CENTENNIAL GUEST EDITORIAL
Orthodontic quackery
Kevin O'Brien
Manchester, United Kingdom
O
rthodontic quackery. What is it, and how does it
relate to the history and the future of our spe-
cialty? The place to start is to dene both con-
ventional orthodontic treatment and what we might
consider to be quackery.
Perhaps the most logical denition of accepted or-
thodontic practice is that it encompasses the treatments
and concepts that most orthodontists should be prac-
ticing or teaching. These can easily be dened as treat-
ment based on credible scientic evidence published in
peer-reviewed journals. It is also pertinent to consider
that without evidence, accepted orthodontic practices
can include the views of experienced clinicians prac-
ticing in the relevant area or the recommendations of
learned societies.
Dening quackery, on the other hand, is more dif-
cult because of the great diversity of orthodontic prac-
tice. I looked for denitions; according to Wikipedia,
we can consider that the quack:
 Promises benets from treatment that cannot be
reasonably expected to occur.
 Recommends against conventional therapies that are
helpful.
 Promotes potentially harmful therapies.
 Promotes magical thinking.
The Oxford English Dictionary denes a quack as a
person who advertises false or fake remedies.
Although these denitions appear reasonable, we
must also consider that there are most certainly blurred
lines between these 2 concepts. This could be because
the denitions do not reect the full breadth of contem-
porary health care. Perhaps a further way to consider this
is to suggest that a quack is a person who knowingly
does not practice evidence-based health care.
At this point, I fear that I am entering dangerous
ground. If we look back at the history of our specialty,
it appears that many of the great advances that have
Professor, Department of Orthodontics, School of Dentistry, University of Man-
chester, Manchester, United Kingdom.
Am J Orthod Dentofacial Orthop 2015;148:202-3
0889-5406/$36.00
Copyright 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.05.001
202
been made are the result of an innovator's proposing
and developing a treatment method that is then adopted
by the mainstream. Examples of this include Edward H.
Angle, who developed his appliances and treatments by
experimentation and trial and error; Calvin Case, who
argued against Angle's nonextraction approach on the
basis of a few case reports; and Rolf Frankel, who, in
relative isolation, developed a functional appliance
that changed the way we treated many of our patients.
As a result, we must be able to differentiate between
the great innovators of the past and the quacks. There is
no doubt that these innovators were not quacks; howev-
er, it is clear that they did not practice the evidence-
based care to which we aspire.
Contemporary evidence-based care
The evidence-based care movement has changed the
delivery and effectiveness of all health care, including
orthodontic treatment. We now have plenty of sound
scientic evidence that underpins a reasonable propor-
tion of our treatments. But there are still variations in
the care that we provide; examples of this are the
extraction-nonextraction debate, different functional
appliance philosophies, and differences in bracket de-
signs. I suggest that these may be considered the usual
differences in clinical opinion that occur when there is
clinical uncertainty.
However, there are also treatments that some might
consider quackery because they are promoted widely
and y in the face of clear evidence to the contrary.
This could, arguably, include some self-ligation claims,
new appliances that promise ultrafast treatment, or
extraordinary claims of growth modication, such as
changing the position of the bones deep in the cranium
with a removable orthodontic appliance.
Although it is easy to be ippant or critical of these
claims, I would like to be open-minded and therefore
suggest a further denition of a quack: the promoter
of a technique or a product who knowingly misrepre-
sents the risks and benets.
We then need to critically evaluate the evidence for
both conventional and fringe treatments. When we
look at the evidence for what we might think of as fringe
O'Brien 203

or quackery-based treatment, it is well established that Is the problem solved?

the level of evidence is weak. Although we have evidence
underpinning some aspects of acceptable orthodontic
treatment, in many areas the level of this evidence also is
weak. In some areas, the levels of evidence are similar!
This confusing situation is compounded further
when we remember that there are also highly respected
practitioners who follow philosophies and make claims
that are contrary to the evidence. A good example of
this is self-ligation, which continues to be promoted
by key opinion leaders, in the face of research evidence
that contradicts the claims. Yet, these opinion leaders
are not criticized to the same degree as some who are
considered to be on the fringe.
In summary, the lack of evidence and the rather
blurred lines often make it difcult for us to differentiate
between accepted and fringe treatments. As a result, I
propose that we can only classify as quacks those people
who know that they are making claims contrary to the
existing scientic evidence and are also practicing their
quackery for personal nancial gain.
Importantly, when evidence is absent, it is incumbent
on the providers of both the quack and conventional
treatments to contribute to studies to obtain the neces-
sary evidence. Until then, each side should not be too crit-
ical of the other. It is time to work together; only then can
we make further quantum leaps in our specialty.

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American Journal of Orthodontics and Dentofacial Orthopedics August 2015  Vol 148  Issue 2