Ravi Nanda - Orthodontic Truths and Myths

[Music] Welcome to another episode of the European Orthodontic podcast, where we'll be talking to Professor Ravi Nanda about a range of topics and his career in orthodontics. We'll be talking about his background, his experience, what led him to the US, his interests in research, hot topics such as early expansion, the role and importance of editorial process and evidence in orthodontics and how we bring the profession forward. My name is Finn Gagan, I'm a council member in the European Orthodontic Society based in Dublin. The podcast is brought to you by the European Orthodontic Society. As the vast majority of you will know, the name Professor Ravi Nanda, he is an emerges professor, former head of division at the University of Connecticut in the US. He's also adjunct professor at the ADA 4th site institute in Cambridge, Massachusetts. He received his dental orthodontic training first in luck now in India and then in Nimegan in the Netherlands and the University of Connecticut. He received his PhD in Nimegan and since 72 has been associated with the University of Connecticut in various roles, including chair of orthodontics. From 1991 to 2017, he has authored with his colleagues more than 300 scientific papers and his emerges editor-in-chief of progress in orthodontics. He's also associate editor of the Journal of Clinical Orthodontics. Welcome Professor Nanda. Thank you, thank you for your kind introduction. I'm very excited to have you and thank you so much for taking part in this podcast. It's my pleasure. Professor Nanda, this podcast, we were establishing a bit of a format and for me, it's a bit of a busman's holiday because when I was a student with urban hagg in Hong Kong, when we would do our literature reviews, some of the things I was interested in were the Journal of Clinical Orthodontics and the written interviews that used to take place with well-known orthodontists. And I was quite interested in what some of the motivating factors were in people I was reading about and in whose research I was familiar as to what motivated them to do what they did. And I feel personally and from experience and from talking to people that's very much tied in with who the person is and their life experiences. So if you wouldn't mind, would you mind introducing yourself telling me where you were born and grew up and tell me why you ended up doing orthodontics? Very good. I was born in British India, which is before India was partitioned into Pakistan and India. I was born on the Pakistan side and at the age of four we moved and lived in different camps at that time and my father was a physician and eventually we moved about three, four hundred miles east of the Pakistan side and I entered Del school because my elder brother, Ram Nanda, who was 16 years older than me and is now 97 years old and healthy. And he was department head there and he said why don't you come and join Del school. And my other elder brother, Suran Nanda, was already a dentist. So three of us ended up being dentist and my eldest brother who passed away last year at the age of 98 was a pediatrician. So I joined dentistry because of my brother and I knew very little about dentistry at that time and when I finished orthodontics sounded very good. So I ended up spending two years at Lucknow University and did my orthotraining. I was supposed to go to Dr. Brody's department in Illinois for my postgraduate work but he wrote me that he was going to be full bright scholar at University of Niamhagan, our Catholic University and he said why don't you come there. So I ended up in late 1966, at least 67, I think January. In Niamhagan Netherlands, under Professor Fander Lindon and Dr. Brody who was there for one year. And then I ended up staying there almost four years and I did my PhD and again did orthodontics with a lot of graduate students. And I was fortunate to spend a lot of time with with my peers, Beard of Pral and Dr. Dutelow and Dr. Boosma and Dr. Fander Lindon. And Professor Nanda, can I ask you a question, had you spent much time outside of Lucknow before you went to Niamhagan? Not really. I was a student and just worked very hard at that time and we had one professor who came down from Germany and Dr. Klaus Schwars and we became friends. He was a few years older than us. And that was Klaus Schwars, who ended up becoming department head of University of Cologne. And then I visited him many times after I moved to Connecticut. So that is my story of Lucknow and Niamhagan. In Niamhagan I did primarily research on development of cleft lip and palate in mice and we published quite a few articles. And when I graduated I ended up having three offers from US and US and Canada. One was with John Cleal in Vinnipeg. One was at Melmoss in Columbia and one was with Don Hildjers in Loyola. And I picked Loyola. He happened to be my brother Ram Nanda's classmate. So I ended up in Loyola for about two years and I got pretty frustrated because I couldn't do research and they were accepting about 21 students in each class and I was the only, a crazy, there were 44 students there and I was the only full-time faculty. And had you intended on continuing your research in cleft palate? Not at all. There was no facility to do research at Loyola. But you obviously knew at this point, it sort of seems to be clear for me that you were heading in a direction of academia already. Would that be correct? Yes. Yes. And when did that become apparent to you? Did