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Part 2 of a brilliant summary of orthodontics and Obstructive Sleep Apnoea

By on February 11, 2019 in Recent posts with 25 Comments
Part 2 of a brilliant summary of orthodontics and Obstructive Sleep Apnoea

This is the second part of Greg Jorgensen’s report on the AAO winter meeting on OSA. This is about the diagnosis and treatment of OSA by orthodontists.

How Is Obstructive Sleep Apnea Diagnosed?

As of right now,  a formal laboratory sleep study called polysomnography (PSG) is the only way to diagnose OSA. Although home study kits and smartphone apps are available and gaining popularity; it was the consensus of the experts who spoke that none of them has all of the necessary features to provide an accurate diagnosis (i.e. none currently measure brainwaves).

Importantly, orthodontists cannot order, nor are they qualified to interpret the results of a PSG. The current standard for measuring the severity of OSA is the Apnea-Hypopnea Index (AHI) which represents the number of sleep disturbance “events” per hour. For adults, less than 5 is normal, 5 to 15 is mild, 15 to 30 is moderate, and over 30 is considered severe. For children, less than 1 is normal (in other words, children should have no apnea or hypopnea events during sleep).

Can Obstructive Sleep Apnea Be Diagnosed In Radiographs?

We can construct Interesting and instructive 3D images from CBCT scans and produce measurements like Minimum Cross-sectional Area (MCA). Although some papers report correlations between MCA values and the “risk of OSA”. We cannot diagnose OSA from radiographs. Only a formal sleep study provides a definitive diagnosis.

Tonsils and adenoids seen in lateral cephalograms may be a factor in pediatric OSA, but again their presence alone does not yield a diagnosis. ENT’s confirm airway obstruction using endoscopy; not radiographs.

Because OSA is not merely a structural problem, identification of “predisposing morphologies” can be misleading. Many patients who have these predisposing morphologies do not suffer from OSA. Conversely, other patients who have absolutely “normal” appearing anatomy may suffer from it.

In summary,

“2D and 3D images do not provide a proper risk assessment technique or screening method.”

What Treatments Actually Help Treat OSA In Adults?

Orthodontics OSA

The “gold standard” for the treatment of sleep apnea in adults is continuous positive air pressure (CPAP). CPAP has a success rate of over 90%. For patients who cannot wear a CPAP, oral appliance therapy (OAT) has been shown to be 65% successful. Although diet and exercise may be used to reduce obesity in OSA adults, this has a very low success rate due to low compliance. Patients treated with gastric surgery may get better results if the weight loss achieved is permanent. Other treatment approaches include myofunctional therapy, oxygen therapy, oral pressure therapy, tongue stabilization therapy, cervicomandibular collars and oral surgery.

Of these approaches, only surgery and permanent weight loss appear to offer possible “cures” for the condition.

What Kinds Of Oral Surgery Are Used To Treat OSA?

Oral surgery involving the oropharynx, nasal cavity, tongue, hyoid bone, throat, and jaws have all been used to treat OSA. Operations involving the uvula, tonsillar pillars, and septum are all aimed at increasing the flow of air through the oropharynx. Tongue surgeries attempt to pull the tongue forward, pull the back of the tongue down, make the tongue smaller, or stimulate the tongue to increase the tonicity of its muscles. These surgeries are only successful if these structures are actually a factor in the collapse of the oropharynx. There is no evidence that a SARME helps prevent this collapse and is not typically indicated for the treatment of OSA. The most aggressive, and most successful surgical procedure used to treat OSA is the two-jaw maxillomandibular advancement (MMA).

Why Would A Patient Need Maxillomandibular Advancement?

The maxillomandibular advancement provides a “cure” for OSA in 86% of patients. Patients may choose this option if they can’t tolerate CPAP, oral appliances, are young and don’t want to spend the rest of their lives wearing CPAP or devices, or if other craniofacial issues exist that justify the movement of the jaws. The biggest challenge for these patients is the change in the occlusion after both jaws are moved. This is why MMA is always performed in conjunction with orthodontic treatment. Although highly successful, there are still 14% of patients who still have problems with their oropharynx collapsing after surgery (not surprising since OSA is not merely an anatomical condition).

