Does orthodontics cure or cause child breathing problems? A new consensus conference doesn’t think so.
Some orthodontists advocate orthodontic treatment for the management of child breathing problems. They have enthusiastically promoted this idea through conferences and social media. Unfortunately, many of their claims regarding the effects of orthodontic treatment have been quite extreme. Importantly, this group tends to instigate debates through social media and conferences rather than critically evaluating the literature, which raises concerns about their claims’ validity. Additionally, they tend to heavily promote any low-quality studies that yield favourable results.
While we may find reassurance in the fact that this is a small but vocal group, there is also a risk that the airway-focused orthodontist may harm children by overtreating them with methods of treatment that lack evidence-based support..
The AAO has held a consensus conference on child breathing problems and orthodontics. I have posted about this before. I was very interested in this paper, which outlines the findings of a consensus meeting of the American Academy of Dental Sleep Medicine. The Journal of Dental Sleep Medicine published this paper.
Rose Sheats et al. Journal of Dental Sleep Medicine. Special Article 1, Issue 11.2
What did they ask?
They held the conference to
“Review the published literature on several emerging therapies for OSA and snoring in both adults and children with the goal of providing guidance”.
What did they do?
They convened a panel of 12 experts to participate in the task force and enrolled 7 expert observers to provide feedback.
The conference operated under a modified RAND/UCLA method, which comprised a literature review and voting process. In short, participants classified the evidence on each intervention as appropriate, uncertain, or insufficient.
They looked at the following treatments for children OSA and snoring.
- Functional appliances
- Expansion
- Myofunctional orthodontics
- Myofunctional therapy
- Lingual and buccal tissue releases
- The role of extractions leading to OSA in children.
What did they find?
They provided a wealth of information about each of the interventions. I don’t have enough space to cover all the details in this post. However, their most important general finding was that the literature was filled with limitations, like small sample sizes, inadequate or missing control groups, incomplete details, and the lack of long-term follow-up.
They put the evidence on each of the treatments in a nice table. I have extracted the paediatric data and put it in this table.
| OSA | Snoring | |||||
| Prevent | Manage | Cure | Prevent | Manage | Cure | |
| Functional appliance | U | U | U | U | U | U |
| Expansion | NC | NC | IE | NC | U | IE |
| Myofunctional appliance | U | U | NC | U | U | NC |
| Myofunctional therapy | IE | U | IE | IE | U | IE |
| Tissue release | IE | IE | IE | IE | IE | IE |
A = Appropriate- supported for use as a monotherapy
U= Uncertain- evidence is lacking
IE= Insufficient evidence-Evidence inadequate to support use of the therapy.
NC= No Consensus was reached.
They came to this conclusion.
“Based on the available literature, none of the therapies examined by the panel were considered appropriate”.
The panel paid special attention to RME which is being widely promoted as a beneficial treatment. They concluded
“There was insufficient evidence to support RME as a treatment to cure pediatric OSA and stressed that expansion should only be considered in those patients who demonstrate maxillary constriction, independent of having pediatric OSA.
They also found that childhood extractions do not lead to OSA in adults or children.
Their overall conclusion was.
“This paper provides guidance to clinicians on the effectiveness of treatment measures, while also directing researchers towards studies in this area. Long term RCTs are needed”.
What did I think?
This paper is both interesting and important in the field. The method for reaching a consensus was clear and logical. However, we should also take into account that the conclusions may be heavily influenced by the quality of the papers they examined. Nevertheless, I found their literature searches to be adequate.
The paper’s most compelling message was that adenotonsillectomy is the first-line treatment for these conditions in patients who are typically under 7 years old. As a result, we should consider the reviewed therapies to be secondary or “rescue” treatments. When considering orthodontic treatment for these patients, we must always remember this simple fact and avoid providing orthodontic interventions as a first-line treatment.
Furthermore, additional evidence is required to support the implementation of any interventions advocated by the airway-focused orthodontic movement for child breathing problems. This aligns with the conclusion of the AAO conference.
The authors also noted that their findings “do not preclude the use of these therapies and reflect chasms in the literature and a dearth of high-level research”.
When they considered extractions, this is a paper that should put another nail in the coffin of the “extractions cause child breathing problems” movement. I’m not really sure how many more nails we need…
Final comments
I have carefully considered both this text and the AAO report. In my opinion, when we talk to our patients about these second-line orthodontic treatments, we need to make it clear that further research is necessary to support their use. Patients can then decide if they want to consider this option. We mustn’t promote these treatments without this information, as doing so would be clearly unethical.
So airway, focused orthodontists, it is over to you in the discussion.
Emeritus Professor of Orthodontics, University of Manchester, UK.
There are two problems with the framing of this question. Does orthodontics help children breathe better? Does it cure OSA? I agree the answer is no simply because the teeth have nothing to do with the problem.
The better way to frame this quesion is: Does the way a child breathes affect their facial growth? And does the way a child’s face grows affect the way they breathe? The literature goes back a long way in the affirmative.
For me, as an “Airway Orthodontist”, my more fruitful question is: Would helping a child breathe better (ie without strain, through their nose, with their lips closed and their tongue on the palate, using the diaphragm, creating optimal gas exchange to feed their cells the oxygen they need) be helpful to their growth and development? Saying no to that is like denying that breathing is the most important thing we do moment to moment.
So the next question is: What can be done by the orthodontist and/or a team of interdisciplinary professionals to help a child breathe better day and night? The answer to this is admittedly complex and varies from patient to patient depending on the source of their obstruction, the physiologic make up, and the habits they have adopted as compensations for difficulty breathing. The answer is never as simple as “use a palate expander” or. “release a tongue tie”. The answer has to be specific to the patient and it may require several “inputs”, some of which will work and some will not. The challange is to not stop until the patient gets better.
