April 08, 2019

What is “airway friendly” orthodontics?

Over the past year, a new branch of orthodontics may have been created. This is called “airway friendly orthodontics”. I thought that I should discuss this.

I am sure that all readers of this blog are aware of the discussions around orthodontic treatment and the airway.  However, I am not sure that we are all up to date with the concept of “airway friendly” orthodontics. This is being touted as a new treatment method in orthodontic care. It is also heavily promoted by some companies and their KOLs. (I think that you can see where I am going with this one?).

Where should we start?

I thought that the best place to start on this was to attempt to define this term and I turned to the great source of orthodontic knowledge that is Facebook and asked.

“What is “airway friendly” orthodontics and how does this differ from “conventional” orthodontics”?

What did I find?

These are some of the responses:

“Better yet…what is airway unfriendly orthodontics”?

“It is a practice that screens educates and refers patients appropriately for suspected OSA”.

“Orthopaedic treatment to prevent OSA anatomical risks”.

“A catchphrase used to scare/motivate patients to request treatment for a condition that cannot be quantified or even defined well by the people providing the service”!

But this was my favourite.

“I don’t see why people call themselves “airway friendly” or “Damon Dr’ or “TMJ friendly” are they saying that other orthodontists are not”?

These definitions go some way to explaining why this area of orthodontics is becoming controversial.

What is our state of knowledge about Childhood OSA?

An excellent place to start this discussion is to consider the summary points of the AAO conference on OSA and orthodontics.  I have covered this before and here is the extended version of the AAO white paper.  I have also done a summary post on orthodontics and breathing.

My interpretation of the conclusions of the AAO meeting was:

  • Orthodontists should be familiar with the symptoms of OSA and refer appropriately for treatment.
  • If an orthodontist is going to treat OSA, they need to be competent
  • Orthodontic treatment with or without extractions does not cause OSA
  • Non-extraction treatment or expansion etc. is not the “cure” for OSA.
  • Orthodontic treatment may have a role to play in treating paediatric OSA, but the first line treatment is medical/surgical.
  • There is no evidence in the literature that orthodontic treatment can prevent paediatric OSA from developing.
Advertising about “airway friendly orthodontics”.

I did a google search on “airway friendly orthodontics”. Interestingly, the first hit was this one from Henry Schein Orthodontics, promoting a course that they are running. It appears that the Carriere sagittal first has a role to play!

It is also clear that the “orthodontic fringe” promote this type of care. Not surprisingly, it is now a central component of myofunctional or orthotropic orthodontics.

When I looked at “airway friendly” orthodontist’s websites. Many of them made claims that were not supported by the evidence. I also saw that a lot of the orthodontists were “prize-winning”, “passionate about orthodontics”, “did not do extractions” “used accelerated orthodontics” and “rapid self-ligating braces”. There is a pattern here.

It appears that the “innovators” in our specialty are the ones who are adopting this new form of treatment, in the face of evidence.

So how do we practice “airway friendly orthodontics”?

When I consider the AAO report and the current levels of advertising, I cannot help feeling that what may be good practice is being hijacked by those who want to make themselves different from “conventional” orthodontists.

I feel that there is nothing wrong with being a conventional orthodontist, as our work should speak for itself, without the marketing claims.

But, how do we deliver airway loving care? This is clearly stated in the AAO report.  We should screen our patients as part of our examination, preferably using a screening tool. If we detect that a patient may have OSA, then we should make the appropriate referral. Finally, we should provide the proper treatment following the relevant medical/surgical procedure, but only if this is not successful.

As a result, it is easy to practice “airway friendly orthodontics”. It is not different from good ethical orthodontics that most of us provide.  I wonder if it is a marketing ploy and is nothing special.

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Have your say!

