Online, in lecture halls and in print, there are fanatical devotees of evidence based orthodontics whose shrill voices lament the absence of science in our profession. For proof and for comedic relief during a long day of seeing patients we recommend reading the American Journal of Orthodontics and Dentofacial Orthopedics, the journal of record for the American Association of Orthodontists.  A casual survey of the last few volumes seems to indicate that the majority of articles are coming from such far off places as Brazil, Turkey and Korea to name just a few. This is a clear indication that the AJODO much like many other publications can’t fill its pages without the inclusion of many of these articles and that the beloved American orthodontic science is at this point, paltry. That being said, innovation is innovation and it doesn’t matter where it comes from as long as it is something worth presenting in a peer-reviewed journal. In the most recent AJODO issue (Dec. 18), we were gobsmacked after reading the article by de Souza-Constantino et al., titled “Patients’ preferences regarding age, sex, and attire of orthodontists”. Their conclusions were:

“In our study, the patients generally preferred female orthodontists, and this preference was strongest among children. Although the participants did not report the professional’s age as a justification, this factor was found to be a determinant of selection. Moreover, the white coat was preferred as the most appropriate attire for an orthodontist because it is associated with cleanliness and hygiene. Finally, participants ranked attractiveness and compassion among the most relevant reasons for choosing an orthodontist.”

The AJODO has a proclivity for publishing studies that agree with what the establishment believes to be true. All too often in the AJODO, if one knows the title and the names/location of the authors, one can accurately predict the results of the study without reading it. To be clear we are saying that most of the time in orthodontic “research” the authors find exactly what they are looking for. You’ll never see a Tweed orthodontist find that non-extraction is better than extraction or that brackets with built in tip and torque are superior to 0/0 brackets, for example. This obvious bias is apparent in most articles and most journals but the AJODO takes it to an entirely different level. Since the AJODO is the publication of record for the AAO it is held in reverence by residents and young orthodontists. The average orthodontic practitioner is struggling in a changing dental landscape. By taking a defensive stance and by doing whatever they can to reinforce their own biases/beliefs, the AJODO leadership is doing a major disservice to the profession they claim to want to defend.

Now, back to this “study” on patient perception and preference and the issues it has:

1)         It’s designed to get the results the researchers expect and want.

2)         It’s done in Londrina and Sao Paulo Brazil but is presented like it is applicable in any country and any region of any country. There are vast differences between the US and Brazil as well as differences among the different regions in the US (and probably regions in Brazil). (We found a systematic review on this study’s topic in medicine (“REAL DOCTORS”) with quite a different conclusion. See figure below)

3)         White coat syndrome/white coat hypertension is a real thing and well documented in real scientific journals. How does this paper’s results square with that fact? It’s not even addressed by the authors.

4)         We assume the participants in the study were patients who already opted into treatment and were patients of record at an orthodontist’s office. Because we are well-versed in the conservative nature of our Brazilian peers it is not unlikely that many if not all of the orthodontists who these patients sought treatment from dressed in the manner that was found to be preferred by the patient participants. This totally biases study design as the participants had already self-identified as preferring the result the researchers hoped to find. It would be far better to survey consumers/shoppers/non-patients instead of those who already bought and paid for orthodontic treatment.

5)         We wonder if the study had found that casual dress was preferred by patients or found that there was no preference if the AJODO would have accepted the article?

Use your head and think for yourself. Just because “the literature” says it is so doesn’t make it so. There is very little if any real science in the orthodontic literature. “Evidence based orthodontics” is a myth. Orthodontics is an experienced-based skill set. Overlay that skillset on the ability to be compassionate, friendly, organized, run on time, market yourself and you have the recipe for a successful orthodontic practice and happy patients. To do otherwise for the sake of defending what we have always done is to put your career in peril… unless of course you’re an academic who can afford to live in Ivory Towers with no regard for what consumers want.

Marc Ackerman

Ben Burris

6 thoughts on “White Coat Syndrome

  1. Can’t agree more! I have spent a lot of time providing dental services in Central and South America. It is a very different professional climate. Don’t feel anyone can say what works there applies in North America.

  2. Great summary! I have never felt so bludgeoned with “literature” as I am now and when I really delve into many of the “classic” studies, they are biased and the conclusions are just not supported by the data. Yet, we have a cadre of old-schoolers that pan every innovation and state piously that “fill in the blank” cannot be done-we proved it in the 70’s, as if the studies done in the 70’s were so well controlled, no other conclusion could be drawn. The orthodontic population is so diverse, it is difficult to impossible to control for all the potential variables on any subject, especially since we don’t know (and certainly didn’t know in the 70’s) which things to control for.

  3. Lou, I’m not sure we are on the same side here. As I’ve mentioned many times before I’m aghast at the total BS and hype that you and the other Henry Schein hired guns are spewing daily. “Soft tissue orthodontics”, “airway friendly orthodontics” (as opposed to airway unfriendly) and “saggiest first” are all merely constructs designed to sell product without regard for efficacy, efficiency, cost to the orthodontist or soundness of principal. In a time when orthodontists should be simplifying what they do and focusing on what we do best, you and the other HSO KOLs seem hell bent on increasing complexity, overhead and confusion. I’m glad you read the blog and I’m glad you feel the need to comment but I certainly don’t condone what you and HSO do and I won’t sit here and let you claim to be on the same side of the issue as Marc and I are.

  4. White coats —-really ??Havent worn one since the moon landings.I am definitely not worried about being thought of as “not a real Dr.”–a lot of the MD,s I know would swop places with me in a heartbeat.


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