Reader’s around orthodontics will be familiar with this week’s guest and author of one of the best blogs around.
Kevin O’Brien’s Orthodontic Blog is an exploration of orthodontic issues and debunking of some of the bad science,
These subjects are just a small part of today’s discussion. The professor emeritus in orthodontics and former dean of the University of Manchester talks us through his student days in the city. We also chat about the limitations of orthodontic training, the state of play in the UK Vs the rest of the world, and much more.
When you look at trials of surgery, for example, it is not necessarily always the technique that comes up with the best results. It’s the skill and the care of the surgeon. And that’s the same with orthodontics. – Prof. Kevin O’Brien
In This Episode
01.36 – Backstory
08.05 – UK Vs the US
11.06 – Deanery, teaching and academia
21.29 – GDC
27.13 – GDPs and ortho
34.02 – Aligner science and new treatments
41.42 – On limitations
44.26 – The blog
55.02 – Ortho for cosmetics and health
01.00.35 – The future of orthodontics
01.05.19 – A quick plug
01.05.34 – Last day on earth
About Kevin O’Brien
Prof. Kevin O’Brien is a former Dean and current professor emeritus in orthodontics at Manchester University.
He is also a former chair of the General Dental Council and the author of Kevin O’Brien’s Orthodontic Blog – an ‘occasionally irregular’ exploration of evidence-based orthodontics.
Kevin O Brien: Ross’s right, is what you don’t know is the problem. And when people think they know it all and that they go back to saying that they think they know it all and can do everything with Invisalign. For example, that’s where they run into problems. It’s not the appliances. It’s the operators and it’s the way they behave. And some of them, unfortunately don’t recognise their limitations. They’re working outside their scope of practise, and that’s where harm occurs.
Intro Voice: This is Dental Leaders. The podcast, where you get to go one-on-one with emerging leaders in dentistry, your hosts, Payman Langroudi and Prav Solanki.
Payman: It gives me great pleasure to welcome professor Kevin O’Brien onto the podcast. Kevin’s got one of the worlds, correct me if I’m wrong, Kevin, the world’s biggest blog in orthodontics, but an illustrious career in academia. And for us, what we want to get out of this obviously is your backstory and so forth, but all those become such a controversial subject ever since it’s grown so massively with the GDP community in the UK. And so there were so many areas of it that need to be addressed. So welcome to the show, Kevin.
Kevin O Brien: Thanks so much for interviewing me on the second day of lockdown on a sunny day in Manchester.
Payman: Yeah. Nice to have you, Kevin give us your backstory. Where were you born? When did you decide to become a dentist? All of that stuff.
Kevin O Brien: Okay. So I was born in Edinburgh, so I am Scottish and then my mother moved to the Midlands in a small country village in North Westshire. where I was bought up. I then came to the university of Manchester in 1975. At that point, Manchester was not the city that it is now, there is a sort of in the depths of depression and I sort of suffered a major cultural shock coming from a small country village, slap bang into the centre of Manchester, which at that point was starting to become a much more multi-ethnic city. And I still remember going and having my first curry when I was 18. And that shows the isolated living that I had.
Payman: Did they have the Curry Mile back then?
Kevin O Brien: They did, but it was mostly sweet centres rather than curry houses.
Payman: On winslow road?
Kevin O Brien: Yeah, I think nine out of 10 of the restaurants were sweet centres.
Kevin O Brien: But again, that was quite a cultural shock for a boy coming from the country village where I’d look out the window and just see cows.
Payman: What was the first curry you had?
Kevin O Brien: It was terrible. It was a chicken biryani in a restaurant in Manchester called the Plaza, which was very famous among students because it was truly terrible. It would cost you 50P. Chicken was cold just thrown on top of the sort of watery sauce. And you only really went there late at night. A few of us, about five years after we qualified, went back and we realised what a terrible place it was. You wouldn’t recognise it as food nowadays.
Payman: What kind of a student were you Kevin? I mean, did you feel like these, the big city, bright lights, did you go a bit berserk on the social side or were you one of those?
Kevin O Brien: No, not really. Not really because I’m quite a quiet person anyway. And so now I think I was a pretty average student, when I was made Dean of the dental school in Manchester. One of the first things I did was go and look at the old student records, because they’re all kept in your office. So I looked back at the records for my year. These were the comments that were made on everybody. The only comment that was made for me was mostly average. That sums up my five years in dental school.
Prav: And so then you did some general practise. You were telling me.
Kevin O Brien: I had four sort of very happy years. I went into general practise straight from dental school. So there was no foundation training or vocational training in those days you went straight out and I worked just off the Langley estate in Middleton, which is an area of very high deprivation for a really nice guy called Allen Kershaw. It was a very simple, it’s a very basic practise and it really was great fun. I then moved to a practise in the centre of Chorlton in South Manchester and was there for another year and a half. They had to take me up to four years.
Kevin O Brien: But during that time I was sort of becoming more interested in sort of hospital dentistry in general. I was beginning to feel that general practise wasn’t quite a hundred percent for me. It wasn’t that I didn’t enjoy it. I just felt that it wasn’t for me in the long term. And then one night I was driving home on the, what is now the M 60 with my wife and six months old daughter and a guy hit us in the rear in the traffic jam, ripped our car off sort of flat in the back of the car and put me off work for six months with a whiplash injury. And then after I had announced that to one of my friend saying right, I’m off for six months, it’s going to be brilliant. He turned up and gave me a box full of books and said, right, it’s now time to start studying again for fellowship exams.
Kevin O Brien: This is your chance. And so I sat down for six months and studied for the fellowship in dental surgery, which put me an inroad back into hospitals. And I took it shortly after that. I took a job as a house officer at the dental school of the dental hospital in Manchester. And I did house office job there, did a job in Newcastle as ass hr and registrar in oral surgery. And then I was very fortunate enough to get on the post-graduate special training course in Manchester led by the absolutely brilliant Bill Shaw, who is professor of orthodontics at that point. And we were the first group of students to go through that musters programme, which was a classic. So two years master’s programme where Bill taught us to be critical and very analytical about research. And that’s where my sort of research interests really peaked.
