Currently on “the Hill” the founder and
head of Facebook is giving testimony on false news and propaganda that his
platform has allowed to insinuate are truths.
By combing through the tens of millions of Facebook accounts, algorithms
(data processing) and Artificial Intelligent produced by Facebook mined public
accounts privately to screen and direct the public to specific companies (or
propaganda) based on payment from advertises and not based on facts or truth
and without ethical standards or oversight.
The unsuspecting public just followed the ads and ended up being
directed to companies who paid Facebook for customers and were allowed to say
and claim anything while directing patients to their own biased doctors. This would have been unethical and illegal in
traditional advertising but social media escapes all scrutiny (until recently
due to election advertising and bots).
I admit I do have a business Facebook
page though I am not very keen in social media and there are long times when it
goes untouched. But I was truly horrified
to hear that a full 60% of Americans get their news from Facebook. For years now I have been getting solicitors
offering to advertise with Facebook and social media; to use formulas and trade
secrets to target my ads and focus prospective patients to my doors. I even remember when I was setting up my
latest website that the hosting company was having ads for Invisalign (pointing
patients to my very competitors!) run alongside my site in exchange for some
animation aps that I added.
“… 60% of Americans get their news from Facebook”
I guess it is just a shock that people
would take ads on Facebook as absolute fact but I am learning that I just see
things different then the public in total.
This is clearly a problem in many fields and subjects/sectors or young
Mr. Zuckerberg would not be worth some 33 Billion dollars (all from advertisers
paying Facebook to spread their “word”) based on a “free” website platform he
provides.
A Quick
History of Previous Public Knowledge
A little over 20 years ago the practice
of Orthodontics was a very specialized and advanced field of dentistry having developed
from 100 years of research and trials. Certification
required two to three years of advanced post-doctorate training at an
accredited Dental School where Orthodontists studied all of the past research
and history as they were tutored by highly experienced, expert Orthodontists
treating upwards of a 100 patients under the guidance of their mentors. Orthodontists learned that function of the
dentition is paramount for the health of the joint, future wear of teeth and
stability of alignment.
In fact, Orthodontists learned that function and occlusion of teeth were more important than esthetics (we were
of course taught to create beautiful smiles along with the function). Lining up teeth for a pretty smile is the simple
part, it is the first step with braces and usually takes only 6 to 12mo; it is
the movement of the roots and the coordination and fitting all of the teeth within
the individual arches (in a moving jaw) that introduced the real difficulties
with tooth movement.
Understanding the inflammatory process
as well as bone physiology and growth of the face and jaw also required much
more education than typical dental school could provide. An understanding of Physics and differential
forces was required to control not just the movements but also maintain the
anchorage on other teeth.
“the public used to be educated directly by the
Specialists and their professional organizations under strict ethical and moral
standards”
In short, Orthodontists were highly
trained and the public used to be educated directly by the Specialists and
their professional organizations under strict ethical and moral standards. There were no companies allowed to advertise
directly to the public, this would have been considered unethical and biased
(which it still is). Likewise, General
dentists acknowledged that although they were experts in restoration of teeth
and replacement of teeth, they were nowhere near the competency of a specialist
and they referred their patients to colleagues they knew could do a better job
(in other words the needs of the patient outweighed the potential for profit).
So what has
changed in the last 20 years?
About 20 years ago, a new product was being
developed from the digital revolution; not from an Orthodontist or dentist, but
from a tech person, a business entrepreneur.
They had no education or license to practice dentistry and were not
bound by any ethical standards or licensing but they realized that they could
use a laser to scan models of teeth and digitize a person’s dentition. They formed a company and modified a method
used by Orthodontists to correct mild rotations and relapse using a series of
stone casts. Instead of taking
impressions and pouring stone models, they would capture a digital rendition of
teeth which they could move incrementally on a computer. For each incremental digital movement, they
would produce a cast and then a clear plastic “aligner” tray that would
incrementally move teeth to the positon altered in each cast. This product was pioneered by Align Technologies
and became known as Invisalign though now there are more than half a dozen
different companies that provide the same clear trays. It was an expensive process for minimal
results but at least it avoided a new impression after each incremental
movement and ultimately avoided braces in mild cases.
