?
- Will the outcome be different than the last white paper five years ago?
We believe the AAO leadership learned a few things from the CBCT fiasco and have taken steps to assure the correct consensus is reached this time – the one that allows an expansion of the scope of orthodontic practice. We know that many orthodontists have a busyness problem and by expanding the scope of orthodontics they hope to increase the numbers of patients in treatment. On the surface, it appears that treating sleep apnea presents an opportunity for revitalizing some practitioners’ somnolent practices and therefore the conclusion has been written in advance. Honestly, we don’t really care if this is the direction the AAO and its membership wants to take but wanted to point out two things:
- It is intellectually disingenuous to believe that any consensus other than one desired by the AAO leadership and the membership will be reached by the new Consensus Committee AND even if that were to somehow not happen, the membership would simply rail against any consensus or evidence they do not like until it is dismissed by the AAO leadership (just like last time).
- It would be a great deal easier, less expensive and safer to solve the busyness problem in orthodontic practices by sticking to what we know and modifying the traditional orthodontic practice model to accommodate more than the 3-4 million orthodontic patients we currently treat each year (4 million cases/320 million Americans = 1.25% of the population receiving treatment annually).