What Treatments Actually Help Children With OSA?

Weight loss alone eliminates OSA in over 50% of young patients who are able to comply (obesity being the #1 risk factor). Hypertrophic adenoids and tonsils are the second most common cause of breathing disorders in children and adenotonsillectomy (T&A) are still the treatment of choice.

If there is an accompanying maxillary constriction, RME therapy AFTER a T&A may be prescribed by the attending physician. Otherwise, for non-OSA orthodontic patients, there is no reason to expand “in the name of airway” if there is no maxillary transverse deficiency or crossbite.

What Is The Appropriate Role Of The Orthodontist In OSA?

The most critical thing orthodontists can do is understand the disease. A realistic review of the most current data leads to the conclusion that orthodontists cannot predict, prevent, diagnose, or correct OSA. However, our role is to screen for the condition, identify those who exhibit signs and symptoms, make referrals to the appropriate physicians, and then possibly provide adjunct procedures or oral appliances as prescribed explicitly by those physicians. It is out of the scope of orthodontic practice to treat OSA on our own.

Can We Prevent Or Cure OSA In Our Patients?

Importantly, no-one has shown that maxillary expansion (with or without TAD support) prevents or cures OSA.

“The effects of RME for children with OSA is mostly supported by low-quality studies (no control groups to compare patients against normal growth) … randomised trials [have] found no grounds for its use.”  

There is no evidence that merely expanding the palate (including the nasal cavity) reduces “OSA parameters.” This is because the size of the nasal cavity is not linked to the collapsibility of the oropharynx. In other words, increasing the size of the underlying skeletal structures does not ensure that the overlying “soft structures” will follow suit or respond differently. Dr Charles Guilleminault, a pioneer in the field of sleep medicine, addressed the use of frenectomies for the treatment of OSA.  In his lecture he suggested that only frenectomies performed in the first year of life have any benefit for OSA. Although there may be other reasons to implement them after the age of 1, OSA is not one of them.

How Can Orthodontists Screen For OSA In Their Practices?

There are two essential tools that every orthodontist can implement right away. First, the Pediatric Sleep Questionnaire (PSQ) is currently the best way to identify OSA in children you see in your practice. It is a simple one-page form that is easy for parents to fill out and for orthodontists to interpret. Currently, the STOP-BANG survey is the best screening tool orthodontists can use to identify adults who have or are at risk of having OSA. When we suspect that a patient has OSA, we should refer them to an appropriate ENT or sleep medicine physician.

What Can’t Or Shouldn’t Orthodontists Do Relative To OSA?

Orthodontists cannot predict, prevent, diagnose, or cure sleep apnea. We should not use treating the “Airway”  as an excuse for advocating specific approaches to treatment. For example, early palatal expansion, non-extraction treatment, non-retraction treatment, etc.

“When one considers the complex multifactorial nature of the disease, assigning the cause of OSA to any one minor dental factor or change in dentofacial morphology is not logical. In spite of this, people create misinformation and widely disseminate it.”

The Urgency For A Consensus On OSA

The title of the Winter Conference was “Sleep Apnea and Orthodontics: Consensus and Guidance” for a specific reason. At a time when the orthodontic profession is under attack from all sides, the last thing we need is misleading advertising and verbiage that divides us.

The findings of this task force were that orthodontists can neither prevent, cause, nor cure OSA. I applaud those in our profession who recognised the importance of screening for and referring potential OSA patients to physicians for treatment even before this conference.

It is imperative that we all come to a consensus and present a consistent message to the public and our dental colleagues before the OSA issue spins out of control.

 

Kevin’s comments

Thanks, Greg, this is a great summary. I am going to digest all this information and then I will write a blog post about this issue and the “new speciality” of airway focussed orthodontics…In the meantime, thanks for all this very useful information.