Kevin O Brien: And it became a very vibrant place to be a postgraduate student. Following on from then. I again was very fortunate to get a medical research council research fellowship for three years to do my PhD. And I did that within three years and then just as I finished there, I was offered a post as a sabbatical at the university of Pittsburgh in the United States where I worked for a year, came back, made senior lecturer. And then about two years after that, they made me professor at Manchester. So that’s really my background.
Payman: When you were looking at orthodontics, what were you talking late seventies?
Kevin O Brien: I started orthodontic training in 1984.
Payman: Okay. Early eighties. So at that point, orthodontics was pretty established as a specialisation. But what would you say were the biggest differences between UK and US orthodontics back then.
Kevin O Brien: Yeah, at that point because of the way that dentists were paid to do orthodontic treatment. UK orthodontics was dominated by simple removable appliance treatment. I can’t actually remember the nuances of the payment system, but in many ways it was a sort of a very high volume delivery of care with what was shown to be very low standards. During that time, I worked with Steve Richmond who is recently retired as professor at Cardiff, and Steve was doing some real groundbreaking work on occlusal disease and quality of treatment. And Steve showed that during that time, the quality of care in the UK orthodontic services, which were, I think it was something like 80% removable appliances, most children or high number of children actually ended up worse than they were before they started because of the very simple system.
Payman: Clearly did.
Kevin O Brien: And what happened was, is that work from Steve led directly to several government inquiries, which then led to, I think it was a change of the method of payment and then fixed appliances sort of burst onto the scene quite suddenly. And I think part of that was due to the advent of smaller appliances, but also it was the method of the payment. In those days, remember dentists were paid on per item of service. So actually the thing that drove prescription patterns was how much you got paid for individual items. So orthos was lowly paid high volume, very basic. Whereas of course, nowadays things have changed quite dramatic. Yeah. To what Orthodontics service should be, which is mostly fixed appliances.
Payman: And the US at the time was way ahead because of this.
Kevin O Brien: US it’s always been based on fixed appliances rather than removable appliances. There were various reasons for that. First of all, the US trained more orthodontists at time than Europe. But secondly, if you sort of go back to the end of the second world war, the European States, and certainly the UK didn’t have much in the way of steel and steel was very expensive. So if you were to provide orthodontic treatment, you provide it with plastic appliances, with minimal amount of steel. Whereas the US of course, was steel rich and they could use fixed appliances probably far more than we could at that point. And then once you established a system of care, built around a very simple method, removal appliances it continues sort of driven by government and health service policy.
Payman: And when you became Dean of Manchester, was that sort of moving into the management side and away from the clinical side for awhile?
Kevin O Brien: I mean, well, one of the things that’s, I don’t know whether it’s fortunate or unfortunate about an academic career, but once you start to do good research. Because I was running a research team there. I picked up another grant from the Medical Research Council for 10 years funding to look at the effectiveness of early treatment for children with very prominent teeth. We were also piling research out every patient in the dental school, in the orthodontic department was part of the research project. I was working with people like, Steve Richmond, Nikki Mondale, who have all gone on to have great careers. And again, many young trainees that I worked with who are now quite high profile ortho dentists all came out of Manchester at that time because it was incredibly vibrant. So we were piling away at research. And then one of the problems is they going to ask you to take on an admin role if they see your research and you built a research team.
Kevin O Brien: I was made research director of the dental school. And then that often you often from that position to end up stepping up as Dean. So, that’s what happened. I ended up as Dean and well, rather reluctantly, I have to admit, I didn’t particularly want to do it. But when the university sort of says, well, we think you should do it. And this isn’t necessarily a request. It’s a sort of a, we’re making an offer you can’t refuse here. And that’s really what happened. I ended up as Dean, which I did for three and a half years.
Payman: That’s mentorship. You’ve taught thousands of students of both dentistry and orthodontics.
Kevin O Brien: Yeah, I think so.
Payman: First of all, can you tell someone’s going to be good early on and how early can you tell? And secondly, it must be like a source of real pleasure to you to see people blossom, who you’ve taught. I mean, is that what keeps you going in an academic role? Because as a private orthodontists, I’m sure you could have done very well, but you never did that.
Kevin O Brien: Yeah. I mean, my mom always used to say, why aren’t you a private orthodontist? There’s all sorts of terms that I have wondered that myself, I was once flying to… I’ll come back to your question in a minute, I was once flying to the American Orthodontic Conference in San Francisco. And as I was sort of sitting at the gate in the economy queue a load of specialists orthodontist, half of whom I had trained were boarded into business class. When I got on the plane, I found I was in the second row of economy. And of course you can see into business class in those days. And they were all waving to me and giving me food. But they came back and had a chat with me and things like that. It was a busy flight. So yeah, it does give me a great… I’m proud I think of all the people that I’ve trained in both specialists and general practitioners.
Kevin O Brien: It does surprise me actually, how many I’ve trained when I go to the orthodontic conferences. There’s always plenty of people that of course recognise me, that come up and talk to me. Yeah. It’s one of the things you look back on and think, well, yeah, that was great to have trained so many people. I actually don’t know how many, I worked at the university for 40 years. So you’ve got to think you’ve got an intake of 60 to 70 undergraduates a year.
Payman: And how soon can you see talent in even undergraduate and also.
Kevin O Brien: In undergraduates very quickly.
Kevin O Brien: We didn’t teach them much in the way of clinical orthodontics because that wasn’t our aim. Because we were treated them to be training dentists who were sort of to screen and refer at the right time and give advice because you can’t cover complex orthodontic treatment in the undergraduate curriculum. But I used to do seminars for students in years two, three, and five and lectures some critical work, but you could always tell them really good students within about one or two seminars. They would be expressing an interest. You wouldn’t have to prompt them, you’ll know the type. And you also know the people who are not going to do perhaps so well in these are the ones that tended to not engage or turn up late. And things like that.
Prav: Got sent to the Dean’s office.