Granted, we’ll be getting a bell curve of results, something that is anathema to most orthodontists. But take it from physicians, educators, and sports coaches: you have to do you best to get the child the best outcome that are possible for them.
Meanwhile, you may use this study to continue ignoring the possible benefits you can be having for your patients. But rather than ignore it completely, just do a simple study of your own: While you’re forming your archwires, ask the patient to close their lips for two minutes and watch their face as they do it. If you see their lips open or their brows furrow in discomfort, you will know there is something more you could be doing to help them get better.
When I see a child with possible breathing problems this is what I do: I check the tonsils and ask parents questions such as does your child snore loud and all the time. Do they have any allergies and so forth. Based on the answers, I refer to pediatric ENT. If there are no orthodontic indications, such as maxillary hypoplasia in sagittal plane, constricted maxilla or multi-teeth crossbite, functional shift, or severe crowding I don’t offer any treatment on younger patients. Often times, these children do better with tonsillectomy, allergy testing, and allergy meds.
The Real Person!
The Real Person!
Thanks, this is the way that I used to practice when I worked with otolaryngology at Manchester Children’s Hospital. Indeed I have posted about the role of watchful waiting and simply letting children grow.
Absolute Truth spoken here. Thank you Barry!
Hi Kevin:
I am not an “airway, focused orthodontist” but I would like to make an initial comment. First, you claim that this paper outlines the findings of a consensus meeting of the American Academy of Sleep Medicine. That is a factual error. I was a speaker at the American Academy of Sleep Medicine conference this year (in Houston, TX) in the “Meet the Professor” session. My talk was titled “Craniofacial Sleep Medicine”. I did not attend the American Academy of Dental Sleep Medicine meeting this year. The Journal of Dental Sleep Medicine is related to the American Academy of Dental Sleep Medicine, which held a separate meeting this year I don’t know, or wish to know, any of the politics, but the AASM and the AADSM are two different entities.
Second, you say the paper’s “most compelling message was that adenotonsillectomy is the first-line treatment for these conditions in patients who are typically under 7 years old”. Although I don’t totally disagree, this is a blanket statement that does not address residual pediatric OSA (a bit like TECSA in some CPAP users or “non-responders” with MADs). In those post-operative pediatric cases, which I believe is up to 50%, palatal expansion is often suggested. My question is: If palatal expansion is ineffective for pediatric OSA, then why is it suddenly appropriate in post-operative cases of residual pediatric OSA? I believe we may be using the word “rescue” with no agreed definition. Take for instance an emergency situation (for example a CPAP device is recalled), the patient may need a “rescue” MAD. Now MADs have been shown to be effective in the treatment of OSA – unlike palatal expansion, according to this study. So the logic seems to be lacking. In fact, to the best of my knowledge, currently no pediatric palatal expander or any other pediatric appliance has received clearance from the FDA for the treatment of pediatric OSA.
Lastly, I totally agree that orthodontic treatment is not appropriate for cases where airway, breathing or sleep is the main concern. Orthodontics is orthodontics, Sleep medicine is sleep medicine. The treatment plan depends on the diagnosis. The dental profession might need a new specialty, either now or in the future. I currently teach Sleep Medicine Fellows – I’d love to be able to do the same for Craniofacial Sleep Medicine someday.
Dr Dave Singh DMD PhD DDSc
Adjunct Professor, Sleep Medicine, Stanford University, USA
Very well said, Dave Singh! Couldn’t agree more.
Thanks, Mike –
“………palatal expansion is often suggested. My question is: If palatal expansion is ineffective for pediatric OSA, then why is it suddenly appropriate in post-operative cases of residual pediatric OSA?”
Per your question:
Given that palatal expansion is ineffective for pediatric OSA, who is suggesting palatal expansion for residual pediatric OSA and where is their evidence? (Seems at first glance to be axiomatic: Ineffective for pediatric OSA:Ineffective for residual pediatric OSA)
Thanks
The Real Person!
The Real Person!
Thanks. I am fairly certain from this and other papers that expansion does not guarantee success in residual paediataric OSA. I wonder if people carry out this treatment in the hope that it is going to work.
The Real Person!
The Real Person!
Thanks, I have changed my post to reflect your first comment. As regards, your second point. This was my interpretation of the paper and you may disagree with their conclusion about the role of tonsillectomy etc. Nevertheless, I think that this is reflected in many sets of guidelines. Or do you feel that orthodontics should be first line treatment?
According to Prof Peter Vig from a recent NetFlix documentary entitled ‘Open Wide’, “…There are no diseases associated with malocclusion, none!
What mght you say to this hypothesis Prof O’Brien?
Thanks
Kevin Boyd
Chicago
The Real Person!
The Real Person!
Thanks. I will reply tomorrow, I’m busy watching England play Spain in the football tonight.
Sorry for your loss
The Real Person!
The Real Person!
Thanks, I’m not to bothered as the best team won. In any case, the real football starts in four weeks time!
The Real Person!
The Real Person!
Thanks, I do not agree with Peter. I worked very closely with him and he is fond of making inflammatory statements. Padhraig published a blog post about the assocation between malocclusion and disease. This was about a paper that I wrote. This does reflect my viewpoint.https://kevinobrienorthoblog.com/orthodontic-treatment-and-dental-health/
Orthodontists play a crucial role in the early detection of obstructive sleep apnea (OSA), identifying craniofacial anomalies and malocclusions that may contribute to or be caused by airway obstruction. However, it is not their role to treat OSA independently. Instead, they serve as essential members of a multidisciplinary team, collaborating closely with sleep specialists for comprehensive care. Just as pediatricians or sports coaches need to spot potential signs of OSA and refer patients to specialists, orthodontists refer patients to sleep specialists for diagnosis and treatment. Similarly, pediatricians and sleep therapists must recognize malocclusions and refer patients to orthodontists for specialized interventions. This collaborative approach ensures patients receive the most effective and holistic care.