you think when you left look now, you were leaving or did you say listen, I'll go to Neymag and for two years, come back, settle for big office, live happily ever after and look now. Not really because my brother Ram, he came to US in 1949, 50 after his dental school at Harvard foresight. And he was with Dr. Mouriz and then he did his PhD in Colorado, Denver and then he stayed in US. He came for a brief time in India and then he went back as a department head in Oklahoma where he stayed almost 40 years as department head before he retired. So I knew, so my two brothers, my middle brother, he was in Ohio state and he had already started teaching with Dr. Sasuni in Pittsburgh. So I kind of liked that idea of publications. I had quite a few by that time. So I kind of liked that research and writing papers and teaching. So I knew at that time that that would be my future. Professor Nanda, in this conversation, already you've mentioned a number of academics from the US and Germany that even now would be considered some of the sort of primary drivers of research coming out of the US in the post war period. That would, that would, that would, that would, that would, it seems like quite a unique time or a unique number of people to be an associated with. It is 100% correct and I was really impressed by all of them. And, and Nymagan was sort of a hub where all the American professors used to come and give lectures and spend time with us and Dr. Brody was there for one year and Fonda Lindon had spent a couple of years in Seattle. So all our, our education was just like what was it, University of Washington? Washington in Seattle. I mean, we never learned to remove all of the places or anything, you know. And why was Nimegain such a hub for American academics? Was there a reason or it just happened to be? I think it was because of Franz Fonderlinden. He, when he came there, he somehow started the program by only taking one Dutch resident in the program and there were at least three from other countries. So my classmates were from Denmark, Beardapprol, Dutell, Maurice McEwen, who came from Bengal Ireland, never finished it, John Jeffries from Australia. So it was a very eclectic group in my program. And then from where you were in the States, did you get to resume your research? Had your focus moved away from Clevverlip and Palette animal-based research? Or how did you find your way back into research? Well, this is very interesting because after one year in Laola in Chicago area, I received a phone call from Charlie Burstone, who happened to be department head in Indiana, at that time. And he said, "Ravi, I read your papers. Would you be interested in starting a new school and a program with me in Connecticut?" And I just jumped at it. I said, "Can I start?" Because I knew, here's a great guy. I want to be associated with it because he was at that time, even guru in biomechanics. So I joined in '71, '72, University of Connecticut started a program, which are LaBurstone. We also had Sam Weinstein, who was also a department head in Indiana, Nebraska. And he joined us. So it was a pretty powerhouse. And I was the youngest 29-year-old in the program there. And so Burstone said, "Look, everybody says that he teaches segmented. And Ravi, you are trained in straight wire or conventional edge wise, so you are in charge of the clinics, so this is how I started teaching, being in charge in the clinics, and at the same time, starting my research." And what I found out was that to work in a cliff-lip in Palatiria, one had to do almost 100% research. And it was impossible because I was competing with PhDs and all that. So I decided to write a NIH grant in 1973, which was funded in 1974 on protection headgear in primates at that time. And that was a time when you could work on primates. And that was the start of my research career. And it went on. I had at least a dozen grants over the years, and clinical work, managing the clinics, and writing clinical papers, and all that. You know, rest is what it is, you know. May I ask, in your time in Connecticut, being a sort of a non-native in the US, looking at the landscape of orthodontic and orthodontic research and academia in the States, we've sort of mentioned, you sort of, you seem to have come in at a time of big guns, really well-known, all of those names that you've mentioned are all familiar to me and to the people listening. Where do you feel today, or how has it transpired when you look across the US and Europe, how have things developed? What is your take on academia, where it is in the States, or if you look across at NIMEG and Europe? What are your contrasts? What are you seeing there? How do you feel it's developed during that long period? Well, I am very intimately tied up with the European orthodontics and American orthodontics. I became member of EOS in 1968, I think, and the meeting was in Edinburgh. And I remained member until like three years ago. I think I don't know why I'm not anymore, but somehow I didn't send the money. So I was the oldest member left, I think, at that time, you know, when stopped being US. So I know the education in what was going on in Europe and what was going on in US. What really happened is that education in US sort of concentrated towards certain procedures. Example is straight wire technique, Andrews came into picture before that Gerraback was there, then Ricketts was there, so bioprogressive. So everyone sort of congregated based on the technique. We used to