Kevin O Brien: There were never sent to the Dean’s office but they got to know pretty quickly that if my seminar was timetable to start at nine o’clock, it started at nine. And that if they turned up 10 seconds late, the door was locked and they’d be whimpering outside knocking at the door asking to come in.
Payman: Prav asked that question because he spent quite a lot of time at the Dean’s office himself.
Prav: Yeah. So have you got any interesting stories where someone was sent to the Dean’s office.
Kevin O Brien: No. In those days, again, dental school has changed quite dramatically. The Dean of the school is… Once you took that job, you didn’t often come across the students on a day to day basis because it was a surprisingly high level job. And so you would delegate most of the day-to-day contact with people down to really, which was sub deans. So I worked very well with, there were associate deans in those days, two people a guy called Ian Mackey, actually, who was a brilliant undergraduate teacher and Ian dealt with all the undergraduate issues. I didn’t have to think about them because Ian had devoted his entire life to treating and teaching undergraduates. And it was only very occasionally Ian came to see me and said, we’ve got a problem. And that’s the way it tends to work. It’s a management role with a management structure beneath it.
Payman: Kevin, you spoke about your education, your specialism and the approach was very much a scientific approach, reviewing the literature, becoming a critical thinker. Has that changed in current day in terms of how the training is structured and what the output is?
Kevin O Brien: Yeah. In orthodontics in the UK, all the courses are pretty much the same. We have to teach the same curriculum. And that includes courses on research methods, obviously critical appraisal and everybody still has to do a master’s thesis which has changed over the years. It’s not as extensive as it used to be. So every specialist orthodontist in the country has had training in research methods, critical appraisal, and they’ve done their own piece of research or be it a small piece of research. So they know how to appraise the literature and how to appraise it critically. It’s not the same in other countries. European countries are pretty much the same. The US, I don’t think is anywhere near Europe in terms of training the specialists in science. I’ll try in english, it’s straight ahead out of the United States than within Europe.
Payman: What about the hands-on element side of things in terms of how much wire bending go or practical aspects of the course have changed? I know I was speaking to a couple of dentists, probably sort of my age or a little bit older, and they were just shocked and surprised at how, when they were at dental school, not obviously specialists, but when they were at dental school, the volume of dentistry they were doing as a student compared to students coming out now it’s like night and day.
Kevin O Brien: Yeah. I mean, it’s something that people often say. And certainly when I look back at my undergraduate training. I remember we used to go into sort of, as an example, here, we would have a block in war surgery, which lasted two weeks. And during that two weeks, I think you sort of had a requirement to take out at least a hundred teeth and do I think it was 29 oral surgical procedures. So at the end of the day, we certainly could take teeth out quite nicely. And we also used to do a lot of amalgams and a lot of restorative work and dentures and things like that. But those were the days where dental disease was absolutely rife. I think people who took a at modern dentists now and said, okay. And they say, they came to look at my clinic list in Middleton.
Kevin O Brien: They would be completely amazed at the amount of restorative work that we were doing. We were doing wall-to-wall amalgams and composites day in, day out because of the high levels of dental disease that we were dealing with. Clearances, dentures, immediate dentures, it was nothing like I imagine general dentistry is now. And I think that’s quite important. We were trained for the times, which was high volume, dentures, fillings, everything like that. And not necessarily to the same standards that people practise nowadays. I think that’s quite important. And then the biggest difference between an undergraduate newly qualifying now, and somebody qualifying when I qualified was the people understand what they’re doing more now than we did. We just did it.
Kevin O Brien: It’s as simple as that. You saw some caries. I mean, you didn’t have to look closely to see the caries. There was none of this agonising over, is this just a non [inaudible 00:21:14]? More often my thoughts were how close to the pulp is this before I get cracking. So times have changed and it’s often a mistake that people make to look back and think we weren’t taught the way they used to be.
Payman: And Kevin, you then took a role of the GDC, the way you’ve described yourself. It seems that would be a counter-intuitive move for someone who’s so into the teaching. And so into the research. How did that come about.
Kevin O Brien: One afternoon I spotted an advertisement from the GDC inviting applications for the chair of the specialist, dental education board. I’d always been interested in specialist training. And that was most of my work actually, to be honest. And so I thought that sounds quite interesting. I didn’t think about it being the GDC. I thought here’s an opportunity to help and perhaps change and improve specialist training for throughout the country. Because this was really, the GDC viewpoint on specialist training, right across all specialties. So I applied for that, trotted myself down to learn them. I didn’t prepare very much because I was busy. I think I was still Dean at that point. And I got the job. Hugh Matheson was the GDC president at that point and they appointed me and I did chairman of specialist dental education board for about two years.
Kevin O Brien: And then we came to the advertisements for the first appointed members of council. And I’d actually really enjoyed working with the GDC at that point. It was refreshing to see another outlook on dentistry from the point of view of protecting the public and that is their entire vision today. And I got more and more interested in this and this wasn’t protecting the public just in terms of fitness to practise. It was protecting the public in terms of levels of training, monitoring, audit, everything like that, that goes with it. So I applied to be a member of the council and I was completely amazed. Again, I was interviewed and I was completely amazed when I got an email one day, a few weeks later saying I was one of the appointed dentists on the council.
Kevin O Brien: At that point, the council was very large. It was 24 people. So I was one of the eight dentists on council and we had a 50 50 split between lay and sort of professional members. And that went quite well. And then Alison Lockie resigned. It was then going again for another chair. And my feeling at that time was that there was an inevitability and it is sort of a graduation that the chairs of regulators are laypeople. And most of the councils at that point had lay people as chair. But I felt that GDC wasn’t ready for that at that point. And so I got myself a bit cross. I was just in a cross mode and everything that was sort of going on with the GDC. So I thought I’m just going to do this. So I put an application in and was elected chair, which completely amazed me. I was quite stunned at this. My wife was completely shocked. I think a lot of people were shocked at it.
Payman: You don’t seem like the type of person who’s good at politicking, but correct me if I’m wrong, but I would’ve thought to become the chair of the GDC. You need to be that type, am I wrong about it.