 

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  1. Vish says:

    Thank you Kevin for posting this addition to the first part. Like I noted before, there is simply no more reason to indulge nonsensical terms like “Retractive-Orthodontics”, “Airway-Friendly” etc. in light of the findings you have presented. At this point, their claims will never be taken seriously.

    That coffin has been nailed shut now. The next step is for “fringe practitioners” to recognize and discard their ill-supported interventions.

    • Kevin L. Boyd says:

      Prof. O’Brien, Gerry Samson and Lisle Johnston

      Do any/all of you support Vish’s hypothesis that a proverbial coffin has received its final nail?

  2. Kevin Boyd says:

    I am pleased that Greg’s summation included information concerning the importance of Ron Chervin’s PSQ as a ‘screening tool’ for identifying children with specific, and scientifically-validated, behavioral phenotypes that can be co-morbid with SRDB/p-OSA; however, to his stated, ‘First, the Pediatric Sleep Questionnaire (PSQ) is currently the best way to identify OSA in children you see in your practice.’, it should be clarified that the PSQ does not intend for orthodontists and/or any other non-physician, to ‘identify OSA in children’, as that would imply ‘diagnosis’. Again, the PSQ had been designed for identifying specific and validated ‘behavioral’ risk traits (e.g., mouthbreathing, snoring, bedwetting, bruxism, etc.) that can often be associated with existing airway disease, or predictive of future risk. Combined with specific co-morbid malocclusion phenotypes in early childhood(e.g., high/narrow palatal vaults, retrognathia, transverse deficiency’s, etc.), the PSQ is made ever more powerful in identifying young kids who might now be suffering, and/or might have naso-respiratory difficulties later in life.

  3. Carlos Flores-Mir says:

    Thanks Greg. Nice wrap up summary. I do support your overall conclusion. We are uniquely positioned to assess our patients for high risk of OSA. The two available tools, PSQ and STOP BANG, although not perfect (if so they would be diagnostic tools); they allow for less false positives as diagnosed by a sleep physician. Other than that this a multifactorial disease (which disease is really not) that should requiere assessment by a multidisciplinary team to decide the need for treatment, treatment priorities and follow up. We can be part of disease management when indicated by the treating physician. No magic bullet.
    Having said that it has also become apparent that we all have to open our eyes to the functional aspect of craniofacial problems. We understand it very little but that is no excuse to discard its importance. More time and efforts are needed to better elucidate how to diagnose and manage oral soft tissue malfunctions. Data has to be collected and reported to be peer-reviewed to support more solid conclusions.

  4. andy pearson says:

    Very useful, thanks. In the previous blog someone commented that 1000yrs ago humans had wide arches and little crowding so therefore crowding is a modern, post industrial phenomenon. I’ve heard this before and have half thought something like this myself but is it true? Were jaws bigger 1000 yrs ago, was there really no crowding? Does anyone have the papers that show this and was the research valid? Thanks.

    • Kevin Boyd says:

      Hi Andy

      Per request, I have emailed to you and several others on this forum some articles and mp3 files regarding how anthropology can help inform us about recent epidemiology of human skeletal malocclusion as being coincident with cultural industrialization. I am really encouraged by this interest.