call it or still call it personality oriented orthodontics. "Oh, I do Ricketts and I do straight wire." So we do okay. In other words, you sort of advertising what you do. Europe was totally different because East Europe was sort of persona, non-grata. They were not there. They didn't know what was going on there. And the Scandinavian education was very academic, also. You know, a lot of papers were coming in the journals at that time. B.R. was there, and you know, Bergen, Kovman, Hagen, and B.R. Melsen. So and then you had the German group which was always into into into removal appliances until Ernst Hosell and all these people came in and they brought in American speakers. And I joined Ernst Hosell group in 1980. So then I started going to Europe a lot to give lectures and meetings and courses. So the education in Europe was always sort of behind from US standpoint of you. Research wise also other than Scandinavia, there wasn't much research going on there also. And so I think both educational processes developed quite differently. But now I see that aligners have brought the two educational processes together somehow and fixed appliances are sort of uniting factor between the two groups. So I think from research standpoint of you, US was very good. But then Europe took it over because now a lot of good research is coming from Europe, Asia, India, China, and Brazil. So so it's not only Europe and US the rest of the world is coming into the picture also. Would it be unfair to say then in a lot of respects, I suppose like in other aspects of life that America would drive the commercial innovation and from that a lot of research would then begin in the US and then start to pick up steam from there in the in Europe, you know, using the fixed appliance and aligner analogy as an example. Yeah, that is true until 1998, 1997 when in Vizlain came into the market. Until that time there was lot of research taking place in US. And most of the research had to do with the longitudinal studies on growth and development, almost all these studies came from US except from B.Ark in Copenhagen. And then there were a lot of studies also on biology of tooth movement, cleft lip and palate. Europe in the meantime was primarily into following what was going on in US. But then the money dried up to do research in US. So the money started coming from from orthodontic companies. So most of the research then sort of veered off towards clinical research and in the meantime basic research sort of started in Europe quite a bit. So had the money from the states originally been federal money or to do these longitudinal studies are excuse me to do these growth studies etc that you'd mentioned. They were all from National Institute of Health and IECR, National Institute of General Research. I over the years had maybe 8 to 10 different grants from them. Even now they are supporting a lot of research but not as much in orthodontics. And so you seeing orthodontists because I read about this and when I was younger I would read about this. Are you seeing ravi nandas come through in the States. Are you seeing? guys who come to you and say, "I want to career an academics," or are they drawing up? Is that as that era ended or how do you feel things are? Very interesting question because it kind of gives you a little bit of boasting rights because at University of Connecticut we always try to accept graduates in our program who we thought would be leaders or go in primarily into education. So the ones I graduated they are pretty active for example Somit Yadav in Dombrasca has three NIH grants, Sunil Vadwa who's chair in Columbia has about two or three different grants, Steve Lindauer is editor-in-chief of angle orthodontist and I can go on. They were all my graduate students so they have stayed very active in research. I have about ten of them who are department heads and other maybe 20 program directors so they have stayed active in research other than that I think University of Michigan, Seattle, North Carolina, not any more as much but they've been active in research but research is going down and down. Did that arise in your department because of the candidates you picked or was it the environment in which the candidates trained or was it a combination of both? For example I remember locally falling into the University of Hong Kong and meeting Urban Hague and for me I hadn't encountered as an undergraduate the type of mind that Urban has asking question questioning things slightly sarcastic and for me that was up until that point as a dentist I felt I had been trained rather than educators would that be a hard way of putting it in so far as very few points up to then had I been asked to my opinion or to think a little bit outside the box and for me that was a rely opener. Our program in Connecticut because of Charlie Burston I give him always the credit was very research oriented from the day one. Charlie received at least three or four NIH National Institute of Health grants on biomechanics in in 70s I received about three NIH grants in 70s same Weinstein had grants so our we were like powerhouse at that time there were other schools too doing research but we had probably the most money for research that means the support staff of engineers we had full-time engineers working in the department computer people working in the in those days and so the atmosphere was all research so in other words when somebody applied in the program and usually we'll have in those time days