Kevin O Brien: You need to be good at politics and it’s one of the things I’m not very good at politics. I’m pretty useless in many ways, but at that time, the politics weren’t that complex. It was getting the BDA back on board which I think was very important. It was getting the dentists back on board and I just quietly went about the job. And one of the things when I do look back that council did an awful lot of really good work in putting building blocks in place, right across the board, in terms of standard scope of practise, direct access specialist training, quietly got on with it.
Kevin O Brien: We made mistakes. Every organisation makes mistakes, but we just quietly got on with it. And I was quite pleased at the end with the work that we’d done. And my sort of feeling when I look back on it is, I’m quite happy now when I look back on it, because there are people that say to me, why you the chair of the council? And I said, yeah. And they said, well, we didn’t notice you. Well, that’s the best chair of a regulator you need is the person that I think is someone who just sits there, gets the job done quietly. And nobody really remembers them in about 10 years’ time because it was smooth and straightforward. And we sorted a lot of things out.
Kevin O Brien: I still managed to upset an awful lot of people and I wasn’t necessarily that popular in some areas of government. But I look back on that and I think we did a good job. And then that sort of leads us through to really a lay chair. The issue of lay chair is very interesting in the councils because the job has changed like all these things over the last 20 years, most of the regulatory bodies now have a lay chairs. I think the only one that doesn’t is the GMC. And that’s really unusual. I mean, I’m fairly confident in saying this. I probably am the last dentist chair of the General Dentist Council
Payman: Kevin, moving on from there and talking about GDP orthodontics. And there’s been a massive surgence of that, I think over the last decade or so. First of all, I guess I just want to get your opinion on how you feel about GDPs doing orthodontics. And what do you think is the appropriate training pathway for a GDP who wants to treat patients and straightened teeth and whatnot, and where do you feel the compromises are in a GDP assessing, diagnosing and carrying out orthodontics when obviously you’re comparing it to someone who’s had extensive specialist training.
Kevin O Brien: Yeah. So again, it’s always helpful to look back to sort of help you look forwards. When we look back, for example, in the time that I said orthodontic treatment was not carried out very well, I think I can’t remember the figures exactly, but I think it was about, there were a fair number of general practitioners who used to do orthodontics again with oral appliances, but there was also a group of practitioners who worked as critical assistance with consultant orthodontist, and actually the common pattern of care in sort of hospital-based orthodontics. And it’s not really hospital-based orthodontics as we know it now. Because the hospital consultant was often the only person providing orthodontics for quite a wide area because there were very few specialists. But what they used to do is they used to see patients, they used to write out treatment plans and either send that treatment plan back to the general dental practitioner that had referred the patient or send to one of the dentists in their district who would also do the treatment using simple methods.
Kevin O Brien: So they were doing simple compromise treatments in many ways under the supervision of a consultant. So [inaudible] orthodontic was not unusual at that point. Then of course, we moved into fixed appliances and this is where there is sort of a degree of a dilemma because it depends what you’re trying to do. So for example, on the undergraduate orthodontic course, there is absolutely no way I could teach eight year undergraduate students to be competent in fixed appliance treatment. Even the diagnosis that’s necessarily behind that. There’s no doubt that that is a specialist subject is most fixed appliance treatments for children are specialist level. That’s not to say that a general practitioner, who’s got a lot of experience in treating children with fixed appliances should not be doing it. And there are many of those around, to be honest, who do a very good job, despite the fact that they’ve not had a specialist training, they’ve sort of learned it over the years.
Kevin O Brien: Yeah. As an example of that, and it’s a bit of a spin off when membership in orthodontics first started, there was one year where there was a moratorium in a way, they called it a moratorium, but I refer it to the called an opportunity. Where experienced general practitioners could come and sit the specialty exam. If they wanted to give it a shot, they had no specialist training. And I examined it in those days. And they were, I think it was about 10 to 15 people who were experienced general dentist who actually took the specialist exam and they passed it easily. They’d have 20 years of experience. So there’s that sort of experiential way of gaining sort of specialist level experience in orthodontics. But really it’s now a dilemma in many ways, because I’ll go back in and there’s no way I think that anybody can quickly and with a reasonable length of time, learn to provide specialist level of orthodontics to children without going on a specialty training programme.
Kevin O Brien: That’s always my advice. Lots of people ask me what do I do to be a specialist or to get good at orthodontics? I’d say your first course of action is always consider specialty training programmes because that’s where you learned to do it very well properly and very effectively. But then we’re sort of getting to that middle stages. Are there groups of people who can have orthodontic treatment that doesn’t require specialist training? And the difficulty here is recognising when you can compromise because you can’t argue that in order to take the decision on whether to compromise and make a treatment simple, you have to be a specialist and specialist thoughts, compromise orthodontics is nothing new. Specialist orthodontists have been doing it for years. You sort of look at people and have discussions in terms of what sort of treatment the people want to undergo. And for years, and I’ve done it with a lot of the kids, I used to treat in the children’s hospital in Manchester who had severe medical conditions.
Kevin O Brien: They couldn’t cope with lengthy orthodontic treatment. And we’d go for a compromise, which in effect would be straightening up those front six teeth. That sort of the concept to the social six. And that I think where mentoring schemes come in now and sort of a certain GDP courses is that there’s nothing wrong. I know several people do this online now, there’s provide online advice to dentists about what treatment can be done as a compromise that would do someone a reasonable amount of good because a lot of adults just want their front six straightening. They’re not interested in the molar relationships or extractions based closures or anything like that. They want to improve their smile by having their front six teeth straightened.
Kevin O Brien: And as long as they know that that’s the compromise and it’s being done by a general practitioner under monitoring, for example, and in a way that perhaps is the contemporary sort of model for the consultant orthodontics service monitoring treatment that I talked about previously, then I think there’s nothing wrong with it. What is clearly wrong though is people being sold courses? Oh yeah, we can do treatment better than a specialist. You just have to come to an airport for a couple of days to learn how to stick brackets and change the wires and off you go.
