The Statement on the Federal Audit Office Issued by the DGKFO is Dishonest and Scientifically Intolerable

After, the Federal Audit Office in its annual report had criticized missing care research and proof of benefit for orthodontic treatment in Germany, this caused enormous excitement. The German Society for Orthodontics (DGKFO), the scientific organization of German orthodontists, presented a press release on this issue on  April 26, 2018 in which the DGKFO declared to support “the enhancement of studies regarding the benefits and effectiveness of orthodontic treatment of children, teens and adults – a high quality care research is included.” Moreover, the DGKFO appreciated, “that the Federal Audit Office asked the Federal Ministry of Health to initiate care research in orthodontics”.

These statements seem less than credible because in 2001 the Council of Experts in health care had already mentioned in its report that despite an exorbitantly high supply level and high annual costs, “epidemiology and health economics had treated orthodontics in comparison to other parts of health care quite stepmotherly”.[1] Care research deals with investigations concerning health care of the population. It investigates how health care services are distributed and who receives them. Moreover, the benefits of these services are monitored. Finally, recommendations can arise from care research, how health care resources can be used targetedly and beneficially. Nor in 2001 neither in 2008, the German orthodontics could answer questions about orthodontic care in Germany. In 2008 the HTA report from DIMDI “Oral health after orthodontic treatment with fixed appliances” was published. Among others, it criticized that there was no proof of health benefit through orthodontic treatment. [2] While the statement of the Council of Experts was ignored by the DGKFO in 2001 a statement was given in 2008: The executive board announced, “that within the next meeting at the end of May the members would discuss the coordination and financing of a multicenter EBM-based scientific study regarding oral health and orthodontics. The project would soon be initiated“. [3]

Even 10 years later, nothing has been published yet. Nonetheless, there’s the urgent question to be answered, why the orthodontic supply rate is at 60 % concerning the public health insurance, whereas the privately insured might even increase the supply rate to two thirds per birth year. This is an exorbitant supply rate and it exceeds twice the rate of Scandinavia – highly developed countries with high quality dentistry. The reason for this development in Germany might be that there are many minor orthodontic findings which are treated neither with a positive effect on health nor improving the quality of life. Furthermore, the question why half of the treatment duration is performed with removable appliances has to be answered [4], although fixed appliances produce better and faster results. In 2001, the Council of Experts had already mentioned these facts without having any influence on the orthodontic supply rate. An answer to the question should be found why in Germany orthodontic treatment duration lasts three to four years which is twice as much as in similarly developed countries. Moreover, it should be explained why Germany has an orthodontist-to-population-ratio from 1:20000, Scandinavia 1:30000 and Great Britain 1:47000.

The only argument given by the DGKFO regarding the health benefit of orthodontic treatment is the risk reduction of front teeth traumata caused by large overbites which were responsible for ”200 millions of traumata per year and their follow-up costs”. No doubt, there is a correlation between large overbites and upper front teeth traumata which could be proved in several studies. [5] But it seems to be risky announcing it as an urgent indication of treatment. Authors of a randomized controlled study concerning early treatment of Angle Class II with large overbite found that patients undergoing later treatment showed a higher number of front teeth traumata but without any clinical significance. Moreover, the authors of this study found that this early treatment followed by a second treatment phase caused a high increase in costs, whereas there were mostly minor front teeth traumata which could be treated easily and cost-effective. This is the reason why the authors didn’t recommend early treatment of a large overbite, particularly as it would have to be started at the age of 6 to 7 being an inappropriate phase anyway [6]. Furthermore, a systematic review showed that ten kids would have to be treated early in order to prevent one from having a new front teeth trauma [7]. In terms of health economy an early orthodontic treatment in order to reduce a large overbite doesn’t seem to be indicated.