Based on available data from the literature and clinical experience with RPE, SARPE, MARPE, (and the rest of the ABC!), we rarely hear patients thanking us for improving or curing their OSA after expanding a narrow maxilla. However, we consistently receive praise and acknowledgements for early detection and referral.
As of 2024, promising that orthodontic expansion alone will solve or significantly improve OSA without a comprehensive approach is unethical and can only be viewed as a practice management procedure.
There are two points that even airway-congnizant orthodontists typically make:
1) OSA is not the entire problem. It is an end-stage symptom of poor breathing that first creates sleep fragmentation and intermittent hypoxia (see the work of David Gozal and others). Sleep fragmentation becomes OSA only when the airway is totally clogged or collapses (for several different reasons). OSA may represent just a small fraction of the airway problems in our population. It is important that we begin to discern breathing problems (day and night versions) well before the problem becomes full-blown desaturation as in OSA.
2) Removing tonsils and adenoids does not always resolve the problem in the long run because the thing that created the excess hyperplasia of tissue is never addressed, and that is poor breathing. Breathing unfiltered air through the mouth overloads tonsilar and adenoid function. Mouth breathing also increases the intensity of allegies. Yes, tonsils are more swollen during youth but that doesn’t mean they should be so big as to plug up the airway. It does become a viscious cycle of hampered breathing and hampered breathing spaces. T&A does clear the spaces but if the breathing behavior remains, then the problem can return (up to 40% of the time).
And guess who does not teach the children to clean and clear their nose, use the diaphragm, slow their rate of breathing and reoptimize the biochemistry of breathing after they’ve had their T&A.? The answer: ENT’s and pediatricians. Who DOES teach these skills? The answer: Orthodontists, myofunctional therapists, craniosacral therapists, physical therapists, and others who have had the courage to take this task to heart.
Look, Kevin and followers. You cannot deny that the rampage of chronic diseases that are affecting our chlldren is growing at an alarming rate. Obesity, metabolic disorders, skin disorders, neurocognitive deficits, life-threatening allergies, digestive and intestinal disorders, and yes, trouble oxygenating the cells, are some of the many challenges children are having in our wonderful modern world. There are a growing number of functional physicians and “wholistic” practitioners who know that this is an existential crisis for a generation who are having trouble becoming independent adults.
Rather than stiff-arming this problem saying “we’re not involved and can’t do anything about it”, please consider that your knowledge, intelligence and skill set CAN have a positive input to solving this problem. Let’s broaden our view from malocclusion and OSA, which are just the tip of the iceberg, to breathing and species resilience and play this bigger game together.
Both of your replies/posts are absolutely superb, Barry Raphael! So well stated. I sincerely hope everyone reads your comments very carefully and I’m very interested to hear Kevin O’Brien’s response.
The Real Person!
The Real Person!
Thanks for the comments. While I appreciate your theories and there is some logic to them. At present, these are simply concepts and hypotheses that require testing. This was also one of the conclusions of the paper that I reviewed. You clearly believe in your treatment. I think that one way forwards is for you tot work with a local dental research institute to start doing some research in this area. If I was still working at the University, I would be seeking funding into the effect of orthodontics on the airway and breathing. This is becoming one of the most important questions in orthodontics. We need to move from theory to research. However, in the absence of research I feel that it is unethical to promote this treatment.
The Real Person!
The Real Person!
I agree totally with you
The fact that this study is inconclusive does not say anything. Have they read the works of Drs Weston Price, Dr. Robert Ricketts, Prof Nelson Opperman? I doubt. The research done in the previous century about this narrowed face pandemic that emerged the past 60 years is all out there.
Question 1:
A ‘distal-step’ deciduous 2nd-molar relationship will always persist beyond age 3 yrs old (as an Angle class II permanent molar relationship), without appropriate intervention by/before eruption of the 1st permanent molars. True or False?
Question 2:
Mandibular skeletal retrognathia, at any age, is a commonly observed malocclusion phenotype often comorbid with Sleep Related Breathing Disturbances(e.g., snoring, OSA, etc.). True or False?
I suggest we have a constructive discussion here (a dialectic rather than a debate).
The Real Person!
The Real Person!
In answer to your questions. 1. I do not know and what is the problem if it does persist. 2. Again, I do not know, do you have any references that support this suggestion.
Dear Kevin
Given your reputation as a tenured faculty/department head and research-informed clinical orthodontist, your answer to my first ‘T or F’ question RE deciduous Class II persistence (“I do not know”), I am both surprised and disappointed. I’d first learned of this phenomenon from Prof. Samir Bishara who had been my Cephalometrics course instructor during my PG fellowship residency in Pediatric Dentistry at the University of Iowa (1986-88); this phenomenon has been confirmed by several other published investigations, most notably Jim McNamara’s team from the University of Michigan (https://media.dent.umich.edu/labs/mcnamara/files/Early%20dentofacial%20features%20of%20Class%20II%20malocclusion-%20A%20longitudinal%20study%20from%20the%20deciduous%20through%20the%20mixed%20dentition.pdf). A few additional references that might be helpful to you are listed below; Also, please have a look at Table 1 Group 3 from this 2009 paper(‘Longitudinal changes in the molar relationship from primary to permanent dentition.’ https://periodicos.uninove.br/saude/article/view/1640).