Kevin O Brien: So that is not correct, but monitored GDPs learning on the job as they go through over several years, creating relatively straightforward adult cases isn’t a problem. I don’t think there’s any orthodontist would disagree with that, to be honest.
Payman: But, Kevin, if a young dentist was going to go on a two day clear aligner course and then provide clear aligner treatment, you were saying that’s compromised treatment. Right. Is that where you’re at?
Kevin O Brien: Yeah. I mean, to be honest, I might get criticised for this. A lot of the aligner treatment is compromised treatment anyway, in many respects, I think it’s-
Payman: Let’s get to that. Yeah. How good is Invisalign from your reading. Is Invisalign better than the other clear aligners and then how do they all compare to fixed?
Kevin O Brien: Okay. So research is showing and research is now starting to be done. And it’s difficult to do research in this area because aligner treatment is very different from fixed appliance treatment. So if someone really needs fixed appliances, they should be getting it. I think that’s the first call. Certainly I’ve never done a aligner treatment. It’s bypass me completely. But in discussions that I’ve got with specialist friends of mine who do aligners, their first offer of treatment is for works fixed appliance treatment. And then that sort of explain that anything else is a compromise. Aligner treatment has to be quite a compromised because you haven’t got the control that you have with fixed appliances. You do see aligner treatment and some practises that are a hundred percent aligners. But research is showing actually that fixed appliances are still providing a better sort of finish and better standard of care.
Payman: How far behind is generally research from, for instance, I’m sure, if you spoke to the people that align they’d tell you, look, what we provide this year is a lot better than what we were providing three years ago because of machine learning and whatever they want to say. Yeah.
Kevin O Brien: Yeah. People always say that. They’ll always say, there’s always something better around the corner. And that’s what we like to hear. Isn’t it? That there’s always something better and companies do that. And it’s perfectly within their rights to do that because it’s the job of the salesman or the salesperson is to sell them appliances.
Payman: No, I get it. Like a healthy dose of scepticism, definitely from someone like you needs to be, that’s really super important. Right. But as a question, if a Tif Koresh type person, not someone in the highest echelons of ortho, yeah. Someone in practise actually came up with a breakthrough. How long would it take before that breakthrough gets onto an MOF course in Canada? I would say 30 years.
Kevin O Brien: Yeah. I mean, that’s the way things are. Research takes time because of course the length of treatment is lengthy. There’s no doubt about it. You’re looking at two and a half years, the average course of treatment, the early treatment class 11 studies that we did that took 10 years to do. And it was one of the studies that completely changed the viewpoint on orthodontic treatment with functional appliances and there were several studies doing similar sort of thing. And we changed the way orthodontics was done.
Payman: So how long was it from the time you started that work to? Is that now taught on Mos all over the world?
Kevin O Brien: Yeah. It’s-
Payman: What the timeframe?
Kevin O Brien: The first part of the studies took five years to do the papers came out very quickly. So they were on the courses within five years. And then they’re classic papers. It is one I think.
Payman: You’re highly prominent person. Yeah. So if you discover something it’s going to get onto the course as much more quickly than if for even Align, discover something. But.
Kevin O Brien: It’s the quality of the research that’s done. So I think the issue is I’m always going to be faced with this is that we need to be… There’s nothing wrong with producing new treatments and saying that things are changing. Self-ligating Classic, absolutely classic thing is self-ligating was heavily promoted. It was going to reduce extractions. Everything would be much faster. It was going to be brilliant and the companies promote it that quite strongly. Then key opinion leaders started talking about how good self-ligating was. And self-ligating became very popular, but then what happened is the research caught up. Actually there is absolutely no difference between self ligating bracket treatment and classical fixed appliance treatment. And we’re seeing this constantly, we’ve got things like AcceleDent the orthodontic vibrator, everybody was making claims that that speeded tooth movement, but it didn’t. Yeah. Vibration doesn’t work, all sorts of things, speed treatment just don’t work. There’s no evidence that they work.
Payman: Does that decortication speed up treatment.
Prav: Does that the one they drill in.
Kevin O Brien: That doesn’t work either.
Prav: That doesn’t work either.
Kevin O Brien: No. The thing that influences the speed of orthodontic treatment is the operator. If you’re a good operator and you see your patients every four to five weeks, it’s quite surprising how fast your treatment goes. Potions, pills, trauma, vibration doesn’t help anybody even the good operators. When you look at trials of surgery, for example, it is not necessarily always the technique that comes up with the best results. It’s the skill and the care of the surgeon. And that’s the same with orthodontics. If you know what you’re doing and you see your patients regularly, you finish them quickly.
Payman: Kevin, How did you feel when you first saw Invisalign. Did you think?
Kevin O Brien: I was very interested in it. In fact, we approached Invisalign to say, do you want us to do a trial?
Kevin O Brien: Because we were trialling everything. We had Invisalign managing come over and meet us in Manchester. And we explained to them what a trial would involve and everything like that. And the time and the cost. And all we got was at the end of the day was the bottle of Californian red wine, which was nice, which they left for us.
Prav: Which year was that?
Kevin O Brien: Crikey, I can’t remember it must’ve been mid 1980s when Invisalign was first coming out. So there’s nothing wrong with the aligner treatment. I need to stress this. Aligner treatment is fine. It works. Expertise got to be really good at it. And you do see some nice results, but because it’s a removable appliance, you’re never going to have the control that you’re getting fixed appliances, but it’s revolutionised orthodontic treatment, it’s revolutionise adult orthodontic treatment without a doubt. But most of it is a degree of compromise, but there’s nothing wrong with that compromise. The danger you get is when someone goes on a course and they think they’re a master of the universe and can do everything. And that’s where things go as wrong. And that’s down to the individual practitioners and their confidence and their scope of practise and overall professionalism.
Payman: Just going back to the GDP also. Have you seen many cases that come back to you having gone to an airport course attendee where you look at those cases and you think, Oh dear, if only they knew how to identify and the reason I’m mentioning this is numerous conversations with Ross Hobson have the main takeaway point from him is always, you don’t know what you don’t know. And the most important part is knowing when to refer and when not to treat.