  1. As Dave Paquette stated, this terminology, which we coined, HAS been hijacked by all manner of orthodontists, some of whom are, in fact, using it for marketing. However, in response to your comments: “But, how do we deliver airway loving care? This is clearly stated in the AAO report. We should screen our patients as part of our examination, preferably using a screening tool. If we detect that a patient may have OSA, then we should make the appropriate referral. Finally, we should provide the proper treatment following the relevant medical/surgical procedure, but only if this is not successful.”, how many orthodontists really screen for airway problems-how many are screening every non-adult with a PSQ, or deliberately looking at for clinical signs and symptoms? A precious few. In 2012, almost none. In fact, there are still orthodontists who crow that anything regarding airway is not even in the bailiwick of the orthodontist. In fact, unless we become deliberate about this subject, we won’t be “screening”. So the simple difference is to start there. On a related note, earlier this year, I believe you indicated that there was no difference orthodontists could make RE: OSA and I sent you over a dozen articles showing just that, asking that you summarize those-as still, this hasn’t happened. Yet, this is your second blog about what we can’t do-I would respectfully ask you to take a moment to look at the articles sent and realize that although some have grabbed the “airway friendly” label and used it for marketing alone, many others are taking a more scientific approach-positing anatomical changes that may reduce airway resistance and testing those hypotheses. There is no “cookbook” approach to this multifactorial problem and most successful treatments involve cooperation between professions, but we can certainly do better than argue against the possibilities while not even learning the basics of how to screen and recognize problems

    • Thanks for the comments. I reviewed the papers that you sent to me and they were generally not of a high standard. As a result, I decided not to post about them because they did not add anything to the posts that I had previously published. Furthermore, the AAO meeting did a far better review of the literature than I could and they came to similar conclusions. As I said in my post there is a role for orthodontists in the screening an onward referral for OSA, but at present claims are being made for much more?

      • I am disappointed to hear that stance, but understand. I realize what you in England have been up against and I suspect anyone mentioning airway and orthodontics in the same breath are immediately suspect. Still, perhaps hearing WHY you feel they are poor studies will guide us to a discussion of what types of studies would be appropriate. Would you consider reviewing the articles regarding the Steiner analysis? When cephalometrics was first used, there were a number of “analyses” used and it seems everyone had their own. I know that the Steiner analysis (or, pick another) is still being used by some. Since we’re holding any new ideas to a high standard of proof, it would be instructive to hear your learned comments on how valuable ceph analyses are. Respectfully, Lou Chmura PS: I would also be interested in whether there really is science showing that “adenoid faces” is a real thing-I know it’s been discussed and taught in many universities, but I don’t see the kinds of studies needed to prove it’s validity.

      • Just a thought-now that the AAO has recommended we screen for airway problems, do you know of any studies that show how many orthodontists are doing so? Might be interesting to see, given the reluctance to consider the possibility we can contribute in this area. L

    • Hello Lou Chmura, would you mind if you can share these articles, as I’m currently scanning articles in regard this topic for a systematic review, and I have got a list reasonably good to initiate the review.

      • The AAO library is assimilating articles on OSA. They currently have accumulated more than 6000. As an AAO member, you have access to their efforts. Reach out to to them and you will be rewarded. Good luck.

      • If you are a member of Orthodontic Pearls, I posted them there-it was not an exhaustive collection, but many I saw as relevant.

      • Why is it half the profession practice happily successfully with a 5 % extraction rate , and the other half have a 30 -40 % extraction rate.
        One technique is airway friendly, tmj friendly , facial growth encouraging . The other is slightly less so .
        The more pro extraction team seem to be the ones posting the more sarcastic , and condescending posts, and don’t seem open to discussion, and the possibility that they could improve what they are doing.
        Comes accoss as the complete opposite of the scientific method they proport to endorse.

  2. Sorry “as still” should read “as yet”

  3. My philosophy is to screen airway on every patient and collaborate with medical professionals, when indicated, with mindful treatment philosophies that encourage nasal breathing and proper tongue placement and mechanics that move forward and not backwards. It’s nothing new for me but the fact that many docs don’t do it is concerning.

