Orthodontics and Breathing at the AAO congress: A bit of controversy?
A bit of controversy!
The role of orthodontics in treating childhood breathing problems is controversial. I thought there would be some clarity when the AAO produced a white paper on this critical subject. Importantly, this paper concluded that there was no evidence supporting a link between orthodontics and causing or curing breathing disorders. Unfortunately, I was naïve, and the claims made by the proponents of “airway-friendly” orthodontists are not going away. This was evident when the AAO invited several “airway speakers” at the recent Chicago meeting. After this meeting, there was a lot of heated and unfriendly discussion on social media. As a result, I thought that I would look at what all the fuss was about. I apologise in advance if you think that I have been too critical, but I am a little cross. A much more polite editorial has been published by Neal Kravitz in a future edition of the JCO.
The discussions were based on two lectures. Audrey Yoon and Rebecca Bockow gave these. Both these specialist orthodontists promote the role of orthodontics in treating breathing disorders. They also published a paper that I was very critical about recently.
This is my interpretation of their presentations at the AAO on a session based on “airway management”. I managed to get a recording of the presentations.
Dr. Audrey Yoon: Maxillary Palatal Expansion for Airway: Myth vs Fact
In the introductory section of the lecture, Dr Yoon discussed the emerging field of sleep medicine and sleep orthodontics. Notably, she pointed out that most of the evidence behind this concept is based on clinical experience. Despite this low level of evidence, Dr Yoon was positive, feeling that expansion is effective in treating paediatric breathing disorders.
The next section of her presentation was devoted to expansion in preschool children. This is a treatment that she routinely carries out. Again, the evidence was based on clinical experience and retrospective studies. She explained that orthodontists could expand the nasomaxillary complex, leading to a change in tongue posture. Importantly, airway expansion makes the airway muscles more relaxed and stable.
She then considered the effect on lymphoid tissue and spent some time on her recent paper that suggested that expansion reduced the size of the tonsils and adenoids. I have posted about this poor piece of research before.
In the closing stages of the lecture, Dr Yoon suggested that orthodontic treatment should be directed at growth modification for Class II patients by bringing the mandible forwards. This was a mystery to me because it is clear from a large body of research that we cannot grow mandibles.
She also presented a case of a three-year-old who she had expanded and modified their growth. This area of the lecture resulted in most of the social media discussion.
Finally, she outlined a set of clinical guidelines that she had produced. The Sleep Journal published this paper. These suggest that there should be a targeted treatment for each growth stage and dentofacial morphology. This leant heavily on the use of growth modification. Which we know is limited.
In her summing up, she finally suggested that more trials are needed, but this did not suppress her enthusiasm for her treatment protocols.
Dr Rebecca Bockow: The Way We Breathe Influences Facial Growth and Development.
Dr Bockow opened by discussing the aetiology of malocclusion. She felt that the tongue’s position and breathing malfunction led to many common malocclusions. Ideally, we must encourage our patients to keep their lips together and tongues towards the roof of their mouths. Furthermore, our children’s food influences facial growth, and breastfeeding is crucial for normal facial development. Unfortunately, she did not support any of these claims with solid evidence. I also thought it was interesting that these concepts are the basis for orthotropics promoted by the discredited UK orthodontic fringe.
Her next concept was that mouth breathing leads to inflammation resulting in tonsillar enlargement and airway resistance. This then influences facial growth. She also discussed the “monkeys with blocked noses experiments” to justify her approach. Unfortunately, this is old “Classic” literature that does not reflect contemporary analysis.
Throughout her presentation, she quoted cross-sectional and retrospective investigations with no discussion of the quality of the studies. She then finished with a series of case reports.
What did I think?
I listened to these lectures carefully. Unfortunately, I could not help feeling that they were identical to the lectures done many years ago on other areas, such as non-extraction, TMD, Propel, Acceledent and Self Ligation. This was because they were characterised by non-critical quoting of carefully selected low-quality papers to make a point. In fact, nevertheless, it was clear that both speakers believed in their philosophy and were passionate about their treatment.
I needed to be convinced about the value of their case reports. Furthermore, I struggle to consider that we could treat 3-year-olds with expansion, mainly as there is no evidence to suggest this treatment could be remotely effective. I cannot think of a single reason that would persuade me to treat a three-year-old.