Kevin O Brien: Yeah, that’s it. I mean, we try and teach undergraduate when to refer and when not to treat, I think that’s the most important thing. Yeah. I’ve seen loads of people who have actually had harm from being treated badly by people who have got involved with some of the airport courses. Where we’ve taken years to get them back on track. Having said that it’s subjective. And again, talking to colleagues, I can’t help wondering if that started to die down a bit. We go back into the 1990s and there was a fair few people peddling, quite poor treatment to the airport courses, both with fixed appliances and unremovable appliances and expansion plates, and thinking that you can grow jaws and all that business that sort of died out recently. I can’t help wondering if there’s sort of been an evolution. Perhaps with great opportunities that really interested practitioners have had to sort of be mentored and work with other people.
Kevin O Brien: Yeah. The whole thing about it is you can be trained in something. It doesn’t necessarily need to be a three-year course, and you can be trained in anything with mentorship programmes or working alongside people. Remember that was the way it used to be done. That was the way dentists used to be trained. But what you’ve got to understand as a professional is your limitations and you don’t know your limitations, you should know your limitations completely. Ross’s right. Is what you don’t know is the problem. And when people think they know it all, and that they go back to saying that they think they know it all and can do everything with Invisalign. That, for example, that’s where they run into problems. It’s not the appliances, it’s the operators and it’s the way they behave. And some of them, unfortunately, don’t recognise their limitations. They’re working outside their scope of practise and that’s where harm occurs.
Prav: SO, Kevin, tell us about your website. How did that come around? When did you have the idea or the brainwave to say, hey, I’m putting up a website and published some information online.
Payman: And how massive it is.
Prav: So my blog now is read pretty much half a million times a year.
Kevin O Brien: I’m a little bit worried. I’m getting obsessive about it this year now. Because it looks as though we’re going to fall below half a million. We took a big hit in the COVID crisis, which surprised me is readership dropped during the world lockdowns. I think that shared the state of mind and that degree of worry that people have hard and are still having, so this of course is a funny year. So I started it as I’ve just finished as GDC chair. And I was getting a bit bored really. And I’ve always been interested in computers, right from the start I’ve bought things like [inaudible] and everything like that. My son is also pretty heavily involved in social media infact that what he does for a job.
Kevin O Brien: So he was sort of talking to me about blogs and that sort of business. So I thought why don’t I start a blog. So I ordered a book on how to write a blog, which just takes you through a step-by-step on how you set it all up. And this is a surprisingly interesting, easy thing to do. So I went to a web hosting company, which charged me 10 pounds a month, read my own blog using free WordPress software, which again was fairly straight forward. And I published my first post five years ago when the British Orthodontic Conference was in Manchester. And I just learnt about the latches that I’d been to see and what I thought of them and I just sort of posted it up. I mentioned it to a few people and it was read by 20 people in a week.
Kevin O Brien: And I was quite pleased with that. And it continued just to slowly grow. And then suddenly after about six months again, I was talking to my son and saying, I’m doing all right and getting about a thousand reads a month. What can I do to boost it? And he sort of looked at me and he said dad, have you heard of Twitter and Facebook? I said, yeah. He said, okay, open those accounts. Set a Facebook page up, I’ll give you a little bit of a hand with the phrasing and let’s see what happens. And the whole thing exploded at that point. The readership just increased massively. And so now it’s read all over the world. Each post is read at least 6,000 times on its first day. As you know probably had to upgrade my website and servers because I was crushing the servers that I was hosted on.
Prav: Is proud thing your website.
Kevin O Brien: I did the website.
Payman: What I found really interesting Kevin, when you came to see me is I was just absolutely amazed at how you’d set it all up on your own and you right it is incredibly easy, but it’s surprising at how many people can’t do that.
Kevin O Brien: I have always messed about with computers.
Payman: Yeah. And no disrespect to your age or anything, Kevin, but when someone you comes along and then you’ve got a website and it’s got so much traffic, I was looking at it thinking, wow you’ve achieved this all by yourself, but you’d got it to the point where it was crazy. And I don’t know if you mind me saying so, but I remember you sticking the donation page on there to sort of open and fund it and just speaks true testaments to the followers and the value, they get out of it. When you sort of put an ad out there to say if you’d like to donate to support this, and you can tell the story if you want Kevin in terms of what happened after that.
Kevin O Brien: Yeah. I mean, that was it. I mean, I used to support it for my lecture fees and things like that. An honorarium that I received from giving lectures. But then I thought the decision that I was going to stop lecturing because I wanted to spend more time with my family and as great as it is being an academic, being flown all over the world to give lectures. And it’s not being churlish or not grateful, but it takes up a lot of your time if you’re giving lectures at large conferences. So I’d taken the decision. I was going to stop doing that. So the source of income from a plug had dropped also coupled with the fact that if you want to professionally written website and professionally hosted, it cost a reasonable amount of money.
Kevin O Brien: Hosting isn’t costing 10 pounds a month anymore. So I decided let’s just see what happens. And when I open donations page. And I had to close that page within a week because my accountant said, if you’re not careful, you’re going to be paying tax on the donations here. And people aren’t giving you money to pay tax to HMRC. So yeah, we closed the first donations after a week. I think I’ve got about 9,000 pounds on that within a week.
Kevin O Brien: Interestingly, a lot of this was from the year US, the big donations were from the United States where people sort of have a giving culture, and I think they get various tax breaks. And there are people now working up the donations page, every April, I’ll do it about April the fourth for the tax year. And there were two Americans immediately donated a thousand dollars straight away and having being so consistently. And so I covered my running costs. The donations page this year took a little longer because I think of the times, but I had to close it after about two and a half weeks this year. And people still come into me and say, can we make a donation? I say, now I can’t, because I can’t make a profit from donations. It would be the wrong thing to do.
Payman: And there Lies the answer to why you decided not to become a private orthodontist.
Kevin O Brien: Yes.
Payman: Can I give you some money, Kevin? No, thanks.