Initially only marketed to Specialists
for correction of mild rotations (for
which they work well), it didn’t take long before these companies started
marketing to the larger pool of doctors (General Dentists) who had little to no
Orthodontic training mainly due to floundering from high overhead and inferior
product. General dentists in competitive
markets that did not have enough restorative work to keep them busy jumped on
the new aligners and it wasn’t long before they were pushing treatment
previously considered inferior. Once the
public accepted the idea of straight-ish front teeth over a comprehensive
functional correction, dentists (and some specialists) were more than happy to
offer this “simple” solution that did not require expert
education/certification or fixed braces.
The next 10
years …
Over the next 10 years, Align Technologies
evolved and managed a campaign to dumb down Orthodontics. Being more of a tech business than a medical
company, Align Technologies likely realized they did not want to have to comply
to FDA testing and standards or regulations.
They instead turned to social media to get their product directly to
patients. With no regulation or
oversight, Facebook was more than happy to push traffic to this new advertiser;
same with Google.
General dentists (and even
un-suspecting Orthodontists) then played right into their hands by selling the
aligners to more patients which Align Technology rewarded with sending even moe
patients. Soon they were openly (but
privately) claiming that they could provide equivalent treatment to traditional
braces. Responsible Orthodontists would
offer InvisAlign to limited cases they knew could be treated and to adults who
would not use braces but may accept clear aligners (even if the results were
not as good as braces).
Many of us would use this opportunity
to educate patients and hopefully get them to go for the full correction with
braces (we are after all doctors and we should be trying to provide what is
best). But as specialists, good
Orthodontists realized that partial movement is sometimes worse than leaving
the original crowding so some patients were refused aligner treatment; these patients
soon learned that many general dentists were not so selective and were more
willing to provide a lesser correction (many out of ignorance, many others
simply for profit) especially those recommended by Align technologies via
Facebook and Google. As more Orthodontists
started offering aligners on a limited basis, the dentists would point to them
and imply they could do the same for less (insinuating all cases and all
doctors are the same). These same dentists
stopped referring even difficult cases to Orthodontists. The joke with most Orthodontists is hearing a
general dentist today tell people “I only treat limited cases” when we know not
a single patient has been referred out since offering clear aligners.
“As specialists, many of us realized that partial
movement is sometimes worse than the original crowding so we refused to treat;
these patients soon learned that many general dentists were not so selective”
After several more years of this,
Orthodontists began seeing their referral sources drying up; they were no
longer able to educate these patients because companies were coming between the
patients and the doctors; bombardment and targeting of ads on Facebook, Google,
TV and other social media was shifting patients that just wanted straight teeth
and assumed braces to “want” Invisalign or other aligners with false
expectations. Many were patients that
were never told aligners were inferior and unable to perform the same as
traditional braces (see my previous posts on Does Invisalign work as advertised?)
and many unethical dentists quietly acted like specialists to sell the
product. Many patients were actually
treatment planned into Invisalign and other companies without any guidance from
independent dentists or Orthodontists.
Advertisers became emboldened realizing
there was no regulation (as did some general dentists) and they began openly claiming
Invisalign and other aligners were just “Invisible Braces” and would provide
the same correction as traditional braces.
These aligner companies started creating levels of “expertise” in
aligners and began pushing comparisons to the “old” and “outdated” traditional
braces even to the point of drawing lawsuits from the American Association of
Orthodontists. Facebook is a prime
example of a platform pushing misinformation.
Of course doctors already providing aligners could not speak up or they
would look unethical.
Worse than that, out of fear of losing
their patients altogether, many Orthodontists have panicked and just accepted
offering aligners; it was the old “can’t beat ‘em so join them” mentality. This is visible in many Orthodontists’
advertising today as they now compete with relatively untrained general
dentists on social media sites for aligner patients. Of
course human nature then demands that these Orthodontists providing aligners
must ardently defend and justify the aligners or they would face a backlash
from their own aligner patients. Actually
quite brilliant use of Facebook and Google in an age with no regulation and directed
onto a public that clearly is swayed by social media.
Does it
matter that Orthodontics is seen as simple?
So why is this important? Can we not just move forward into the 21st
Century of dentistry with aligners for all and a beautiful-ish smile with no
thought of function? Do we even need a
specialty anymore? Who cares about
function? Kids certainly won’t, they just want straight front teeth and isn’t
it all about what teenagers want anyway? And besides, braces are unsightly so
why not give the patient what they want?
