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.
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.