  5. Louis Yarmosky says:

    Dear “That coffin has been nailed shut”,
    I am afraid to tell you there are ideas, data and experiences that are alive and well inside.
    I feel like we are talking past each other. We both want the same outcome. A healthy , well functioning, aesthetic and stable dentition in a well functioning and healthy individual. However, it appears that some are just looking at the mechanics to move teeth around to fit a orthodontic norm that in many cases is disconnected from the functioning complex of the surrounding structures and muscles. So the question is what are the goals of orthodontic treatment and does orthodontic treatment effect other health issues in either a positive or negative manner?
    I think you are saying that orthodontic treatment can not prevent, treat or cure sleep apnea. I would in a very limited way agree with you if traditional orthodontic treatment is all you are talking about. I also think you are saying that traditional orthodontic treatment that involves extractions or head gear or other procedures which retracts the dentition towards the oral pharynx does not exacerbate the potential for sleep disordered breathing and apnea . I do not agree with that however
    Air way orthodontic is a multi disciplined approach which combines traditional orthodontics with the understanding that nasal breathing, proper tongue posture and movement and correct swallowing habits are the key for individuals achieving their genetic potential for proper jaw development and straight teeth. We are genetically programmed to have straight teeth with wide jaws and room for third molars and the tongue. You don’t catch crooked teeth and narrow jaws, you develop them because of muscle dysfunction as a child and you relapse after orthodontic treatment if the dysfunction is not corrected. So why do we ignore that fact and not do what we can to restore function to its natural genetic potential.
    What is the resistance to understanding the underlying reasons that allows our bodies to function properly and achieve maximum health. I hope past norms will not stop us from learning new realities. Would you be interested in learning how you could even better be able to achieve your orthodontics goals as well as general health and wellness? I did and it has been one of the most exciting times in my professional life as a Pediatric Dentist.
    Who knew breathing was so important

  6. Kevin L. Boyd says:

    Dear Andy

    Please read Robert Corruccini’s ‘How Anthropology Informs the Orthodontic Diagnosis of Malocclusion’s Causes'(https://www.bookdepository.com/How-Anthropology-Informs-Orthodontic-Diagnosis-Malocclusions-Causes-Robert-S-Corruccini/9780773479807).

    Marianna Evans, a dual-boarded orthodontist and periodontist, and I have been analyzing pre-industrial crania for over 5 years now at the U Pennsylvania Museum of Archaeology and Anthropology as post-doctoral visiting scholars there. We are finding support for the hypothesis that appreciable skeletal malocclusion in modern H.Sapiens, is pretty much an epigenetic effect of cultural industrialization. I will be happy to send you links to essays and lectures on this topic if you would email me off of this forum ([email protected]).

  7. Vish says:

    Dear Louis- Isn’t that something, though? There are still Flat-Earthers and others who are allergic to reality. I do not concern myself with those entities.

    Your disagreement reflects a refusal to accept the facts. The science has spoken.

    Airway Orthodontics, of the Friendly or Unfriendly subtype is about as real as a Turkish Unicorn. While that may be a fascinating topic on the Turkish Mythology Blog, it is incongruent on this blog.

    Time to dismiss all these claims and unshackle yourself from these ludicrous theories. This controversy is over.

  8. Dr. Mulroney says:

    Dr. Boyd –
    I do support this hypothesis. There was no reason to ever suggest a cause and effect relationship and it has been proven to not exist.

    Charles Tweed was right and Angle was wrong. However, like Nosferatu, I suspect that the uncritical and unethical will attempt to resurrect this. To no avail. The masses are awake and will accept nothing short of proof.

    • Kevin Boyd says:

      Dear Dr. Mulroney
      Please clarify, precisely what specifically is the ’cause and effect’ relationship hypothesis that you claim has zero support? and also please cite the references that apparently refute your stated hypothesis.

      Thank you for considering.

      Kevin

    • Kevin L. Boyd says:

      Dear Dr. Mulroney
      Just to keep the conversation within the confines of the Scientific Method, valid hypotheses are neither proved nor disproved, rather, they can be subjected to rigorous investigations in order to support, or fail to support, the original speculation. Or, in the words of Sir Karl Popper, the British philosopher who, in ‘The Logic of Scientific Discovery’ (1934) argued that scientific hypotheses can never be finally confirmed as true (i.e., proven), but are tested by attempts to falsify them.