maybe 200 and Charlie Burston would say oh this guy is an engineer his background is engineer his background is mathematics let's take him into the program so so it was combination of both I mean research environment was there the money was there for people to do research and we look for individuals who would do research and may go in teaching we were not 100% successful because you know financial issues play a role too some would come in with a PhD and then they go in practice but that's the name of the game you know in education I've noticed in these podcasts that we've done and this is possibly due to my own experience from mindset at the moment we talk a lot about digital and technology and invariably we come under the subject of appliances but I wanted to talk a little bit about you know technology has changed information and you have a very established background in publishing in editorial process and at the moment both in the wider world and in orthodontics we're seeing changes for example Kevin O'Brien's blog has been a very different direction and hugely impactful I feel on orthodontists and in one of his recent posts he talks about falsehood in orthodontics and I wanted to talk to you a little bit about your take given your credentials experience on where we are today and if you don't mind this question going on very long it does I think tie in with the change in academic environment a little bit doesn't it there's not quite as many people coming through as may have done when you hit the states first where are you with this or what are your thoughts on where we are in terms of the role of what is the correct information and how orthodontists receive the latest best standard evidence in order to practice that's a that's a really hard question let's start with falsehoods in orthodontics and then we can talk about where they come from I think internet has played a big role in perpetuating a lot of falsehoods because when the residents when I talk with some of the residents and I ask them if they are on Facebook or Instagram and if they say no they almost have no idea about people who post there such as such as Gavin they have no idea what Gavin posts because unless you are on Facebook and you are one of the maybe 20,000 or 15,000 people who follow him so so that information becomes very limited now the question is where is that coming from if you look at for example the blog of Kevin it kind of it sort of takes more like a negativity approach to he points more about the problems than what I would say what is good in orthodontics what is going on all the time and and then people jump at it and he doesn't like KOLs and he doesn't like the research which is coming in the in the literature and that's where the falsehoods start because Kevin is 100% right in that and that's what then students end up reading in their in their literature classes so our problem right now is that we have too much research which is pretty poor research going on in universities especially in US also because many programs say we are going to give you master's degree so you have to write a thesis so the net result is that thesis is written on a small project and then everybody wants to publish it so now we come into the journals they have to publish it well some journals are very critical others are not and then we have a lot of journals who should not be there at all these are the journals for profit they're coming from China India Turkey Brazil and you can publish your papers I see orthodontic papers appearing in OBGYN dermatology journals all kinds and and then these are the articles which people take and key opinion leaders and they start talking about G you know you can do this you can do that example is these days like everybody's talking about in pediatric dentistry and some orthodontist the tongue tie that the children when they're born you should cut their tying tongue tie right away because the jaw growth is going to be better or you are going to expand the pallets that three or four year old or you come up with some crazy appliances which is going to expand the jaw so the breathing is going to be better I can go on and on and on and these are the falsehood some start from the internet some start from these poor journals and some start from good journals who are not very careful and that's what Kevin was talking about in one of his blogs that research guard published it should not have been so combination of factors we have a problem with with with information the companies are so sponsoring it, they are paying people to write articles. I mean, I just look at it and I'm baffled. I was editor in chief for 13 years of progress in orthodontics. When I started, we used to get 150 articles. When I left 750 articles, submissions were received and we published only 45. So you wonder what happened to the rest of them. Well, I know it because Springer would send me what happened to the articles which we rejected and 250 articles were published in about 16 different journals. So they get published and they are in the literature and people just follow them. That's the problem. I'm sorry for the long answer, but I get excited when I see this type of problem taking place in orthodontics. Well, I know just without sort of trumpeting our own journal, the European Journal of Orthoms, but I know the amount of time and attention that our current editor, Dr. David Rice, takes. But I also know there is a small group of very dedicated people who will help with