The statement on the Federal Audit Office issued by the DGKFO is deeply dishonest and scientifically intolerable. It’s you, professors, who have circumvented the question of orthodontic supply levels for decades. In 2001 the Council of Experts had suggested to define criteria for minimizing orthodontic treatments and to rearrange fees in favor of the efficient but poorly rewarded fixed appliances. In order to reduce the supply-side induction of demand the Council of Experts recommended “a modest reduction of training capacities” and to make use of the free capacities “in order to improve research and teaching” [8]. The Council of Experts is absolutely right but the DGKFO doesn’t seem to have this on its agenda. This might be up to the DGKFO’s self-image. Regarding the statements of Prof. Hirschfelder, former president of DGKFO, “a beneficial cooperation between the scientific society and association of orthodontists” (BDK, the professional lobby organization of German orthodontists) was favored by the DGKFO. Then, the president-elect (and current  president) Lisson announced, “the coordination between science and professional policies is important – tasks of the latter shouldn’t be part of the DGKFO’s work” [9]. Nevertheless, the BDK asks for a high supply level and the inappropriate but profitable treatment with removable appliances. So it seems that the DGKFO doesn’t want to play the spoiling role!

References:

  1. Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen. Über-, Unter- und Fehlversorgung in der Kieferorthopädie. In: Gutachten 2000/2001, Band III. 14. Zahn-, Mund und Kieferkrankheiten. Bonn 2001. https://www.svr-gesundheit.de/index.php?id=337
  2. Frank, W., K. Pfaller, and B. Konta, Mundgesundheit nach kieferorthopädischer Behandlung mit festsitzenden Apparaten. HTA-Bericht 66, Deutsches Instituit für medizinische Information und Dokumentation (DIMDI), Köln 2008. https://portal.dimdi.de/de/hta/hta_berichte/hta205_bericht_de.pdf
  3. Deutsche Gesellschaft für Kieferorthopädie. Stellungnahme der DGKFO zu dem  von  der  Deutschen  Agentur  für  HTA  (Health  Technology  Assessment) des   Deutschen   Instituts   für  Medizinische  Dokumentation  und   Information (DIMDI)    in    2008    veröffentlichten    Bericht    über Mundgesundheit    nach kieferorthopädischer Behandlung mit festsitzenden Apparaturen von W. Frank, K. Pfaller und B. Konta. 2008. https://www.dgkfo-vorstand.de/fileadmin/redaktion/veroeffentlichungen/DZWHTA050508.pdf
  4. Krey, K.F. and C. Hirsch, Frequency of orthodontic treatment in German children and adolescents: influence of age, gender, and socio-economic status. Eur J Orthod, 2012. 34: S. 152-7.
  5. Shulman, J.D. and J. Peterson, The association between incisor trauma and occlusal characteristics in individuals 8-50 years of age. Dent Traumatol, 2004. 20: S. 67-74.
  6. Koroluk, L.D., J.F. Tulloch, and C. Phillips, Incisor trauma and early treatment for Class II Division 1 malocclusion. Am J Orthod Dentofacial Orthop, 2003. 123: S. 117-25.
  7. Thiruvenkatachari, B., et al., Early orthodontic treatment for Class II malocclusion reduces the chance of incisal trauma: Results of a Cochrane systematic review. Am J Orthod Dentofacial Orthop, 2015. 148: S. 47-59.
  8. Sachverständigenrat zur Begutachtung der Entwicklung im Gesundheitswesen. Fazit und Empfehlungen des Rates. In: Gutachten 2000/2001, Band III. 14. Zahn-, Mund und Kieferkrankheiten. Bonn 2001. https://www.svr-gesundheit.de/index.php?id=338
  9. Deutsche Gesellschaft für Kieferorthopädie. DGKFO Mitgliederversammlung: Prof. Dr. Jörg Lisson einstimmig zum Präsident Elect gewählt. Presseerklärung vom 13.10.2016. https://www.dgkfo-vorstand.de/service/news/details/dgkfo-mitgliederversammlung-prof-dr-joerg-lisson-einstimmig-zum-praesident-elect-gewaehlt-5.html