Kevin O Brien: No, it is that several people have said to me, why don’t you charge for this one? You charge a pound to read it, because obviously that would make a considerable amount of money. But all I’m doing is sort of I’m writing posts on my viewpoint, which is occasionally controversial, but all I’m doing is putting my interpretation of research papers and explaining the good and the bad things about them. I’ve also been joined by Patrick Fleming, he is professor of orthodontics down at the London hospital. And so there are now two of us writing the posts, but we both believe that education in many ways should be free. And I think it is important to think that actually there’s an awful lot of the readers of this blog are from, When I look at the readership, most of it is United States because of the concentration of orthodontists and then sort of the Western part of Europe.
Kevin O Brien: But then we move into other countries in which training isn’t always available, resources aren’t available to the degree that they are. Dentists and orthodontists generally are not as wealthy as they are in other countries. And so we get a lot of readers who are actually very grateful to be having something for free because they haven’t got the money, for example, the spend money. So it is that concept, that education, if we can do it for free, it should be free. And that’s what people’s donations in fact are paying for, which I think is good.
Payman: Do you get much stress from it? Does the AcceleDent contact you and say you just ruined our business. Do you get trolled?
Kevin O Brien: The times when I’ve turned it up. There’s times when I’ve crossed the line with people and I’ve thought, shall I post this? And I thought, yeah, maybe, and then I’ll hit send. But no, it’s not stress. I quite like doing it. It only takes me about half a day, a week to do it. Doesn’t take long to write one most of the time. And then the remaining time is editing it and getting search engine optimization and all the other stuff that goes with blog posts, so it doesn’t take me long. I like doing it. It’s something that I like writing and I like writing about stuff and explaining things to people. And Patrick does the same. The only time that I got stressed a lot was when I was sort of attacked by quite a few key opinion leaders in the United States. They said some pretty unkind things about me. It caused me a bit of stress, but then I thought, hey, how.
Payman: Because of what you were saying about them, were you were saying-
Kevin O Brien: It was a pretty blunt attack on key opinion leaders who are promoting treatments without evidence. They were sort of being clinical salesmen. I was blunt and they let me have it, but a lot of their comments weren’t nice and it troubled me a bit. But then I thought, well, this is the world of the sort of social media. They can sue me if they like, I thought, yeah, my business that supports the blog is worth a pound. And I don’t intend to go back to America for quite a long time. So it was more tougher ducks back, but it did trouble me for a couple of days, but then that’s why I think that’s a fact of life. Occasionally, if you’re not upsetting people, sometimes you’re not getting anywhere.
Kevin O Brien: And it is something that I feel quite strongly about is paid key opinion leaders. You get six figure sums from some of the companies and you start lying about the products that they’re trying to sell. So yeah, this not as a key opinion on slot every couple of months or so just to knock them back into shape. And that’s one thing that the blog does quite nicely, but it’s mostly educational. I’d hope it’s mostly educational.
Payman: I think I’m conscious, we’re both running out of time. So one thing I wanted to address Kevin, I’m fascinated by the sort of the aura that orthodontics has managed to get for itself. I get the same dentist saying to you, I don’t know if you know, Kevin but we’re in teeth whitening and composite bonding. I get the same dentist said to me I’m not interested in teeth whitening that’s cosmetic treatment, but refers loads and loads of kids and things for ortho. And in the back of my head, I’m thinking, well, orthodontics is a cosmetic treatment. I mean, how much of orthodontics has health benefits and I’ve noticed that there’s quite a lot of dentists selling orthodontics based on the health benefits of it. How do you feel about that?
Kevin O Brien: Well, we’ve just done a paper that was published in the American Journal of Orthodontics that in fact said that there was the surprising lack of evidence for the benefit for orthodontic treatment across the board. Now that’s not to say that that isn’t a benefit. And I think it’s very important to stress that is we didn’t find any evidence for it or much evidence for it. And the reason for that is that we’ve been asking the wrong questions. And most orthodontic research for example, is involved with how straight are the teeth, what someone’s skeletal pattern and things like that. Which we haven’t sometimes very little in a way of actually asking patients the way that they benefit, how do they feel? And those are very important factors. So when you look at the benefits of orthodontic treatment, you’ve got the various non cosmetic benefits such as treatment of impactions, large overage that are subject to trauma in young children, severe crowding, which may lead to tooth decay and periodontal Poppins.
Kevin O Brien: But that crowding has to be severe. The crowding that most of us see even on a referral practise is not going to lead to increase caries or periodontal disease. So then you sort of look and think, well, the cosmetics that is important too. We go back to the appearance of people’s teeth. And again, over the years, this has changed quite dramatically, predominantly I think because people becoming more aware of themselves and their appearance and societal norms have changed. And again, we’re all much more aware of our appearance than we are used to be. And just in terms of the way we look our way to narrow and all that, because we’re photographing ourselves all the time. And when you then transfer that back down to the generation of teenagers now, and certainly for the last five years with selfies and photographs and posing and everything like that, I would say, and this is just a hunch because there’s no science behind this that are sort of young people that we treat or seeking treatment are very different from those from 20 to 30 years ago.
Kevin O Brien: And they are concerned with the appearance of their teeth because of that great importance that’s placed on appearance. And that’s what you’re treating, you’re treating someone’s appearance. Now the next question then is that treatment of someone’s appearance cosmetic. And at what point does improving or changing someone’s appearance become a health benefit in terms of their overall way they feel about themselves and their self-esteem and their various interactions, because then you sort of move into sort of mental health benefits. So there’s only been one study that has ever really looked properly at self-esteem and orthodontics, and that was done by us. And it was part of the class 11 studies that we did looking at interceptive treatment of class 11 problems in young children. And we found that a group of children who received functional appliance treatment these were kids with big overjet. When that overjet was reduced, their self-esteem boosted, and they were getting teased less.
Kevin O Brien: What then happened when we followed them through for the next five years, the kids who didn’t get treatment early caught up with them in terms of their self esteem. So there was no difference in their self-esteem when they were 16, but there was when this group of patients were nine or 10, and that might’ve been very important and we didn’t measure it really now I’m kicking myself to say, if I did that study again, what would we do many other things. So there is something to it. It’s easy to say it’s just cosmetic.