reviewing, with administration, with maintaining that. And I think he must have the patience to job to do the job he does. You have to be a very strong gatekeeper. I don't know how he does it. No, he has done an amazing job with European Journal of Orthodontics because I have published many papers in that journal because one of the things as editor in chief, I follow what nature, science magazine follows and that is as editor in chief, you don't publish papers in your own journal. And I see this thing happening all the time in orthodontics. People put their name in as a fourth author, fifth author, but they are editor in chief of the journal. And that brings bad vibes to me, you know. And European Journal of Orthodontics is amazing. It is fantastic journal. I must say that. Can I ask a sort of esoteric question or a sort of hypothetical question? What is the solution to that? Do we create by consensus a group of journals or do journals come together and agree on certain principles and pass that information down? Or have you any idea how you stand given the weight and the imbalance caused by the change and technology from digital, the huge changes by disrupting companies and the impact financially that they bring and the wealth and the muscle that they bring in marketing? How do you stem that dam and make sure that the information that is going to young orthodontist to students, is there a solution? Is there any ideas out there? Yes, the ideas are there, but ideas are run into problem because last year Ted Eliard is, who was my associate editor, department head and Zurich, and a good friend of mine. He wrote to the editor in chiefs of European Journal, AJO, DO, and Galarthodontist myself, OCR. And he said, here's an article. We should all publish in our journal as editorial. And basically talks about some of these publishing houses that what are the good journals, what are the good journals we should stay away from and how this information should not be dispersed, what is being published in those journals and all that. Well, Springer did not publish it because Springer said that would sort of invite lawsuits from people. So the net result is that we kind of stay away from something like that. But we all know that there are journals outside, have no impact factor. And sometimes they will say they have an impact factor, but I don't know which, where they get that. And they keep publishing these papers. And so it has to start from the universities, they should not push people from publishing, they should be more critical. We have a problem. We have information overload going on at this time in orthodontics. From all over, all over, this orthodontic company. One example is that with the aligners, you can expand the palette. I mean, maybe even in one or two cases, but we all know that it takes pounds of force to open a switcher even at 12, we are already known. And this is, to me, just an important segue to another point, which is, I feel there is huge value in the biomechanics learned as a postgraduate student. And in fairness to both professors in Hong Kong, it was such a melancholy of people. So Urban came in with a background in Begg and had worked specifically with tip edge appliances. Bokrabi had trained in Northwestern. And with Sheldon Rosenstein came over. We had Dark Vichman come over a couple of times. We had a number of people from Korea and Japan, Miao technique, all sorts of things. And today, some of the appliances we use, the aligners, whether they are conventionally produced, thermal-formed aligners to say some of the innovations in shape memory. How does an orthodontist translate the biomechanics they've learned into a new appliance? How would you go about, you came in under Charlie Burstone and you're involved with direct printing aligners? How would you recommend it from your own experience? You take that knowledge, the things you've learned, because I think people sometimes feel a bit challenged by that. They're proficient in a certain type of appliance. And yet they see aligners or they see different appliances has been used. But my gut feeling is the biomechanics, the biology, the orthodontic diagnosis and treatment planning remains a constant. How do you change your appliance and keep that learning, that education so that your patients benefit from your experience? You know, I have always maintained that biomechanics rules orthodontics, the clinical practice. My, the example I give always is that till 1979, we were only using stainless steel wires. And then came in shape memory wires. And these shape memory wires completely changed the way we practice orthodontics. I think that was one of the biggest innovations of having beta titanium, nickel titanium wires, copper nitite wires. Why? Because we can use big activations, small amount of force, and the force is going to decay over a long period of time. We don't have to activate all the time. So for me, that was the biggest innovation. All the other things which happened were diagnostic, which is very important, you know. So I leave that aside. Now comes in, for example, tags for skimming. Well, people started using tags, absolute anchorage, but they had no idea that once you have a fixed point and then you are using the other side to move, biomechanics will apply, and that biomechanics is going to be quite different. So, so I got into that and we wrote a book and a couple of quite a few articles on that subject. So it brought biomechanics into tags. The sad part about