As to your follow-up question for me (“what is the problem if it does persist?”), all I can say sir is, Wow!
To my 2nd ‘T or F’ question RE Class II mandibular retrognathic mandibles as being a common malocclusion phenotype known to be co-morbidly associated with SRBD/OSA, there are myriad published papers within top-tier journals that give attention to this phenomena.
As each/all of the study cohorts described within the aforementioned references absolutely do not contain a control group (from which a therapeutic treatment intervention for diseased individuals had been deliberately withheld….as that woild be considered an ethical no-no and thus not survive an IRB review), well Kevin, I guess you can rest your case.
Some references RE deciduous class II persistence
1. Frölich FJ. A longitudinal study of untreated Class II type malocclusions. Trans Eur Orthod Soc 1961;37:139-59.
2. Frölich FJ. Changes in untreated Class II type malocclusion. Angle Orthod 1962;32:167-79.
3. Arya BS, Savara BS, Thomas DR. Prediction of first molar occlusion. Am J Orthod 1973;63:610-22.
4. Bishara SE, Hoppens BJ, Jacobsen JR, Kohout FJ. Changes in the molar relationship between the deciduous and permanent dentitions: a longitudinal study. Am J Orthod Dentofacial Orthop 1988;93:19-28.
5. Baccetti T, Franchi L, McNamara JA Jr, Tollaro I. Early dentofacial features of Class II malocclusion: a longitudinal study from the deciduous through the mixed dentition. Am J Orthod Dentofacial Orthop 1997;111:502-9.
PS-and thank you Prof O’Brien for pointing out that Prof Vig had proclaimed an unsupported hypothesis RE no association between malocclusion and diseaseand was ‘fond of making inflammatory statements. Padhraig published a blog post about the association between malocclusion and disease….’
While Orthodontists are scoffing at early expansion, myofuntional therapy, functional appliances in the treatment of POSA, pedodontists are quickly getting upskilled in providing those very therapies right under our own noses! I have seen visible improvements in my patient’s breathing post expansion and myofunctional therapy and that includes my own daughter.
Also those who need extractions later means that their jaws did not grow adequately. They undergo ‘camouflage’ treatment. Wouldn’t be obvious that Dentofacial Orthopaedics at an early age would have been beneficial to them?
The Real Person!
The Real Person!
Thanks can you point me towards any high level research that suports your argument. I will then post about it.
I find it really surprising that many orthodontists are still of the opinion that changes to the structure of the airway, of which the oral components play a significant role, have no impact on the function of the airway. Those of us who who are cognisant of the airway in our orthodontic provision rarely work in silos. Our multidisciplinary approach involves input from colleagues in the fields of ENT, neuroscience, myofunctional therapy, osteopathy, sleep medicine and others, many of whom refer to us because they can see first hand the positive (and negative) impacts on the airway our orthodontic interventions can make.
It’s a shame that you seem to cherry pick the papers that support your narrative and use this “evidence” to push your agenda.
Commiserations if your team did not win last night, the evidence clearly shows that England are the second best team in Europe, however… let’s not go there.
The Real Person!
The Real Person!
Thanks for the comments. Just to clarify a couple of matters. I do not cherry pick papers to write about. I select papers on their level of scientific evidence. As a result, I do not cover many of the papers that are used to promote treatmeent for breathing problems. This is because most of them appear to be retrospective or do not have controls. As a result, they do not take into account the effects of growth. I would be prepared to change my viewpoint if you could point me to one high level study into the effects of orthodontic treatment on SDB? Thanks for the commiserations about the football, the best team won and the evidence also shows that England are far from the second best football team in Europe/
Dear Dr Hukmani
Per your mention, ‘…. While Orthodontists are scoffing at early expansion, myofuntional therapy, functional appliances in the treatment of POSA, pedodontists are quickly getting upskilled in providing those very therapies….’, you, yourself, represent a growing number of RO’s(so-called ‘Real Orthodontists’) who are no longer scoffing at indicated and appropriately-timed/applied dentofacial orthopedic interventions for Dx: maxillary/mandibular skeletal (transverse and/or sagittal) hypoplasia by/before, or shortly after, the age 72 months-old.
I’d also add that many IO’s(so-called ‘Imposter Orthodontists’) such as myself et al, who are Pediatric Dentists or Primary Care GDP’s trained and experienced in, not only risk-assessing, definitely diagnosing and managing treatment of non self-correcting/reliably-persistent
skeletal malocclusion phenotypes (e.g., distal step/class II, MSTD with/without posterior dental crossbite, adenoid facies/high-angle/vertical growth sensitivity) in early childhood, are also no longer scoffers at early intervention and adjunctive OMT.
I’d also like to mention that most clinicians such as yourself, myself and others, are very likely competent (per formal training and/or parental experience) in management of these kids’, and also/especially their parents’, anxiety that is often associated with provision of very early (deciduous/early mixed-dentition) orthodontic-dentofacial orthopedic treatment interventions.
Why is it that these fringe practitioners have the time and energy to indulge in fanciful hyperbole and mythical theory, but are NEVER able to produce any evidence of their ludicrous claims? Their statements beggar belief, and belie a complete and utter lack of understanding of how scientific evidence, cranio-facial growth and genetics work. The studies they rely upon are not even worth the paper they are printed on. At this stage, and based on the plethora of data, it is quite fair to conclude that these therapies are all financially-motivated and have no scientific basis to them. It is time that these pseudo-scientific individuals learn a thing or two about science and evidence and stop putting patients through needless and harmful mistreatment.
You’re obviously entitled to your opinion, but to say it is financially motivated, needless, and harmful mistreatment is fallacious.