As simplistic and benign as this may
sound, it is creating a real problem in modern dentistry. Companies have now been allowed to advertise
and throw propaganda at the public with no real oversight or moderation. And they are thriving thanks to Facebook and
Google; squashing real research and drowning out 100 years of education and
truth with half-truths/purposeful omission and sometimes just plain lies. Claims are made and supported with “company
sponsored research” even after being disproved by real research; articles that
criticize or challenge these companies in any way are pushed to page 25 on
google through the billions of dollars of advertising from Invisalign and any
dentist that offers such. And if even a mention of dentistry, tooth alignment,
smiles or braces crosses Facebook, Invisalign ads pop up immediately to claim
they are the only answer and, by the way, here is where you can get it.
So what are
Risks of poor treatment?
When teeth are moved (no matter the
appliance), there are risks of pushing teeth out of the bone causing recession
or loss of bone and early loss of teeth.
These effects are not immediate however and may not show for many years,
being later wrongly attributed to genetics or some other unknown when in fact
it can be from poorly placed teeth.
 |
Note the recession of gums as the teeth have been pushed out of the bone to correct rotations.
Traditional braces allow more control
in all three dimensions to prevent this and specialists are trained on what
movements are good and which are detrimental.
Forces have been controlled and can be modified to suit the movement
with specific wires, segmented wires, and good knowledge of physics. Trays cannot control the force like wires,
they have one thickness and all movement is based on distance or degree of
rotation, not force. They do not take
into account bone density, physiology, individual morphology or differential
root sizes/resistance in the bone.
|
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Patient K.B. previously treated with Invisalign, fontal view.
|
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Patient K.B. from the side showing protrusion of font teeth, pushed out by the aligners to correct rotations. This patient still has a fixed lower retainer revealing that this is how the dentist left this patient as "completed".
|
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| Patient K.B. being re-treated with traditional braces to re-align teeth while pulling front teeth back/upright over the bone to prevent recession; permanent teeth were removed to allow full correction. |
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Patient K.B. during braces from the side.
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| Patient K.B. after traditional braces to collect the dental protrusion from previous Invisalign failure. |
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Patient K.B. after traditional braces were employed to upright the front teeth and center them over the bone to prevent recession.
Compare these teeth now versus the initial
protrusive teeth. This treatment required
removal of teeth which could not be performed with Invisalign so the dentist
simply kept pushing the teeth out with the aligners until they lined up. |
Function when chewing is very precise; placing
teeth in “alignment” but not fitting them to the opposing teeth when the jaw is
in function can absolutely lead to excessive wear on teeth, fracture of teeth,
poor chewing efficacy and of course, chronic joint pain. In fact, I have seen many cases that have
interferences in the bite and poor function actually introduced by aligners and
research confirms this (see the research study above). Some patients present with new joint pain due
to poor occlusion that was never there before their “alignment”. This would never be accepted in restorative
dentistry; would anyone go to a dentist
that gave you a “pretty” crown that didn’t fit or had no contact for
chewing? Because that’s exactly what
they sell you with aligner treatment.
All of these cases reveal bites that remain open with no contact on molars. This has been shown to be a common problem with Invisalign (see research below).
Relapse can be rampant in aligner cases
due to expansion of the dental arches to gain space by increasing the length of
the arch. For 100 years we have known
not to expand the width of lower canines as they ALWAYS relapse but aligner providers
just turn their eyes to this fact. This
is why aligner providers now offer many years of trays in case of relapse. But
is this good for the teeth? Constantly
re-treating the teeth? Research continually shows increasing the time teeth are
moved or are in treatment can lead to root resorption and loss of teeth.
Shortened roots from long-term tooth movement and re-treatment
In children we can expand the actual
upper jaw bone (see my previous blog on expansion) however during our middle
teens, these upper bones fuse and cannot be expanded without surgery. That also does not stop unscrupulous dentists
from “expanding” the teeth to gain space for aligners; unfortunately for the
patient this only pushes the teeth out of the bone which will lead to either
recession or immediate relapse after treatment.
If held indefinitely with a retainer, the patient may actually lose bone
and eventually teeth from this procedure.
There are many cases that have been “treated” with Aligners that are
being held with permanent retainers where recession is inevitable and the
patient is ignorant of the ticking time bomb in their mouths. Time will tell if the damage done on these
patients is correctly attributed to previous poor treatment.
Just as in Patient K.B. shown previous, fixed bars are placed in these patients actually holding the teeth outward and over-expanded which is literally causing the recession right in front of the dentists' eyes.
In many adults with long-term crowding,
the teeth have determined where the jaw bites down. This normally includes a shift to one side or
the other, front or back or even vertically.
