Breathe, breathe in the air. Don’t be afraid to care. A conciliatory post on paediatric OSA.
This is a follow-up post to my earlier comments on the lectures on paediatric OSA at the recent AAO meeting. I have decided to revisit this subject as I just listened to Farooq Ahmed’s recent podcast with Audrey Yoon while I was on a relaxing holiday on the Norfolk coast in the UK.
The podcast
This was a wide-ranging discussion about her treatment of paediatric OSA. In this discussion, she let Farooq know that she thought that I was disagreeable in my criticism of her lecture. I want to apologise to her for my tone. While I thought that I was being robust, I clearly upset her. This was not my intention.
I was also very reassured by some of the points she made in the podcast with Farooq. I have summarised them and hope I have got them correct. However, some still concerned me.
Concerns
I want to deal with the concerning ones first. When Farooq asked her about the absence of trials in this area, she felt that this was because treating OSA in children with orthodontics was not like taking a pill that can be tested in a trial. This is a common misconception about orthodontic trials. There are very few interventions that cannot be tested in a trial. This is because if we enrol sufficient participants, we can measure the effects of different phenotypes on treatment outcomes.
Farooq also challenged her claims that orthodontics can stimulate mandibular growth and help reduce OSA in children with mandibular deficiency and OSA. However, current class II research reveals that orthodontic treatment cannot change or stimulate the growth of the mandible.
Important points
In other areas, her views appear to have changed from the lecture that she gave. These were
- There appears to be a trial being planned in the future.
- Orthodontics is not the front-line treatment for OSA.
- If a child has no transverse or AP discrepancy, orthodontics has no role in treating OSA.
- She agrees with the contents of the AAO White paper.
- The evidence underpinning orthodontic treatment for paediatric OSA is weak.
This last point is the most important and was also a conclusion in the AAO White paper.
What did I think?
We do not know if orthodontic treatment has a role in treating childhood breathing disorders. This is because there is a lack of evidence to support this treatment. I think Audrey agrees with this because of her comments about the need for further research, and she indeed showed more caution for treatment in the podcast than in her AAO lecture. I am certainly in equipoise about this treatment. Importantly, if clinicians are in equipoise about a treatment, it is ethical for them to propose and carry out a trial.
This is not difficult to plan. Importantly, this subject should attract the attention of funding bodies as it looks at an important clinical condition and potential treatment. We can factor in the treatment results from the current low-quality studies to calculate the sample size and plan the study.
The wheel keeps turning.
In many ways, this is similar to our speciality’s position in the late 1980s, where early treatment for Class II malocclusion was being promoted. The profession also recognised that there was uncertainty about the effectiveness of this treatment. As a result, they persuaded the funding bodies to fund the early treatment of Class II malocclusion studies. We are at this point with orthodontic treatment for childhood breathing disorders. Importantly, if we do not do these studies now, we are in danger of following the wrong treatment protocols. Furthermore, we may enable some of our less scrupulous colleagues to exploit this uncertainty to promote unnecessary and harmful treatment of vulnerable families. This is also why we need to be cautious in our presentations.
This subject is important and I will happily be an advisor for the trial design. Still, the investigators must build links with a University and/or Clinical Trials Unit. This would be an excellent project for a young post PhD faculty member who wants to make a real difference in orthodontic care for our patients.
If anyone wants to get in touch to get any advice, email me at [email protected].
Emeritus Professor of Orthodontics, University of Manchester, UK.
Kevin,
I’ve been practicing ortho in the same small community for 40 years. From the end of Begg through the straight wire and functional appliances and TMJ eras, and into the self ligation falsehoods.
When ever I see a post from you, I stop what I’m doing and read it.
Thank you for being the voice of reason and promoting the “truth” through many of these years!
When, from the standpoint of the “bottom line,” everything works and nobody dies, a call for evidence is seen merely as an impediment to the orderly flow of commerce. Stories about decades of clinical success? Post hoc ergo propter hoc.
I agree with you, Kevin. OSA treatment is a special area of consideration since it represents an intersection of disciplines (a bit like a cleft lip/palate team). On the one side there are those with no craniofacial training and on the other those with no formal sleep training. I was surprised when the late Dr Guilleminault of Stanford University presented at the World Sleep Society (2015) because it was clear to some orthodontists in the audience that his craniofacial knowledge was somewhat deficient. (Most orthodontists know that teeth are not attached to the jaws via synchondroses; there is no intermaxillary synchondrosis, and there are no dentoalveolar ‘growth centers’, etc.) Similarly, the (medical) audience was shocked by the outcomes presented by an orthodontist, as the preliminary successful outcomes (based on palatal expansion) were not anticipated. The bottom line is that formal/specialist research training/education is required for those that aspire to lead in the development of novel OSA treatments. As you have already said, KOL and populist opinions are interesting, but do little to progress our collective knowledge and skill in clinical practice in this complex area of collaboration.
I takes a big man to apologize for anything. I congratulate you on your response ,and look forward to the ongoing debate on airway intervention