  9. John Wise says:

    In Carlos Flores-Mir’s excellent comment, he stated: “We understand it very little but that is no excuse to discard its importance. ” To those of you who attended the Sleep Apnea Conference and/or read the summary presented here, please do not interpret the information presented as the final word on sleep apnea and its relation to orthodontics. The studies to evaluate outcomes and treatment effectiveness are REALLY HARD. Sometimes, excellent studies provide more questions than answers. Why does T and A improve OSA in some patients but not others? Why does RPE improve OSA in some but not others? Why does T and A combined with RPE improve OSA in some but not others? These types of questions and their not so obvious answers are at the heart of the matter. We’ve only scratched the surface of research in this field. To have the false belief that the final nail has been inserted in the coffin is bad science. Science proposes questions then seeks to answer them. We have lots of questions still unanswered in the field of OSA and its relation to what we do as orthodontists.

    Like Dr. Flores-Mir, I served on the sleep apnea task force, and I am more jazzed than ever that what we do is extremely beneficial to our young patients. Orthodontists are the world experts in oro-facial growth and development. We have alot to offer on this subject. Lets tap on the brakes on putting nails in coffins. That may take a few years. And while we’re at it, lets try and work together instead of making comments disparaging our colleagues. Or, as John Denver said in his song “Rhymes and Reasons”: “Come and stand beside me, we can find a better way.” Lets stop looking for nails when we should be looking for answers.

  10. I got this email today regarding a patient who has had sleep disordered breathing for the last 5-6 years. CPAP intolerant and has undergone UPPP surgery and also nasal surgery (but both surgeries did not help get better sleep). Any suggestions on how to address this skeletal Class III case?

  11. John Wise says:

    A quick story from the Sleep Apnea Conference at Marco Island. I asked a good friend of mine and top notch orthodontist what he thought of the presentations so far. He and I had been listening to the exact same presentations, mind you. He stated that it was all very interesting but there was no way that he was going back to his practice and start doing RPE’s on every patient that walked in the door. At that point, I stopped him and said, “Wait a second, not one speaker has advocated that position. Not one.”

    My point is that sometimes we hear what our biases want us to hear. Or worse, we tell the story after the fact of what a particular conference or article stated, and just get it wrong. As a serious profession, we need to have a higher level of discussion about issues like this. Lets stop retreating to our corners and espousing generalities that are misleading at best and destructive at worst.

  12. ThomasRatliffDDS says:

    For those OSA patients that cannot tolerate CPAP or BiPAP to forcibly maintain a patent airway, a tracheostomy will bypass the offending limiting structures. Patients tend to refocus their attempts to accommodate to CPAP/BiPAP wear when discussing this alternative. Weight reduction and/or bimaxillary surgery suggestion does not seem to have the same motivational effect of recommiting to CPAP/BiPAP wear. Perhaps its because of the need to give up swimming with the tracheostomy.

  13. The head over time grows from a small nut to a large melon and continues to function dynamically. Within this changing structure, volumetric proportions are balanced for multiple tasks need for our survival. Orthodontists are also the best medical providers to work with surgeons to advance the mandible or both the mandible and maxilla in a OSA team. I call that a cure which a properly done PSG can document. We should be an integral part of any team optimally treating this condition. Many, myself included, find the CPAP to be difficult at best. Although the pulmonologist and sleep clinics are quick at diagnosing the condition using PSG, and of course recommending the CPAP; that us usually the end of their medical involvement. Many simply do not used these intrusive devices. Medical reimbursement should be routinely done using PSG to evaluate the effectiveness of these removable advancement appliances, at present it is like “pulling teeth” to get this done. There is no reason that a removable devise also should be routine used to lower the positive pressure used on CPAP making them more user friendly.

    I have been using Bionators since 1980 as a mandibular repositioning device for both open and close anterior bites in Phase I Class II cases. Although, I cannot suggest that I have created “yards and yards” of bone; after all, we are a profession using very small dimensions which all factor into a stable finished case. Functional changes from Bionators improve mouth breathing and deviated swallowing. Active and passive translation of the mandible must alter the growth process. All tissues of the craniofacial complex are adaptable. I also worked for many years starting in 1981 with a local dentist /otolaryngologist making many bionators to hold the occlusion for his OSA patients. I think an Orthodontist has the best ability to use a removable split/orthotic or mandibular repositioning devise, without the unwanted shifting in the occlusion from long term nighttime use. If we as a profession do not help in the team care of TMD and OSA, we are missing out on a very satisfying level of health care and unfortunately resigning that care to other dental practitioners who try to “treat the airway”. With the designs coming out using Invisalign too advance the mandible our specialty’s involvement in this will be important into the future.