Payman: I’m all for it being all cosmetic, don’t worry. But it’s the fact that it’s wrapped up as health that I’m interested in because teeth whitening has health benefits, by the way.
Kevin O Brien: That’s what we don’t know about artist. It depends what you call health.
Payman: Well teeth whitening is good for the gums in terms of the peroxide is good for Gingivitis. You get less plaque adhesion to the teeth. You get less root caries but we don’t talk about that because it’s the cosmetic side we talk about, but-
Kevin O Brien: But you don’t measure you see remember health isn’t just bodily health. It’s also mental health. WHO definition of health.
Payman: Of course.
Kevin O Brien: And it is, I can’t quote it exactly at the moment, but there is something about social, psychological health.[crosstalk 01:00:34]
Prav: Sorry to interrupt you. But you’ve been very evidence-based and looking at research and all of that. I’m going to ask you a question. That’s maybe counter-intuitive now, what’s your hunch. I know you probably don’t like talking about hunches cause you like evidence, but what’s your hunch on the future of orthodontics? I mean, what’s got your attention in the near future and talking a bit further ahead, is this idea of machine learning AI and all that. Do you think that’s really going to work? Do you think direct consumer is going to get to a point where we don’t need orthodontists because of the technology?
Kevin O Brien: Yeah. Orthodontics reinvents itself every few years because there’s the cycle after cycle of new appliances, nothing is new, self ligation wasn’t new. It’s been around for years for example. So breakthroughs in orthodontics I would like to see a method of making teeth grow faster and in the hands of good operators, you’d see no reason why that shouldn’t happen. There must be improvements in the cosmetic look of our appliances. We are moving that way. There’s got to be a movement away from steel. We’ve had ceramic brackets for a while, but they’re still not as good as steel in many ways. So we’ve got to move away from that. I think the trouble with direct to consumer care is I don’t understand how you could do it in terms of looking after the patients properly.
Kevin O Brien: I think that’s the key issue. Tele dentistry and everything that is fine and it does work. It’s worked telemedicine and tele dentistry is working. So there’s a lot of scope for that, but all that involves is constant monitoring and looking after people. So I think that at the moment, direct to consumer, no matter how fancy they try and dress it all up is not going to compensate for the orthodontist or dentist detecting something going wrong and changing their treatment.
Prav: At the moment I think it is a disaster, but do you think going forward it could become a thing or?
Kevin O Brien: I don’t understand how it could without that contact of the professional, with the person who knows what they’re doing. I think that’s the issue.
Payman: Kevin, What you were saying earlier is a dentist who’s done a five-year degree, has been on an airport course and sees the patient’s mouth in their chair can still mock it up. And now we send some Potsy off to the patient and say, take your own impression, sunshine, and we’ll straighten your teeth.
Kevin O Brien: Yeah. So that’s the issue there the dentist working outside their scope of practise, it’s not the system of care that’s causing the problem. It’s the dentist. And we will never eliminate people who work outside their scope and make mistakes. It’s a risk that we all take. And that probably is quite small. If you think about it. Because I think most dentists are sense of a line. Most health care professionals don’t want to harm people.
Kevin O Brien: They don’t mean to. They don’t like mistakes, but mistakes happen and that’s life. But if you’ve got nobody looking after the patient, even if it is just simple aligner treatment, it can go wrong. And I think it, from the point of view, protection of the patient, that’s quite important is that the patients still need protecting.[crosstalk 01:04:22]
Payman: If Kevin O Brien was going to design a direct to consumer system. What would it involve? Would it have a dental monitoring thing with a patient taking a picture every day or what?
Kevin O Brien: Yeah. That’s how, I mean, orthodontics is delivered like that in some countries, it’s the way that some people are, I think people that live in remote areas, the orthodontist is on the end of a computer instructing dentists on what they should and shouldn’t be doing, that is remote treatment. Is not direct to consumer though that’s the issue. The thing that’s missing out of the direct consumer is the protection of the patient by the professional. We always have to go back to that is as we’re all professionals and that’s the way we should be acting. And you take that out. You’re going to have problems.
Payman: Kevin, give your blog a quick plug so that people know how to get to it. And then Prav ask one final question. I know you-
Kevin O Brien: Yeah. Getting to the blog is easy. Just type Kevin O’Brien’s orthodontic blog into Google and you’ll find it.
Prav: Excellent. Kevin, my final question, we ask everyone this, imagine that your last day on the planet, and you’ve got your family around you, what three pieces of advice would you like to leave them with? And to finish that question off after that is how would you like to be remembered?
Kevin O Brien: I would always say in terms of advice to people is be kind, be calm be mindful. Don’t stress too much about everything, how I’d like to be remembered. I suppose I’d like to be remembered as someone who did make a difference to orthodontics and dentistry really. I’m quite pleased with what I have done. And I suppose I’d like to think, well yeah right I helped good changes to dentistry and orthodontics in what I’d hope is be quite a gentle, but very occasionally a bit of an aggressive indefinite way. And I suppose that would be about it.
Prav: Thirdly, you certainly have made a massive difference to orthodontics and dentistry. No doubt about that. It’s been wonderful. Thank you so much. I’m sorry. We had to run out of time like this. I know you’ve got to run yourself, but it’s been brilliant. I feel like we need to see you again.
Kevin O Brien: Anytime you like. I’m off to go and increase the income of a local vet.
Prav: Thanks, Kevin. Thanks a lot.
Kevin O Brien: Okay. See you soon. Take care.
Outro Voice: This is Dental Leaders, the podcast where you get to go one-on-one with emerging leaders in dentistry, your hosts, Payman Langroudi and Prav Solanki.
Prav: Thanks for listening guys. If you’ve got this far, you must have listened to the whole thing and just a huge thank you from me and Pay for actually sticking through and listening to what we had to say and what our guests has had to say, because I’m assuming you got some value out of it.
Payman: If you did get some value out of it, think about subscribing. And if you would share this with a friend who you think might get some value out of it too. Thank you so much for listening. Thanks.
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