To prove my point, watch this video and listen to the parents explain how detecting an airway issue and addressing the malocclusion in their 6yo child changed their lives:
https://youtu.be/wJFP_9NFnv0?si=wkzSyxRg7IgTDLa6
To be honest, it saddens me that you have relegated yourself to just being a tooth straightener. Interestingly, I used to feel the same way. However, I used my knowledge of craniofacial growth and development and biomechanics to challenge the dogmas in our profession and it enabled me to change more lives than I ever could by just straightening teeth. Don’t get me wrong, straightening teeth and creating beautiful smiles is awesome. But it doesn’t compare to changing the quality of life of a suffering kiddo. Based upon your comments, I have to assume that you’ve never changed the life of a suffering younger patient and seen firsthand the effect your knowledge and skills can have on them and their family. However, just because you’re not willing or able to perform evidence-based treatment (see my comment above) to address the malocclusion of younger patients doesn’t mean you have to spew such vitriol at those who are. It’s unprofessional and, truth be told, makes you appear as if you feel threatened and/or intimidated by your colleagues who are able to perform treatments that you are not.
I sincerely hope you watch the video as it may help you understand why those of us who believe we are more than just tooth straighteners are so passionate about this treatment approach/philosophy.
I don’t feel the panel did anything more than confirm what we already know – that there is no single therapy that we know of that can predictably and reliably improve SDB/OSA in all patients. It’s important to note that they didn’t say that these treatments have zero efficacy or should play no role in the management of SDB/OSA. They simply said that the impact is unknown or uncertain – as a MONOTHERAPY. That’s not new, surprising, or controversial information. We’ve known for quite some time that there is no “magic bullet” that will cure SDB/OSA. That’s why they made the following comment/disclaimer:
“The conference participants considered each of these emerging therapies as monotherapies to determine whether they were appropriate to use in the majority of patient cases. The recommendations in this paper are therefore not intended to replace a clinician’s best judgment when determining the appropriate therapy for their individual patient. Emerging therapies may need to be considered in combination with other more proven therapies or when other more proven therapies have failed. Qualified dentists are strongly encouraged to use their clinical expertise, knowledge of the patient’s unique circumstances and the patient’s values and preferences to determine the best course of action and obtain informed consent from the patient, regardless of the therapy provided.”
Even adenotonsillectomy is not effective as a monotherapy, which the panel acknowledges. In fact, in a 2010 Study by Bhattacharjee et al. in the American Journal of Respiratory & Critical Care Medicine that looked at 578 children across 8 sleep centers in the US and Europe and found that only 27% of children who underwent adenotonsillectomy had complete resolution of their OSA.
I would encourage everyone to read and follow the 2017 position statement of the ADA, which states:
• Dentists are encouraged to screen patients for SRBD and refer, as needed, to the appropriate physicians for proper diagnosis.
• In children, screening through history and clinical examination may identify signs and symptoms of deficient growth and development, or other risk factors that may lead to airway issues.
• If risk of SRBD is determined, intervention through medical/dental referral OR evidenced-based treatment may be appropriate to help the SRBD and/or develop an optimal physiologic airway and breathing pattern.
Therefore, the goal of every dentist/orthodontist should be to recognize if/when the patient is a mouth breather and/or snorer, refer to their medical colleagues if/when necessary, and then perform evidence-based treatment to normalize the growth and development of the face if and only if a deficiency exists. It’s really not more complicated than that.
Kevin – my offer still stands to have an open debate with you on this topic. It’s clearly something that you are interested in, so I’m honestly not sure why you refuse to engage in an academic discussion with a colleague for all to see. The profession would benefit from it!
I would pay good money to see such a debate. Kevin would get absolutely hammered.
Is it really fair to expect Kevin to debate folks who like to propose lofty theories without any proof to support it, and with data actually refuting their positions? Who will benefit from a debate where one side refuses to let facts get in the way, or completely rejects evidence they don’t agree with? And on what platform? If you want to have a discussion, the first step is to ante up the evidence. And these folks can NEVER get past that hurdle. A debate can only be had when both sides understand, and play by the rules. Denial ain’t just a river in Egypt, and that’s certainly not up for debate. We, the silent majority, are fed up with these attempts to discredit the science while replacing it with nonsense. In the name of Airway, SDB and other such illusory drivel, these folks are blowing roots out of the bone while homunculating patients and expanding Angle’s classification. And all without a scintilla of evidence. And they ask us to open our minds? Perhaps it’s time to look within and see why these perspectives and practitioners are held in such disregard.
When all you have are unfounded opinions, and in contravention to the existing data, what should we call that if not financially motivated and unethical mistreatment of patients. I have ZERO interest in watching videos or visiting your blog. That is not how science works. You need to put up the data to support your position and you have consistently evaded, deflected and failed to do that. It’s quite clear why that is.
What is saddening to the rest of the specialty is practitioners who are “Airway-Friendly” etc. embark on a series of completely unnecessary, worthless and potential harmful mistreatments, and all while creating new malocclusions. Should the opinions of folks like that even be considered? I think not.
You make tall, fanciful claims, yet you prove none of them, and appear to lack veracity. The only lives that were changed were for those hapless victims that were subjected to this nonsensical treatment and now find themselves worse off than before. Based on your statements, you appear to have delusions of grandeur about your ability to “change lives”. NONE of which is of the slightest probative value whatsoever. All we see is circular and spurious ill-logic with nothing to substantiate it.
Evidence-based treatment is clearly something you do not understand. So maybe it is best to learn about what that means before subjecting additional victims to what can only be called blatant mistreatment. If you perceive derision and vitriol from your colleagues, you are correct. Perhaps you need to look at the consequences of the litany of pseudo-scientific therapy that is being perpetrated against these poor hapless patients. What is unprofessional is quackery, and not the questioning of it.