    • I believe that most dentists, including orthodontists, do not understand the relationship between airway dysfunction and malocclusion. This is sad, since the medical/dental literature for over one hundred years has discussed this. This relationship discussion was more prevalent in the medical literature than in the dental literature during the early years. But it appears that this concept has been lost over the succeeding years and now being “discovered”. According to the literature 25-40% of the patients in a typical dental practice have some sort of SDB pattern, and we are talking adults. Since “the child is father to the man” (from the Moody Blues) you could infer that that relationship fits with the child population as well. In the childhood orthodontic population, I believe that the incidence of SBD, myofunctional dysfunction, and poor airways are a greater proportion of that cohort. Unfortunately, most doctors do not screen properly, do not know how to screen, and have a failure to be able to look beyond the teeth. I have seen too many cases where the symptoms were treated (malocclusion) and the cause (compromised airway) was never recognized. I just find it hard that if you have an orthodontic practice and don’t recognize at least one OSA case a month on a child, then you are not providing a real service to your patients, nor being a “doctor” (which means teacher). That is one of the significant reasons that corporate entities are taking big bites into the orthodontic market.

    • Fantastic Amanda

      How do you screen airway? A mirror? A two dimensional ceph? Is there evidence for your method? Do you have a research laboratory to ensure that it is accurate?

      How do you encourage nasal breathing? And you measure this too? Or just assume it’s better after tonsils and adenoids are removed? Some ENT’s see everything as a nail when then hold their diagnostic hammer.

      Tongue posture? Why would that be more important that toe posture? Long and short faces have the same requirements? Tall and short people should wear the same size shoes with the same toe posture? Evidence for tongue posture and anything?

      Mechanics that move forward? Damon? Extractions that move the molars forward, or non extraction that move the molars back (but not by much)? Don’t forget Newton’s Third Law please. Or expand everybody and diagnose nobody.

      This lack of rational thought is the reason a mouth guard can be marketed as a myofunctional device, without any evidence to support the hypothesis.

      Bring on the marketers and snake oil salesmen (or saleswomen)!

      • To address the first. An Epworth screen combined with a STOP-BANG can give you about 60% accuracy, when you add factors like anterior signs of wear, tongue scalloping, tongue coating, Mallampati and pharyngeal grade screening you can increase the accuracy of your impression to 85% plus. Diagnosis? NOT. Test with HST if allowed, refer to MD appropriately. There are separate screens for young children and history is important. Figures above are from the literature. Recognizing your shortcomings and getting the appropriate training is the correct thing to do.
        As to the rest of the snide remarks, no comment!

      • That’s pretty disrespectful bro. Sorry that some of us care to supplement our therapy with sensible habits, which is the most conservative and basic thing we can do. Come on man.

        • I agree it might have been worded differently, but the questions are still relevant to those who would provide it. What is the protocol for screening? Is there one? What criteria are people using to determine when a referral is appropriate other than the obvious i.e. snoring, mouth breathing etc.? Do we really have a role other than screening, and what evidence is there that we do? Some of what is being advocated is indeed sensible and some is not. Which is which? Some of the names I see associated with this definitely do not lend credence.

          • The American Academy of Pediatric Dentistry has a nice summary of their screening recommendations. Added to recent publications about the effectiveness of the Pediatric Sleep Questionnaire (PSQ), my protocol is this:
            1. A few simple questions added to our health history form.
            2. Conversational questions during the exam.
            3. Clinical evaluation that includes dental and skeletal issues along with tonsil situation.
            4. Administration of PSQ should 1, 2 ,or 3 point that way.
            5. Appropriate referral.

      • Dr. Attric- Your condescending and sarcastic reply to Dr. Wilson’s comment is highly disrespectful and inappropriate for this serious discussion. My hope is that Dr. O’Brien will make it impossible for you to post on his blog in the future. Please discontinue this mode of communication. It is not helpful to our profession. Thanks.