Essentially, the jaw shifted around to a “best fit” and the patient
learned to function there. If the shift
is too great, we get excessive wear and chronic jaw problems such as TMD. Aligners cannot take this into consideration
as the trays are made from the beginning.
Even with a modification of trays later in treatment, the jaw can
continue to shift throughout the entirety of tooth movements as different teeth
begin to hit and others no longer hit.
As the jaw shifts, the relationship of
every tooth changes but the aligners cannot accommodate this; you get upper
teeth aligned (somewhat), lower teeth aligned the same, but then they do not
fit together. As the jaw now has to
shift again to find a best fit after treatment, you introduce wear and tear on
the teeth and joints and can create TMD where there was a balance prior to
aligners. Traditional braces are
adjusted regularly and good Orthodontists look for these inevitable shifts
throughout treatment. Even with
traditional braces, corrections can be very difficult causing changes or
refinement in treatment many times along the way.
|
Of course compliance is a great concern
as we see Invisalign advertised to kids even 12 to 13 years old (before 2nd
some teeth are even fully erupted).
Nothing works if it is not kept in the mouth. Brace are absolute; they work 24h and they
show where any shifts in the bite occur; removing trays in and out can leave a
memory of a poor bite throughout treatment which then is never corrected. Also, teeth that do not move (and aligns
simply cannot move all teeth), may be blamed on a lack of compliance putting
the blame on the consumers when it is really the product or a combination of
product and patient. Roots can be
difficult to shift though the bone making space closure more of a “tipping
closed” with aligners instead of the whole root moving. Theoretically they could move roots more but
it would take four times as long and 100 more trays! The most recent fake ads I have seen suggest
Invisalign treatment leads to less plaque and better oral hygiene. Studies now refute this false claim as well.
Compliance with removable aligners is
not absolute; many cases simply do not finish and the patients simply stop
pursuing the correction.
What does
the Research on Clear Aligners REALLY show?
“Our results suggested that
about 1.5 mm of overbite improvement can be expected when the Invisalign
appliance is used in deepbite patients. A previous systematic review on the
stability of deepbite correction reported an average of 3 mm overbite correction with fixed appliances [50% more
effective with traditional braces]”
Khosravi, R. Management of overbite with the
Invisalign appliances AJO-DO April 2017
Invisalign [treatment results] only 41% mean accuracy
of tooth movement with a range from 18% to 47.1%
(j.ajodo.2007.05.018;www.ajodo.org)
Mean percentage of single tooth movement
goal of only 57% (j.ajodo.2013.10.022).
When results from Invisalign were
compared to traditional braces using American Board of Orthodontic standards,
the Passing
rate of cases treated with Invisalign were 27% lower
(j.ajodo.2005.06.002).
Another more complete study
(j.ajodo.2004.07.016) actually concluded that there was a “minimal improvement in occlusal score
based on Board standards from 47 to 36.4 [0 being ideal] and there was a
negative change (2.5x worse AFTER treatment) in posterior occlusion contacts
with Invisalign.”
This last investigator summarized
Invisalign treatment by stating “According to the OGS [Objective Grading System
used for the American Board of Orthodontics], Invisalign did not treat malocclusions
as well as braces … Invisalign was especially deficient in its ability to
correct large anteroposterior discrepancies [overjet] and occlusal contacts.”
Another article published April of 2017
in the AJO-DO (Journal of the American Association of Orthodontics) was
published that confirmed previous findings (j.ajodo.2016.09.022) showing
Inivisalign only 50% effective as braces in opening a deepbite and considering
there is already an average relapse of @50%, the net change from Invisalign
after treatment is zero.
So what’s
next from these companies?
The next logical step is for these
aligner companies, which have been storing information from years of cases
treated by dentists and Orthodontists, to cut the dentists themselves out. I am tempted to argue these doctors deserve
as much but it is the public who will be left with a perception that
Orthodontics is like bleaching your teeth or getting a manicure; as if you can
do the same as a Specialty trained, Board Certified Orthodontist directly from
a commercial on tv, a kiosk in the Mall or a mail order box of supplies.
Facebook has already essentially
convinced the public through Social Media and advertising on TV that only the
front teeth matter; that Orthodontics is just about straightening front teeth
with no need to mention function. They have used the general dentists to trick
Orthodontists to offer and accept aligners despite the many shortcomings and
high overhead; they have worked quietly to equate Inivisalign with “Invisible
braces” and create a pseudo-specialty of providers that they refer
directly. Now that these advertisers
have the patients directed to them through Facebook and Google searches, they
are offering aligners with no dental supervision or an “off-sight dentist” to
review or oversee the case which of course is nonsense as most of these
products are made out of the Country in Mexico, China or Cosa Rica.