I’m neither threatened, nor intimidated by folks that have nothing to base their opinions on. However, me and several others are extremely disappointed, and frankly quite incensed at what appears to be attempts to generate profit at the cost of patient benefit, and in the absence of supporting evidence. It is past time you and the others stop with these attempts to push this ludicrous pseudo-scientific drivel.
With all due respect to Dr.’s DeLuke and Raj, you each seem to imply that a ‘debate’ might be an ideal form of discourse for approaching a solution to this (not yet clearly-defined) problem. Why not instead maybe consider starting a civilized conversation(i.e., a ‘dialectic’) here, amongst myriad participants over the years on Prof O’Briens elite forum, about first, clearly identifying ‘The Problem’/‘A Problem’, or a short ‘Subset of Problems’, that if/when a solution can become/seem achievable, we might all start working with, rather than against one another?
I’d suggest for starters that we could consider as a common and worthwhile objective:
That each/all of us agree that we should, within the limits of our training, experience and scope of our qualifications, do our utmost, individually and collaboratively (with allied HCP’s), to assure the most optimal ‘growth and development’ of the inter-connected dento-facial-masticatory and respiratory complexes, for the greatest number of individuals within our reaches, at their earliest feasible age, and with the least amount of patient/parent burden.
Thanks for considering
Debate, conversation, discussion, forum, etc. – I’m honestly open to any/all options that would create more awareness, cohesion, and respect amongst colleagues who are on opposite sides of this issue. Written forums such as this tend to quickly devolve and no progress is ever made. Hence, we end up having the same written conversations and “debates” over and over again without accomplishing anything. It’s counterproductive and results in each side digging in further in a futile attempt to prove that their right and that those with an opposing viewpoint are wrong. The only thing it succeeds at is creating a bigger rift between us which neither benefits our patients nor our profession.
I would love to see a live discussion/forum where 5 or so colleagues on each side of the issue present a couple of cases showing pre-tx, post-tx, and retention records, backing their treatment approach up with data/literature to support their treatment decisions. Other panelists can then question the presenter and a moderator can mediate the discussion. The presenter can also take questions from the audience. We still may not see eye-to-eye afterward, but we will at least have a greater understanding of how and why those with dissenting views and opinions feel the way they do. I think the entire profession would benefit from something like this!
I would be happy to volunteer as a presenter/panelist if someone sets this up. I’m confident that engaging in this type of civil discourse would prove to be far more effective than written one-offs posted on a blog page or FB thread.
Dr. Boyd – Nobody is suggesting working “against” something. It’s very simple – Those who make the claim need to ante up the evidence. That burden has not been met despite repeated requests. We have folks that are clearly out of their depth (both clinically and scientifically) pushing unscientific treatments on patients and with tremendous damage being done. That is something we are very much against.
The time for dialectic dialogue has unfortunately elapsed, since these claims have been made for decades (and by many of the same folks) and yet not a shred of evidence has been produced in support of it. In contrast, the evidence against these claims continues to mount like a mushroom cloud. In conclusion, those that say so, MUST produce the evidence. Barring that, there can be no meeting of the minds/ constructive conversations etc.
When the evidence is lacking, motives justifiably are with viewed with suspicion and a jaundiced eye. Due to this, several of us heuristically reject theories proposed by those who consistently fail to accept the data or play fast and loose with their alternative facts. The ONLY way this will ever change, is for those proponents to meet the burden of proof. If not, these ideas will be met with the skepticism and/or derision they deserve.
These posts and comments sadden me.
Effectively it highlights the near religious beliefs brought to the table by the opposing teams and highlights the narrow mindedness to understanding the complexities of sleep apnoea.
For example, to suggest the first line treatment is adenotonsillectomy is too simplistic. Yes it is- if they are the problem. But it’s a waste of time if the cause is nasal turbinate swelling caused by allergies.
The other issue here is the quest for justifying the therapy must cure the disease to be justified. Not true. If expansion in the right patient can reduce the severity of their disease that is still a win.
I’ve been an ENT for a long time now and I’ve moved from the mindset of “I can fix everything “ to I need a team to help me- dentists, orthodontists, myofunctional therapists, speech pathologists, allergists to name but a few.
The cited paper in this post does not prove anything other than a group of people debated a topic and mostly agreed to be not sure. The problems with consensus is they are a net outcome of far more robust discussions that would be far more interactive to listen to. We don’t know what bias or knowledge these people brought to the table. We don’t know if the consumer was a majority outcome or simply a veto of a few to lead to things being decided to be inconclusive.
As I’ve offered plenty of times, if you ever want to have a discussion on this topic Kevin, I’m happy to do so. An argument is not my wish/ simply a discussion.
Dr David McIntosh ENT Specialist
Dear Dr.’s Raj, McIntosh and DeLuke et al,
Thanks to all three of you gentlemen for each positing at least one plausible hypothesis for catalyzing a constructive discourse (i.e., a dialectic) within this arena.
Proposed Hypotheses(4):
1. Dr. Raj(1):
‘….. The time for dialectic dialogue has unfortunately elapsed……’;
2. Dr. DeLuke(1):
‘…. engaging in this type of civil discourse would prove to be far more effective than written one-offs….’;
3. Dr. McIntosh(2):
‘… the quest for justifying the therapy must cure the disease to be justified (is) Not true;
and,
‘If expansion in the right patient can reduce the severity of their disease that is still a win….’
If I may ask of each of you:
A. Dr. DeLuke and Dr. McIntosh,
Might either of you agree with Dr. Raj’s speculation that engaging other colleagues in constructive discussions is one for which its time has already expired(i.e., implying neither a plausible nor useful exercise)?