    • Fantastic Amanda! Your comment is right on. Thank you for the post. I agree that other practitioners need to take a hard look at this topic and the generally positive outcomes can only benefit our patients. As a multi-factorial disease, OSA is extremely difficult (and expensive due to the PSG requirement) to study. Orthodontists, for now, need to focus on common sense treatment mechanics and deliver treatment that is appropriate for the situation. No matter what caused the narrowness in the palate or the recessive chin or the crowding or the overjet or the crossbite… the orthodontist is uniquely qualified to have a positive effect on the growing face. We are the experts in this realm (orofacial growth) and need to take a leading role in the identification through screening and treatment where appropriate. This not radical or ‘out there” its just common sense.

  4. AFO is like a UFO…unidentified and unidentifiable.

    As is quite evident now, this fabrication was created with the intent of selling CBCT units, under the manufactured fallacy that it is the standard of care (but it doesn’t diagnose OSA, and has reliability issues with airway measurements).

    In addition AFO morphed to include the Carriere appliance in it’s claims of improving airway, all without data of course.

    So, in conclusion, this is a meaningless term (like retractive orthodontics, face-focused orthodontics, forwardodontics etc.) and is being used to perpetuate a scam. There is zero reason to treat these claims as anything but utter nonsense. We move teeth forwards/backwards etc. depending on the situation. Larsen and Rugh have debunked all that quackery with their paper. It’s time to move on.

  5. The discussion so far in regards to this posting has been centred around the concept of identifying patients at high risk of OSA so that they can be referred for fully appropriate diagnosis by a sleep physician. That is from my point of view one significant service we can do to our patients. We are not suppossed to diagnose OSA but we can screen for it. Some may not want to consider screening for a medical problem and that is still OK as we do not have the legal expectation to do so.
    Multidisciplianary management is the next point. We can be of help, when indicated, to manage specific OSA patient’s phenotypes. This is where current research is underway: Who would benefit or not from specific orthodontic approaches? In adults some patients do respond well to almost any mandibular advancement/reposition device, some only to specific designs and some to none.

  6. Given that the UK’s NHS states(https://www.nhs.uk/conditions/orthodontics/):

    1. Orthodontic treatment (usually with braces) is most often used to improve the appearance and alignment of crooked, protruding or crowded teeth, and to correct problems with the bite of the teeth. and;
    Orthodontic treatment is usually only started after most of a child’s adult teeth have started to come through.

    2. This is usually when they’re about 12 years old, but depends on the number of adult teeth and the growth of their face and jaws.

    Prof. O’Brien, might you be curious as to whether or not it might be helpful for UK-trained (and elsewhere) orthodontists to at least screen children for malocclusion traits earlier than age twelve, say at least by age seven years as is the recommendation of the Amer. Assoc. of Orthodontists (https://www.aaoinfo.org/system/files/media/documents/Right_Time_for_Ortho-MLMS-hl.pdf)?

    There are several scientifically-validated physical/craniofacial/malocclusion phenotypes (e.g., high/narrow palatal vault, deciduous/mixed dentition crowding, retrognathia, cross bites, open bites, etc.), and myriad behavioral traits (e.g., snoring, bruxism, habitual mouth-breathing, bedwetting, night terrors, etc.), as well as pertinent birth history circumstances (e.g., pre-term birth, low APGAR scores, maternal-gestational apnea, low birth weight/small for gestational age, first/second hand smoke exposure, etc.) that are often co-morbid with sleep and breathing problems in children as early as the deciduous and early mixed dentition (i.e., before age seven years), and thus possibly indicative of existing sleep-airway disease, or predictive of future increased risk. Pretty much all health professionals who see children, and especially orthodontists who might on occasion see kids before age twelve in the UK, are optimally positioned to identify vulnerable children with utilization scientifically-validated screening tools (e.g., PSQ); as you state, making appropriate referral, but at much earlier ages than is now considered conventional in the UK, would be a great first step.