So is this
the future, is Orthodontics dead? Will
we see the end of traditional braces?
It is a proven fact that traditional braces
are far superior to aligners in many aspects of Orthodontics (see research
below). Of course you would never know
this since billions of dollars in advertising are spent to bury actual
scientific studies comparing Aligners to braces on every search engine and
spent to direct anyone thinking about braces directly to aligner companies such
as Invisalign or Smile Club (now partially owned by Invisalign); just try and
google information about Invisalign and all you will find are ads for providers
and efforts to “dispel myths” claiming Invisalign is just as good if not
superior to traditional braces (information provided over and over by aligner
companies, the largest being Align Technologies). And who do you ask if your
dentist provides Invisalign? Will they
be objective and honest; will they know the research or even tell you they
aren’t specialists? Will they claim it
is equal to braces? Will they rely on
fake news and fake information on Facebook?
Will they go to page 25 on Google?
The future of Orthodontics & Dentofacial
Orthopedics is really in the hands of the public. If the public chooses to ignore function,
ignore the way teeth hit and ignore the damage from poorly positioned teeth
such as openbites or TMD Jaw Pain, then we may see the end of the specialty as
it has been known.
From the Orthodontists’ view, why go
three more years into debt after four years in dental school and four years of
college just to work through a very difficult post-doctoral program when you
will just to go out and scan teeth for mail-order aligner trays? Can we make the public want what’s best? Can we counter a billion dollars a year in
advertising against us? Even in our own
Journal thee was a letter to the editor from an Orthodontist chastising his
colleagues for not giving in to what patients want, for resisting the
inevitable and suggesting we are snobs for demanding a higher standard than what
the public wants.
He stated that we should not do things
that hurt our profession financially and that it is far better to use aligners
than lose the business to dentists. I
almost think it was a plant from an aligner company as the logical next step is
to bypass doctors altogether.
Companies know that from the patients’
standpoint, there is no reason to pay a doctor when they are just going to scan
the teeth and send it away to Costa Rica or Mexico; why not just go to a kiosk
in the mall and pay the company directly for the trays (yes this is already a
thing)? And Facebook is their vehicle to
spread this propaganda.
Ultimately Orthodontists have done a
poor job protecting the public from predatory advertisers representing these
unregulated companies and even the American Dental Association has turned a
blind eye so that general dentists do not lose a stream of revenue (after all,
the ADA is made up of those dentists who don’t want to bite the hands that are
feeding them). Orthodontists have been scared to speak out against their
general dentists colleagues out of risking losing referrers; they instead just
joined them in providing aligners which has now lent a false credibility to the
companies’ advertisements and propaganda in the public’s eyes and lowered the
standards of those specialists. Facebook
and advertisers in Google are winning and it has led to a predictable fall in
standards.
Food for
thought …
So will we see the death of true
Orthodontics? Will Orthodontists have to
give up the cases that are simple and only treat the most severe or those that
failed from aligners (expect $10k/case for real braces in the future if this is
the case). Will dentists even seek to
become specialized if mail-order aligners is what the public demands? Would a dentist put a crown in without proper
function? These are serious questions as we witness for the probably the first
time ever, a once respected profession turn into cheap salespeople and a respective
branch of dentistry actually go backward after so many years of advancements.
If you have questions or comments
concerning this or any orthodontic question, please feel free to make a
complimentary new-patient appointment at either my Steiner Ranch location or my
North-central Austin location on West 35th street and MoPac.
Dr.
James R. Waters is a 1996 graduate from UTHSC Dental School in San Antonio,
1997 graduate of Advanced Dentistry from the UNMC in Nebraska and the 2001
Valedictorian graduate from the prestigious Saint Louis University Orthodontic
Program receiving the J.P. Marshall award for clinical excellence in 2001. He holds a Bachelor’s Degree in Science,
Doctorate in Dental Surgery, a post-doctorate certificate in Advanced
Dentistry, post-doctorate Degree in Orthodontics & Dentofacial Orthopedics
and a Master of Science Degree in Orthodontics and is a Diplomate of the
American Board of Orthodontics. Dr.
Waters and his wife of 22 years live in Austin, TX with their 4 children where
he has a thriving, multi-faceted Specialist practice with locations in Steiner
Ranch and North-Central Austin. You can
learn more about Dr. Waters at BracesAustin.com.