B. Dr. Raj and Dr. McIntosh,
Might either of you agree with Dr. DeLuke’s statement which suggests that engaging in civil discourse would indeed prove to be far more effective than written one-offs?
C. Dr. Raj and Dr. DeLuke,
Might either of you agree with Dr. McIntosh’s
hypothesis positing that a ‘quest for justifying a given therapy’ (e.g.,Tx: A/T surgery) ‘must cure the disease’ (e.g., Dx: ATH w/SDB/OSA co-morbidity) in order to be a valid is not true?
Or, might either of you agree with his contention that ‘If (palatal) expansion in the right patient can reduce the severity of their disease(s)(e.g., Dx: MSTD w/ATH and/or SDB/OSA co-morbidities) it is still a win….’?
And to each of you, and Dr. O’Brien an other participants here,
Per my own suggestion that proposes that,’
each/all of us should agree to, within stated limits, do our utmost, whilst collaborating p.r.n. w/other HCP’s, to assure the most optimal ‘growth and development’ of the inter-connected dento-facial-masticatory and respiratory complexes, for the greatest number of individuals, at their earliest feasible age, and with the least amount of patient/parent burden?
NB-the above scenario represents a sincere attempt, albeit a crude one, to engage all readers here in a common quest to first identify, and then try to find solutions for, patients afflicted w/systemic/general health problems that may, or may not be, comorbidly-associated (i.e., not necessarily causatively-associated)w/suboptimal development of the intimately connected dentofacial-masticatory and respiratory biological complexes.
Dr. Boyd – My responses are below
There’s no reason to continue the conversation via civil discourse without data being produced to support the positions. Talking is not proof. Until the evidence is put up, it’s unfair to expect the rest of us to waste our time anymore. The person proposing discourse is likely trying to increase views of the podcast they may be involved with.
I also do not agree with Dr. McIntosh. The intervention absolutely must work predictably, and on a large %age of those subjected to it. Otherwise how do we know if it even works? The severity of the disease may be reduced by a litany of factors that have nothing to do with palatal expansion. If it works, it should work across the board. So I could not disagree more. What is being proposed sounds like a solution looking for a problem, or a priori conclusions looking for supporting data. That’s not how science works.
Your suggestion, while well-meaning, is very nebulous and rather obscure. It’s also missing the most important words – Scientific Evidence. So I will have to stick to the evidence, and not follow your suggestions since the majority of it appears unsubstantiated. It is time to ante up the data. NOTHING else will suffice.
I am very surprised by your stance. We accept adenotonsillectomy as a treatment, it does not have a universal outcome- 20% have residual disease and 20% of those that respond later relapse. Is that to say it has no place because its results and not on what would be considered a large %?
As for evidence, we have the data – pubmed is a treasure trove. We also have gaps in knowledge and we have major gaps in clinical observation- we know a narrow transverse dimension of the maxilla is a risk factor for adults in developing upper airway obstruction. We also know a retired mandible to be the same. And these outcomes are founded in childhood development. There is speculation I guess to say that fixing this in childhood sets the person up for life on a better foundation than leaving their skeletal insufficiencies as they are, but with informed consent and explanation that we are trying to avoid a problem developing decades away, many people seem to be keen to consider such mitigation.
Dar Dr. Raj
Perfect, while you hadn’t proposed it as such, your stated speculation (hypothesis), ‘There’s no reason to continue the conversation via civil discourse without data being produced to support the positions.’, is precisely what’s being called for…thanks!
And, I will be most interested in what Dr. McIntosh, and/or others, might think about the reasons for your civil disagreement with his refuting a hypothesis positing that ‘… therapy must cure the disease to be justified.’.
I happen to agree with Dr. M’s contention that performing, say for example, Tx:A/T surgery per Dx:ATH, is indeed a validated surgical indication (for ATH) even though it might not mitigate other associated co-morbidies, such as SDB/OSA, hypertension and/or hypoplastic malocclusion phenotypes, etc.
The Real Person!
The Real Person!
I’ve followed these comments closely and they are interesting. I think that it is relevant that the proponents of orthodontic treatment want a debate or discussion. This is what I drew attention to in the first paragraph of my post. It appears that they would rather debate than come up with evidence that supports their treatment or philosophy. As a result, my comments remain the same. I wonder if the proponents of orthodontics to treat SDB would like to let us have the reference for one high-level study (just one!) that shows orthodontics has a role in managing this disorder. If this is not possible then perhaps they could work with others to carry out trials into their treatment.
Importantly, I do not want to hear them state that this is not possible because of the complexity of the disorder and its treatment. This argument against trials is complete nonsense.
I have to agree with Dr. O’Brien. The proponents of this unfounded therapy appear to prefer the comfort of nebulous theories as opposed to the (harsh?) reality of science. A debate can only be had when both sides are willing to ante up. Otherwise it just becomes a circular back and forth, with no conclusion. This perfectly suits those who embark on such fringe interventions, as it allows them to continue with their unsubstantiated therapy.
I suspect that there is also reluctance to design or carry out such studies, since the findings would likely not be favorable to those who have already concluded that something works. Obesity is a major risk factor for OSA, and with excellent data to support the connection. Yet you don’t hear much about diet counseling etc from these Airway folks.
It is long past time for those who make these claims to realize that they are dealing with members of the specialty who will demand evidence, and will not be swayed by red herrings or long-winded erroneous logic. The more they continue in the same vein, the more tenuous their position becomes. It is time to put up the evidence or accept that there is none to support what they do.
The onus is entirely on those that make the claims to support the same. And the better the evidence, the more that onus is complied with.