    • Thank you Kevin Boyd for your most sensible comment.Orthodontists, it seems, are not interested in the airway so it is fortunate that many GDPs are gaining knowledge in this subject.

  7. I totally agree with Dr. Attric. All these protestations are ludicrous. He asks pertinent questions. Supplement therapy with what habits? The data has spoken clearly – Airway friendly is a hoax.

    • The Attric comment was highly disrespectful. It is simply not OK for a forum like this. He likened attention to tongue posture, an obvious thing to be mindful of in the oral cavity, to toe posture in his sarcastic tirade. The other “protestations” are calmly and sensibly delivered and should provide substance to ponder, at the very least, if not integrate in practice to deliver a different level of concern for well being. Every professional naturally has a conundrum when our patients do not speak the same language nor tell the same story as the “evidence”. Just as skepticism to the (existing) evidence makes some of you cringe, ignoring our patients probably makes all of us cringe, no matter what side of this debate we pledge allegiance to.

  8. Thank you for posting this Kevin. Not sure if you are familiar with AirwayDontics. This is another term coined by some quack and basically pushes non-extraction, non-surgical, early orthodontic treatment which they call a Phase 1 Smile. You can see the damage done by this nonsense. Time to end pseudo-scientific babble. What are common sense mechanics? Are extractions allowed in Airway Friendly orthodontics? Is retraction allowed? Retraction is required and will never end (if that is the goal). If not, this is quackery. Simple.

  9. The talk about screening is good but I am a little perplexed since pediatricians see patients from infancy and the American Academy of Pediatrics has Clinical Practice Guidelines on OSA. The cited article is from 2012 and, as far as I can tell, the guidelines are still operative since there is no update. I certainly agree that orthodontists, pediatric, and general dentists can routinely screen but do you really think that many undiagnosed and untreated cases will be found? If so, does this mean that the physician community is performing at a substandard level? Please note: I would like to distinguish undiagnosed from untreated as there may be patients that have been diagnosed but do not pursue treatment.


    • Hello, Barry. Thanks for this valuable reference and rational comment.

    • My experience with local pediatric medical providers is that they are overwhelmed by managed care, runny noses and flu symptoms. Very few of them take the time to become educated about dental signs of OSA. And screening, which takes some time in practice, is rarely done. I’ve tried for years to enlist these first line providers in basic dental/orthodontic screening techniques with little to no avail. My grand hope is that the sleep apnea connection may get their attention. Time will tell. Its important for orthodontists to engage in respectful dialogue so we can have a somewhat unified position on OSA. The AAO’s recent white paper goes a long way towards that end. We still have a lot to learn on the subject. Lets all keep our eyes and ears open and stop with the snide, disrespectful comments. Please and thank you.

      • “Very few of them take the time to become educated about dental signs of OSA. And screening, which takes some time in practice, is rarely done.” Wow I guess this is the poster child for substandard considering the American Academy of Pediatrics guidelines that were accepted and published in 2012. Granted I live in an area with a Children’s and General University Hospital network with residency and fellowship teaching programs in all medical and dental specialties. The neurology department runs a pediatric and adult sleep apnea lab/clinic headed by a Harvard and Johns Hopkins graduate who has an excellent reputation (interestingly she has also written two novels) as a clinician and researcher. To the best of my knowledge, all the pediatric offices in my area screen for OSA. However, as Dr. Wise points out, his practice is tailored to his location, which unfortunately has inadequate medical care.

  10. As one who has had to turn from conventional orthodontics (27 years) to airway-friendly orthodontics (10 years), I think I can add to the conversation. I did not do it for the economic opportunity though there is plenty now. I did not do it because of the evidence, of which there is also plenty now. I did it for the realization that our children are suffering from a problem for which we can help: they are having trouble breathing.