Furthermore, I was disappointed that neither speaker mentioned the AAO White paper. It is fine to discuss breathing and orthodontics, but there is no point in completely ignoring a significant piece of work that does not support your theories. I was also very unclear why the AAO published their work on this subject and then invited speakers who disagreed with their findings with no counterpoint from those who contributed to the white paper. It appeared that the AAO congress committee did not consider the AAO viewpoint. In other words, the right hand doesn’t know what the left hand is doing.
Final comments
However, in fairness to their presentations, we must consider whether they have a point. At present, they do not. Their protocols are not evidence-based. I note that Dr Yoon works with the sleep centre at Stanford Sleep Medicine Centre. She, therefore, has access to considerable resources to support clinical trials. It would be great if she led a randomised trial into this treatment. It is not difficult to do, it is ethical, and it would surely attract funding because it is an important question.
Finally, those who promote a treatment must search for solid evidence to support their recommendations. At present, this evidence is lacking. Until then, major conferences should not include orthodontic fringe speakers in the programme.
Emeritus Professor of Orthodontics, University of Manchester, UK.
Is it possible to have a .pdf version of these posts. I find it useful to archive them, and a .pdf would be handy. Forgive the question if I somehow missed a link to a .pdf
Yes, I have donated…;)
Thanks for the comment and the donation! I have never thought about generating pdfs of my posts. In fact, I do not know how to do this, but I will give it a go! Best wishes: Kevin
You can just print in pdf form. Or, if you have a iPhone, take pictures and then printing in pdf form.
Thanks, I have suggestd this and lets see if this works.
I have found out how to do this. If you look to the right of the blog post (on a computer) you will see a share box. Click on that and it takes you a page full of icons, one of these is print. Then just use the save as pdf option.
I believe that evidence to support claims of efficacy are important and I admire your work yet all of us practice day to day using techniques many of which could not stand up to this level of scrutiny. I do, however, support your efforts. I do not employ dental sleep medicine in my practice, but I practice in a community where there are those who do. Some of it is based on little or nothing but the charisma of the practitioner (“he is so professional” one patient said when looking for a second opinion from me). There are several general dentists in my community who advocate the exact techniques and practices you saw in this presentation and expect expansion on any five-year-old with breathing issues. Try to convince them that the evidence is lacking to support this in such a sweeping manor, and you better have your own ride home.
The University of Michigan advertises a “mini residency program” as we speak (for $10,000.00) on this very subject likely with no more substantiation for the teachings than we are seeing in your post.
I hope that in time there is more work yay or nay on this but as long as it provides such an income stream, I not hopeful.
Art
Thanks for this fair overview, Kevin – it’s good to know that there are folks like you, Dr Kravitz, etc. that can assess some of these claims objectively –
That those speaking for these improper treatments talk with such enthusiasm, and likely believe what they are saying, is no great shock.
Any street huckster knows that the best way to convince others of something which is not so is to believe that thing themselves. The best way to convince themselves of this untruth is to repeat it over and over, as they do online, in print, and in lectures. Of course, having a financial incentive only adds to their motivation to believe.
Lastly, while up on the podium pushing and repeating this mistruth over and over for profit, they have yet a third reason to be enthusiastic. If they can convince us that something is so, then they have even more justification for believing the mistruth themselves. They convinced us of it, so their points must be sound and that is more justification for them to believe. It is a vicious cycle.
If this was a victimless crime, all of this would be merely interesting observations in the psychology of con artists. However, these are 3-year-old children they are treating, and sometimes taking CBCT radiographs on, for no good reason. IMO, doing this without just cause and a scientific basis is harmful. Worse, they are up there on a podium trying to convince us to harm children too.
So now we are at it, for those in the AAO and our national organizations, please realize that allowing these orthodontists to speak is not “hearing both sides of an issue”. It is facilitating harm to children. Is this what we want to do? Isn’t that the exact opposite of why we went into the health professions?
Charlatans will always be with us and they will always be trying to find the cracks in the professional walls which we erect to protect our patients. We cannot eliminate them entirely. What seems inexcusable, is when we let them through those walls, by allowing them to speak at our meetings and, dare I say it, publish poor-quality research without adequate review.