aliners is that it was brought in the market by an orthodontic company. And that orthodontic company was only interested for the first 16 years or 18 years when they had the patent that how they can sell more. So they were doing research, but they're telling schools to do research, but they were sort of controlling it. You know, what you can publish, but you cannot publish. We refuse this type of research in our department. Someone tells you that you got to show the results to them. So what happened was that they really didn't look into biomechanics at all, like how to improve it. And the study after study came in and said that efficacy of aliners is not very good. So some movements, you get 10%, some you get up to 80%, and nobody worked on that, but they kept on introducing new products. Well, until they hired John Martin, John was our engineer at Connecticut. And John went there and did something. good and he said, "Okay, we need attachments." Well, attachments are like brackets because now you are applying force on the brackets, you are applying on the attachments. So there's very little difference. So John at least brought something very different there. But still that was not the answer. Even the studies which just recently came from Australia, they basically talk about that you are not getting what you are supposed to get, what you plan. So that brings us to like how a company is going to control. And then the new companies come in and they follow the old company because they don't want to veer off too much because people are used. So we all become sort of lazy in our offices. You know, you scan, you send it to the company and they send you all these aligners and you just give them every three, four weeks to your patients. That's not good orthodontics. So when I heard that there was a resin which has the shape memory characteristics just like we had nickel titanium and beta titanium, I kind of jumped at it. I saw, my gosh, there's something like this exists, you know. And then we did research, we worked on it. So this is the first time a product is launched with about 30 to 40 papers already in the literature and good literature. So that's my interest. So I think in future, I hopefully all the other companies will go into this shape memory effect. That means you are not applying direct force on the black, on the attachments, but you are moving the tooth by changing the shape. So the material is just like nickel titanium wires. You know, you use it, you take it out and the material goes back to its original shape. So that's so I so I really think that biomechanics should not be forgotten. And now I'm so happy that more and more and more articles are coming on thermoformal liners about biomechanics. I'm very proud of progress in orthodontics. We really published some very good articles and interestingly where are they coming from, from Italy, from Castro, Floreo, or they are coming from China, or they are coming from Brazil, almost very little or nothing from US. So this is this is the state of affairs, you know, we have become complacent. And we just follow what the companies tell us and I am just trying to move away from that. Long answer. No, it's a great answer. And I was really interested to hear it. So there's, and I think it's a really good note to end on. And again, like some of our speakers in the past, this is a conversation which personally I could probably continue for another couple of hours, but we're not going to, but I hope to see you again soon. And I just want to say to our listeners that I hope they enjoyed this. What I think is a great opportunity to speak to Professor Nanda and to give us some insights into where we are in orthodontics and utilizing his career as a kind of a process, but we will see where we are today and into the future. If you could spare a couple of minutes to fill out his feedback survey for this episode, would be grateful because it's great to know what you guys are listening to and what you find useful and that would be super. And I'd like just to thank again, Professor Nanda for joining us. It's really great. Well, thank you very much, Finn. And I'm so happy that this podcast took place under auspices of European orthodontics society. The first society I ever joined in my life in 1968. Thank you very much. Now, before we sign off, I just do a quick reminder like I do to please subscribe to the podcast so you get a notification when the next one is available. And we hope you will join us next time. It's almost like a continuum because we will be speaking to Professor Kevin O'Brien. Finally, please come to visit us in June in Krakow in Poland at the 100th annual Congress of the EOS from the second to the sixth of June. Krakow promises to be a fantastic Congress. I visited the center, the town itself is phenomenal, a huge history. And I think it's going to be a great event celebrating a century of EOS Congresses with well over 2000 orthodontics from around the world. We hope to see you there. This podcast was brought to you by the European orthodontics society, a membership organisation with over 3000 members from all branches of the orthodontic profession working in private practice, hospitals and universities throughout Europe. To find out more, visit www.eosEurope.org and follow the EOS on Instagram, LinkedIn, Facebook and X. All views expressed on this podcast are solely those of the host and guest speakers. Do not reflect the opinions and beliefs of the European orthodontics society.