    There are hundreds of reasons a child stops breathing through their nose and begins to compensate by breathing through their mouth, doesn’t use the diaphragm, and increases their breathing rate by two-fold (Kevin, I almost feel silly having to go through this, but it is not registering with many). Mouth breathing, open mouth posture, and overbreathiing have significant health effects which have been documented for over a century.

    The fact that open mouth posture may eventually lead to sleep apnea via swollen tonsils, inflamed tissue, or underdeveloped jaws is almost beside the point. OSA is but a SYMPTOM of poor breathing. Like malocclusion, it is the result of chronic habits. This is why we cannot demonstrate a causal link between OSA and malocclusion. They may be associated (evidence abounds) but they do not cause each other; they come from a common etiology that is, poor breathing, soft tissue dysfunction and the consequent collapse of the facial anatomy.

    To practice airway-friendly dentistry (not just orthodontics) you have to help a child have an airway that they can easily breathe through (from the tip of the nose to the bottom of the throat), and teach them how to breathe through it easily (helping them “unlearn” all their compensatory habits).

    How much of that can an orthodontist do? Certainly not everything. Yes, we can help the airway enlargen by getting the jaws (both jaws) to grow forward in the face and away from the back of the throat. Yes, we can help increase tongue space in the front of the mouth so the tongue doesn’t have to be relegated to the throat. Yes, we can teach kids healthy breathing habits like breathing through the nose (so the air is clean and doesn’t irritate the tonsils), keeping the lips together and the tongue on the palate at rest (so the maxilla can develop fully), and how to swallow without using the facial muscles (so the teeth don’t get pushed around) as a compensatory aid. These are all things that are well within the bounds of dentistry no matter where you practice. And, yes, we can be aware of any techniques we use that may work against the aforementioned goals.

    And yes, we can be aware of breathing issues, whether they happen during the day or during the night, so that no child with a breathing problem goes unidentified. And we must work cooperatively with other healthcare practitioners that can do things we can’t. We need help from people: who can make sure the sutures of the skull are not being hampered from proper growth, who can teach proper function to the tongue are oral musculature, who can evaluate the airway for physical obstruction and remove or repair them, and who do many other things that lend to better facial growth and development, better nutrition, better posture and better sleep.

    If you are neither aware of the real problem nor know how to look for it, you’ll never be able to practice airway-friendly dentistry. If you think palate expansion alone will solve the problem, there is much more for you to learn. If you think OSA is “the problem” – like the AAO does – you are being distracted by a red herring.

    And…btw, this problem is so huge, we will need every one of you to begin paying attention. Learn about Flow Limitation and its devastating effects on neurocognitive development (from studies done in the UK), on behavior, or organ function, and on overall health. Once you begin to look, you will see it in virtually every child with crooked teeth (remember, it’s just an association…) There is so much to learn. I am just a beginner.


  11. Interesting discussion! I also believe that there is no such thing as ‘airway-friendly orthodontics’. The upper and lower airways are typically addressed by two different medical specialists (ENTs and Pulmonologists, respectively). Orthodontics is mostly about dento-alveolar structures, unless there are complex/severe cases where the orthognathic surgeon relies on the orthodontist for ‘decompensation’. Thus, there is a need for a new dental specialty to address the upper airway, especially for those with a craniofacial phenotype that is associated with an increased risk of sleep disordered breathing (Sutherland et al. Sleep Breath, 2019). I will also be presenting some findings at Chest 2019 and the American Thoracic Society 2019 conferences that embrace the recent findings of the AAO position paper; however, the theme of my thought process is that the ‘gradual adaptations that occur with long-term oral appliance use’ may be harnessed to remodel the upper airway for a patient’s benefit (although an orthodontic finish may still be required similar to where the orthognathic surgeon relies on the orthodontist for ‘decompensation’).