So where else but pubmed to guide us?
In this paper they are treating adults. They are expanding the paste. Now as I said this palate formed in the developing years. Down the track these people have sleep apnoea and it is better for the expansion done. This treatment reduces the risk of complications of OSA. This is not insignificant.
https://pubmed.ncbi.nlm.nih.gov/35102477/
Meta analysis in kids
Overall the evidence of benefit they found was there but not enough yet to allow carte blanche therapy for all but it likewise should not be dismissed.
https://pubmed.ncbi.nlm.nih.gov/36525781/
And really this is the issue
Many people are seeing patients get better in front of their eyes, and they continue to proceed to offer the same. Those that have not seen it remain skeptical but rightly ask for more research to shift their point of view. To deny there are papers showing benefit is naive but to say the benefits are conclusive is also naive. What is indeed needed is the collaboration that should come from the academics and the clinicians to resolve this. To suggest the time has passed to do so is nonsense – we all need to keep pressing forwards, together, and remember we can’t let our education get in the way of our learning.
As to a universal outcome for a treatment- this is folly- there is no universal and predictable assurance the outcome will be delivered with any healthcare intervention and this is no different.
Why are you still commenting in this thread? You remind me of mainstream media. You are obviously some sort of paid shill. Your pseudo-intellectual rhetoric isn’t fooling anyone. Why would anybody be against helping children? You’ve insisted on Data… and more data. (Get yourself a CBCT scanner and start treating from age 6 and watch the magic happen.) Airway-centric intervention means that the dentist’s focus is not on the teeth, but on the craniofacial respiratory complex, CFRC. It’s an anatomical region that dentistry shares with ear-nose-throat doctors, oral surgeons, speech language pathologists and myofunctional therapists. And guess what? All of these professionals who care about the wellbeing and healthy development of children are onboard.
Who is the paid shill? The one that recommends CBCT in 3 to 6 year olds with ZERO basis to support it’s use, OR the one against unnecessary radiation to children.
Whose rhetoric is pseudo-intellectual? The ones asking for evidence, or the ones arguing against the need to provide it?
Why the rage and anger at being asked to prove your point? The interventions you are recommending come with significant cost, potential harm to patients and with zero proven benefit.
Somebody is being helped here, but it’s certainly not the patient. Or should we say victim?
What does “caring” have to do with anything? Unless of course, you are alluding to yourself and the proponents of said pseudo-science not caring that the facts don’t support your theories.
Dear Prof. O’Brien
To your mentioning ‘…..appears that they would rather debate than come up with evidence that supports their treatment or philosophy. As a result, my comments remain the same. …’, you’d failed to mention the other option, a dialectic, for how this discussion might most constructively proceed; and, ‘….I wonder if the proponents of ‘orthodontics to treat SDB’, as you obviously understand sir, orthodontics/dentofacial orthopedic interventions are indicated for treating only malocclusion. If you’d please take a look at the second linked (meta-analysis) paper (https://pubmed.ncbi.nlm.nih.gov/36525781/) that Dr. McIntosh had recommended, the authors had clearly discussed within their conclusive comments this very concept (‘…this treatment cannot be suggested as elective for OSA treatment. An orthodontic indication is needed to support this therapy…). And, to Dr van Rensburg’s rather colorful/poignant comments and recommendation to ‘….start treating from age 6….’, I’d say it would be best practice to not wait that long to at least perform validated risk assessment, if not Tx or refer for Tx of suspected persistent(non self-correcting) skeletal malocclusion phenotypes with/without possibly-associated systemic disease co-morbidities.
Further to the discussion and resistance to change, this narrative review has only just come out
It highlights what I’ve been saying
1. Skeletal deficiencies are a contributing factor in many cases of paediatric osa
2. Correcting the same delivers benefits
3. Correcting them in children can mitigate against upper airway obstruction in adults
This is real world experience and those that are not open to it, that’s ok, you are not obliged to participate, but likewise you are swimming against the tide by disparaging it
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11257894/
The Real Person!
The Real Person!
Thanks for this reference. This is a great example of the point in my post about quoting poor-quality literature. This is a poor-quality narrative review that does not give us any concrete, evidence-based information at a level higher than a glorified case report. I hope most orthodontists trained to interpret the literature do not fall for this information. Surely, you can do better than this?
Dear Prof. O’Brien
First of all, thank you sir for keeping this ongoing conversation (constructive dialectic) going. As a peer-reviewer for a few top-tier (British and US) scientific journals, I think your mentioning that the review paper Dr McIntosh had referenced was, ’…. a poor-quality narrative review….’, seemed a bit misrepresentative of your own(emeritus), and the co-authors’ qualifications as credible and clinically-experienced scientific thinkers.
As you are likely aware sir, I happen to know firsthand that there are several within your growing(?) readership over the years since I’d first participated, that seem interested in constructive discourse regarding some of the oral health-related controversial topics you’ve frequently posted about here. But, with all due respect, I think you might be nearing a point of departure with some of them, and possibly now beyond which you will likely be able to attract more of them….which I feel saddened about.
Goodbye, and Slainte!
Respectfully,
Kevin (Kev) L. Boyd, DDS, MSc(Human Nutrition)
Pediatric Dentist
Depts Dentistry, Sleep Medicine(consultant)
Lurie Children’s Hospital
Chicago
Well said,Kevin Boyd. IMHO well documented anecdotal evidence is stacking up and discouraging early treatment because of so called “lack of scientific evidence” is not in patients’ best interest. “Do no harm” but watchful waiting, in some instances, could be tantamount to negligence. Societies like the US Airway Circle and UK Society for Dentofacial and Function are responsibly exploring this approach to child health.