British Orthodontic Society comments on claims being made about orthodontic treatment.
The British Orthodontic Society has issued a statement that addresses some of the extreme claims surrounding orthodontics. I am sharing this information to ensure practitioners and patients are informed about this important advice.
The BOS statement
In light of the completion of a recent GDC fitness to practice case, we would like to clarify our position on the issue of claims that may be made about orthodontics.
As a professional society and charity, the British Orthodontic Society promotes the highest quality of patient care through the advancement of scientific research and education. The British Orthodontics Society’s first duty of care is to patients.
The British Orthodontic Society advocates that you proceed with caution and seek alternative advice if you are told that a recommended orthodontic treatment or approach will do any of the following:
- Cause your child’s cheekbones to rise or their jaws to change significantly in position – such changes may occur naturally as part of a child’s development but the BOS is not aware of this being achieved as part of orthodontic treatment
- Cure or cause jaw joint problems – there is no evidence for this
- Improve speech – there is no evidence for this
- Improve breathing disorders – there is no evidence for this
- Improve your child’s intelligence –there is no evidence those patients with crooked teeth or sleep apnoea are less intelligent than others
There is no scientific evidence to suggest patients can change the shape of their face or improve their intelligence by chewing or holding teeth and the tongue in a closed position or indeed making any kind of facial movements.
The British Orthodontics Society funds research into orthodontics and is always willing to consider alternative views provided these are backed by scientific evidence. The Society welcomes independent thinkers and innovation in orthodontics but all views must be supported by clinical evidence of the highest quality.
If ever in doubt, patients should seek a second opinion.
What do I think?
I will not comment on the GDC case or the panel’s decision. However, I would like to emphasize that the BOS comments are pertinent to various extreme claims regarding orthodontic treatment. It is encouraging to see that a specialist society has taken the initiative to make such a clear statement.
Emeritus Professor of Orthodontics, University of Manchester, UK.
The Real Person!
The Real Person!
Wonderful post
Thank you
Colin Richman. 404/784-7272, [email protected]
there is risk that the BOS statement could cause undue schepticism regarding advice given by reputable and well qualified orthodontists. I don’t think that there is any question that rapid maxillary expansion provides nasal airway expansion. Damon also presented, possibly controversial, evidence of nasal airway enhancement attained by use of his appliances. Nocturnal wear of mandibular advancement appliances is an effective and under-utilised treatment for obstructive sleep apnoea.
Getting the message right is a difficult balancing act. A second opinion is a good idea for all aspects of healthcare, though in our field there is a considerable risk of conflicting opinions causing confusion.
The Real Person!
The Real Person!
Dr. Howels,
I must respectfully disagree on most points made, though not all.
“Nasal airway expansion” might be rationally expected from palatal expansion. This is true of at least of the nasal cavity, the non collapsible hard tissue supported portion of this. However, the phrase “Nasal airway expansion” or “Nasal airway increase” is frequently used to imply that irrelevant changes are relevant.
To start, there is no research justification for what the nasal airway volume should be. Likewise, there is also no research support for what constitutes a meaningful increase in nasal airway volume. There are no volumes or changes in volume justified in the research.
More importantly, these non-defined volumes, even if changed, may have no effect on what is important for the patient.
What is important to the patient is the presence or absence of obstructive sleep apnea (OSA).
All too often a change in “Airway” volume is implied to have a positive or negative effect on the patient, while what really matters is the presence, absence, or improvement in OSA. The airway can be related to OSA, though not always. It is not the airway that is ultimately important. Rather what is important is whether or not a treatment improves a patients OSA, their apnea hypopnea index (AHI).
With regard to children, valid well done research has established that “watchful waiting” has the same effect as palatal expansion on the treatment of OSA.
So in pediatric patients, palatal expansion might, as claimed increase “nasal airway expansion”. However, this is irrelevant as it does not improve what is important to the patient, their OSA, as evidenced by their AHI scores utilizing valid research and “watchful waiting”.
With regard to Damen’s claim to “nasal airway enhancement” the word “enhancement” is an even more nebulous ill defined term. What constitutes “enhancement”? We know there is no meaningful improvement in pediatric patients OSA from true orthopedic palatal expansion. This seems even more unlikely with the dental, non orthopedic, “expansion” or facial dental tipping that Damen achieves. That the Damen system does not achieve orthopedic palatal expansion is not “controversial”. More, despite decades of existence, much marketing, and hundreds of millions of dollars worth of brackets sold, there is zero evidence that the Damen system achieves orthopedic palatal expansion. Evidence now, decades later, seems to point more towards posterior roots having been tipped and translated outside of the supporting bony base.
Lastly, there is a point we do agree upon, mandibular advancement devices (MAD) does have some research evidence that it can reduce AHI scores for some adult patients with mild to moderate OSA.
However, there is no evidence to support that this is effective for pediatric patients nor that we should avoid the most effective treatment for OSA in pediatric patients. Referral to a medical sleep specialist to evaluate for OSA and the appropriateness of the removal of tonsils and adenoids.
Moreover, in adult patients, while sometimes effective, there are the inevitability negative dental consequences of flaring of the mandibular incisors and frequent development of openbites. We need not remind orthodontists that pressure, even night time only pressure, on teeth eventually moves them. A MAD appliance worn decades only at night is the equivalent of class II elastics worn “only at night”. Considering damage this ultimately causes to the dentition takes little imagination.
I will also agree on the value or 2nd opinions. Nature and our creator gave us a sense to determine when we are and are not in danger. Second opinions give patients a greater chance of being able to sense when they are being told pseudoscientific rationalizations about things such as orthotropics and Damen airway enhancements, and when they are being told about research supported treatments.
Thank you, well stated.
The Real Person!
The Real Person!
Whilst maxillary expansion may provide a small degree of short term increase in volume of the nasal cavity the evidence does not support the claims of improvement in sleep/breathing problems. These conditions are caused by soft tissue problems ( such as tonsils and adenoids). The whole business built around this is a scam and any ethical practitioner should refuse to be involved in it.
The Real Person!
The Real Person!
I agree, Kevin, but it’s worth noting that orthodontic diagnosis/treatment and diagnosis/treatment of pediatric OSA are two different things. Altho there may be an overlap in treatment methods used (e.g. palatal expansion), the outcome measures are disparate.
The sub-statement “there is no evidence that patients with sleep apnea are less intelligent” remains debatable. It depends on your definition of intelligence. If we agree on, say, “Intelligence is the capacity to learn, understand, use knowledge, solve problems, make decisions, adapt to new situations, think abstractly, and manipulate the environment” then I think the BOS sub-statement on pediatric OSA might be an oversimplification since it’s not the role of orthodontists to make neurophysiologic assessments.
Kaemingk KL et al. Learning in children and sleep disordered breathing: findings of the Tucson children’s assessment of sleep apnea (tuCASA) prospective cohort study. J Int Neuropsychol Soc. 2003;9(7):1016-26.