    Side comment: Newton’s Third Law law does not apply to a biologic system that has its behavior encoded by genes. Here, we may rely on an epigenetic phenomenon to address craniofacial issues instead (Parsons et al. Mind the gap: genetic manipulation of basicranial growth within synchondroses modulates calvarial and facial shape in mice through epigenetic interactions. PLoS One. 2015)

    • Sir ~just to clarify ,are you stating that forces are irrelevant in this situation and all growth ,in this area is purely genetically driven ??
      Thankyou .

      • Not at all, Dr Thompson – but consider the question, ‘When is a force not a force?’ and the idea ‘when it fails to provide an appropriate physiologic response’. Put simply, teeth move without the application of force(s). (Tooth movement is known as ‘tooth support’ in the literature to differentiate it from orthodontic tooth movement). We have historically described these tooth movements as eruption, ‘passive’ eruption, mesial drift, relapse, etc., which are dependent on dynamic gene expression in response to environmental signaling (an epigenetic phenomenon, which is not restricted to the craniofacial region) that results in phenotypic variation, observable as clinical changes.

    • Dr. Singh- I appreciate your discussion and your ideas about a new specialty. I disagree somewhat with you on the effect that orthodontics, actually dentofacial orthopedics, can have on air way. Several 3D studies have shown the increase in size of the nasal passages post RPE and even root position of upper molars creates a cause and effect in the sinuses. Naturally, just because we enlarged the upper airway, it does not automatically translate to a reduction in OSA. But its a start. Common sense alone tells us that a larger upper airway will decrease resistance as air comes and goes. Studies on these matters are exceptionally difficult to perform due to the multifactorial nature of OSA.
      Orthodontists are the clear experts in craniofacial growth and development, and we have 100+ years filling that role. I feel like we have a lot to say on airway and hope that additional studies can shed even more light. I am a big believer in creating a community network which will include several types of practitioners, not just ENT’s and pulmonologists. We can be on that team with allergists, Pedi MD’s and DDS, Neurologists, on and on.

      • Hi Dr Wise – I agree with you. Actually, we have also published a few studies with our medical colleagues supporting the points that you make, but these studies are not targeting the ‘dentofacial’ tissues. The aim is to target the site and severity of upper airway obstruction. But some argue that it’s not possible to ‘enlarge’ the airway. So, what is the mechanism(s) by which this enlargement is produced and maintained? Our studies point towards airway remodeling, in line with what you’re saying. However, since dental and facial tissues are not the primary therapeutic concern, I suggest that specialty-trained dental/orthodontic professionals provide these services, since the AAO position paper makes it clear that the upper airway is not the chief concern of the orthodontic specialist.

  12. In response ,generally and specifically to Dr Winnick,s comments ,I would have to state (with some outstanding exceptions,the level of expertise and willingness of MD,s to co~operate with Ortho’s ,in my area, leaves a lot to be desired.”Substandard” as an descriptor would not be difficult to defend.This occurs (over my 35 yrs. of efforts )despite my close proximity to a Dental School and a tertiary care ,major adult and paediatric Medical School ,with much speciality training and research ,at a high level ,being carried out.
    My concerns from my area of Canada are as follows ;
    Primary care physicians are overworked ,burnt out and underpaid.Our semi ~socialized system is largely responsible for this.Quite understandably ,this results in a reluctance to scrutinize for breathing issues ,which are perceived as less important and /or obvious.This was my experience in the UK also.
    Pediatricians are often more aware and motivated but ,on a personal level ,I have never had an ortho.referral from a pediatric specialist .Since basic medical care ,in Canada ,is “covered “and orthodontics is not ,most pediatricians do not encourage or feel motivated to refer beyond and outside the “free”system.
    My own experiences with the paediatric ENT docs .regarding my kids ,was less than ideal .I had to bring the attention of them the relevant protocols, by their own professional bodies ,that related to tonsillectomy.Again a reluctance to make appropriate ortho.referrals for similar reasons to the above .
    As far as adult ENT docs .Unfortunately ,there is demonstrated little interest or knowledge in “matters dental “.Our semi ~socialized system does not ,financially and /or otherwise encourage ortho.referrals. There is little referral, as regards OSA appliances as a group of ENT,s own a chain of providers of CPAP machines .In my area ,this is a blatant disregard of conflict of interest issues but never acted upon.It “goes under the radar”
    I do not see any hope for change or improvement relating to all of the above and am too frustrated to attempt any changes myself !!!
    Great discussions ,!!