Many dentists have already fallen prey to these false beliefs. Dentists perhaps do not have the training to know better and need us to lead them out of this dark valley, not contribute to the problem. We as a specialty are better than this. As they will always be there, we have to keep these charlatans relegated to the fringe orthodontic groups and certainly not in the mainstream scientific respectable ones, certainly not at our national conventions. We are better than this.
Thank you for posting and taking a stand on this!
Charlatans? How accusatory, insulting and inflammatory. In short your words are derogatory and harmful. If you wanted to have some meaningful dialogue and help our patients, you would avoid this.
Thanks for the perspective, Kevin. I’m currently Chair of the AAO Committee on Conferences (CCON), so I did want to add a little clarification. CCON does have 2 authors of the White Paper as members – one of which was directly involved in selection of this track, so there definitely was no lack of internal communication. There clearly is a great deal of interest in this topic and research is actively being published by these presenters, which is why they were selected. We were aware selection may be controversial (although perhaps not to this degree), but felt is was important to provide some of the perspective behind the “airway-friendly” claims frequently discussed. Granted, I completely agree with your assessment that better study design is needed and the current evidence is not sufficient to alter the current conclusions of the White Paper. The track was meant to show the various viewpoints on the topic, with the other speakers in the track more in line with the current White Paper treatment recommendations, but more Q&A or active debate between the viewpoints could have been included. Thanks for the comments and we’ll take them into consideration for New Orleans!
Thank you for speaking up. I would not want to wait until there is “sufficient” evidence. This has been in the literature for many years.
We are doing more harm by doing nothing
Not all points of view have equal validity, and this is much more so when one side continues to perpetuate specious information. The consequences are rather pernicious and dangerous. A case in point being the consequences wrought by practitioners of Orthotropics, the AGGA appliance etc. The veneer of legitimacy that is granted by allowing such views to be propagated from the podium, has far-reaching and very deleterious consequences. Among other things, maxillary expansion in three-year old victims has the potential to fracture the Vomer, deform the nose etc. Permitting the dissemination of such types of harmful canards begins to resemble tacit endorsement. Would the AAO thus not bear some culpability if members decided to act upon the information they were presented? After all, they only heard it at the world’s largest and most prestigious orthodontic conference.
Not sure why my global expertise did not share on the thread, but here it is again.
Dr. O’Brien, you have many valid points. The missing connection is the synergistic affect of the mechanical changes as well as the structural changes and how this is affecting the nasal breathing within the airway complex, and complex it is. It’s not a structural change, but the pressure flow relationship in the physics of breathing that needs to be looked at and measured.
I work closely with an ENT airway lab over in the EU, and we look at the logarithmic aerodynamic changes that do in fact affect anything done in the oral cavity, and visa versa. It’s as if the dental communities are trying to implement medical community theory without quantifying the mechanism. This can be done. We also know that 25% of patients have some form of nasal compromise that will dictate your treatment flow and options. We also have a way to quantify the transnasal pressure changes due to any manipulation in the oral cavity or the zygomatic area of the face. Would love to share the information and the latest research.
The good news is have been invited to and spoke with orthodontic and dental programs about the physics and aerodynamics of their treatment.
So, we are aware that the cause of the majority of sleep apnea, be it Obstructive Sleep Apnea, Upper Airway Resistance, etc. is the facial growth? The airway is hooked onto the bones of the face, they determine the dimensions of the airway and how far apart the soft tissues are. Of course obesity is a large factor, but you can become very obese and not have OSA if you have a well grown enough facial structure.
There are cases like with Central Sleep Apnea which no doubt have nothing to do with the facial growth, cases where there might be extremely large tonsils, growths, etc. in the throat or nasal airway. Sure those are not facial problems, but realistically they are a small fraction of the greater % of cases.
The obesity side has also been investigated at length. If you just look at the literature you will see studies where they have tried to have their patients lose weight to see how effective it is for treating OSA. It can be effective yes, but even when they choose their patients carefully (looking for very high BMI), they still are only able to cure, maybe half? The average reduction in AHI % is usually quite low as well, so the reality is that many of the patients just will not respond well to the treatment, even if they lose weight. And let us not fool ourselves that every person with sleep apnea has very high BMI, it could not be further from the truth.
Because of the above reasons I think that it is absolutely preposterous that orthodontia, orthognathia, etc. are not largely responsible for treating these patients.