  13. Dear Andrew

    Aside from the problems intrinsic to lack of non-reimbursement associated with non-covered pt. services, per your mentioning, “have never had an ortho.referral from a pediatric specialist .Since basic medical care ,in Canada….”, would you please speculate on some other potential factors as to why peds. physicians don’/won’t refer to you? And, if so desired, how you might change this non-referral pattern? If interested I’d be happy to share with you why/how my/our experience is quite different with peds Sleep Med doc’s, pediatricians and peds ENT’s from 4 different tertiary care children’s hospitals in the Chicago area.

    I will be presenting several before-progress and after-Tx records, including paired PSQ-behavioral trait data, at several natational meetings this spring, summer and autumn, including the Amer Thoracic Soc., the Canadian and Colorado Socs. of Peds Dent and Am Soc of Dental Sleep Medicine. Please email me off Prof O’B’s forum if interested in further discussion about how we work collaboratively with peds physicians and details about our Tx protocol. I will also send you chapter manuscripts i’ve authored/co-authored from three different textbooks on Peds Sleeo Medicine, Peds Allergy and Michael Friedman’s newly revised textbook, ‘Snoring’.

    Kev-Pediatric Dentist (i.e., not an orthodontist)

    [email protected]

    • Many thanks for your reply and thanks for your kind offer that I will gratefully accept.
      Essentially ,in my view, in my area,there is no financial incentive for MD,s of any stripe ,to go off the reservation and make the extra effort to go the extra mile and push this exciting are forward.
      Few folks have an intellectual curiosity that prompts them to make the extra effort rather than just send in the usual codes for reimbursement .
      Sad but true .Trust me ,I have made the effort ,multiple times .

  14. This has been highly entertaining. I just wanted to weigh in on the discussion. I see a lot of similarities to the ortho/TMD controversies that we experienced in the past. I had an interesting situation. I had a patient, a female teen, no remaining growth, full class II with an acceptable profile. I Started a treatment plan that included removal of the maxillary 1st premolars. Shortly after starting tx, they moved and the new orthodontist told them they never should of had the teeth removed because it would give her OSA. They wanted to open the space and place implants. As far as correcting the class II, they didn’t have a viable plan that would not have retracted the maxillary anterior teeth and resulted in exactly the same result I would have produced. A little common sense is required ( in my humble opinion).

  15. James:

    An excellent response that illustrates the current dilemma that orthodontists are presented with in the face of ‘airway orthodontics’ (no pun intended 🙂 I believe that if a patient presents to an orthodontic office and an orthodontic diagnosis is reached, then, all things being equal, an orthodontic treatment plan can be offered. If, prior to the orthodontic diagnosis, however, screening reveals an increased risk of SDB, then appropriate referral is called for. But here’s the issue; currently it is thought by Sleep specialists that, in the absence of clinical symptoms, such as hypersomnolence, a patient with an AHI < 10 is not in need of treatment. In view of this clinical scenario, I believe that a specialist in 'craniofacial sleep medicine' could address this sub-population as a preventive measure since some studies show that, left untreated, SDB worsens, sometimes to the extent that systemic consequences, such as atrial fibrillation, can't be reversed even with adequate CPAP usage in middle-aged patients with excessive daytime sleepiness. As you know, atrial fibrillation is associated with an increased risk of stroke – so, at least prognostically-speaking, a specialist in 'craniofacial sleep medicine' might not be a bad investment in terms of systemic health and longevity.

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