    Michael V. Garvey

  14. Kent Starling says:

    Is the statement “The “gold standard” for the treatment of sleep apnea in adults is continuous positive air pressure (CPAP). CPAP has a success rate of over 90%.” accurate?

    The conclusion from the study:
    Long-term compliance with continuous positive airway pressure in patients with obstructive sleep apnea
    Norman Wolkove, MD FRCP, Marc Baltzan, MD FRCP DABSM, Hany Kamel, MD, Richard Dabrusin, MD FRCP, and Mark Palayew, MD FRCP (Can Respir J. 2008 Oct; 15(7): 365–369.) is:
    “We have identified distinct populations among patients diagnosed with OSA and prescribed CPAP. Slightly more than one-half of these patients remained compliant and highly satisfied with treatment at long-term follow-up. However, approximately one-half of all such individuals had either not accepted or abandoned CPAP use, often citing discomfort with the apparatus as the reason for noncompliance.”

    The conclusion from: Trends in CPAP adherence over twenty years of data collection: a flattened curve
    Brian W. Rotenberg,1 Dorian Murariu,1 and Kenny P. Pang (J Otolaryngol Head Neck Surg. 2016; 45: 43.)
    “This review represents the most up to date data on secular trends in CPAP adherence. The findings are sobering. Our data suggest that despite numerous changes to machine and mask dynamics as well as behavioral interventions, CPAP adherence remains a severe problem for management of patients with OSA – the concept of CPAP as gold standard for OSA therapy is no longer valid. This paper’s data regarding a comprehensive assessment of CPAP adherence can be used when developing OSA treatment guidelines and when counseling patients about their OSA and the relative likelihood of treatment success for the various therapies at hand.”

    So while some claim that CPAP is super successful the data in many studies isn’t so favorable.

  15. Prof Seong-Seng Tan says:

    Dear Louis,

    Where is the evidence for your statement that “we are genetically programmed to have straight teeth with wide jaws”? As a pediatric dentist, you owe it to your profession to refresh your knowledge by reading a modern textbook on genetics and molecular biology. In particular, recent discoveries on the interactions between genes and the environment.

    • Kevin Boyd says:

      I agree that we, per our genome, are ‘genetically-equipped’ , rather than ‘peogrammed’, to produce an uncrowded 32-teeth occlusion (i.e., a craniofacial and connected respiratory complex) optimized for habitual nasal breathing during wakefulness and sleep, when/if we (H.sapiens) were/are born, bred and grow & develop within ‘non-Western exposed’ cultures; this fact is substantiated by decades of collected data from the human fossil and pre-industrial skeletal records. But to use the term ‘genetically- programmed’ implies a ‘predetemination’ modality of heritability, or, in accordance with Watson and Crick’s ‘one gene-one enzyme’ or ‘Central Dogma’ theory of genotype-phenotype formula for trait production, is no longer valid since the Human Genome Project (some 20 years ago) revealed that we have roughly 23,000 coding genes yet can produce some 100,000-200,000 enzymes(proteins). Having a basic working knowledge of Epigenetics (genome-environment interaction) and Anthropology/Evo-Devo would definitely change the tone of this heated discourse I think, but curiosity seems to be stifled per the fact that these subjects are not pre-requisite to dental or medical education and thus do not inform clinical diagnosis and Tx planning/practice…..not yet anyway.

  16. There are several facts showed in our daily practice and by several studies regarding the effectiveness of maxillary skeletal expansion and mandibular distraction surgery in the treatment of snoring and OSA that are quite contradictory to some of the opinions stated in the comments to these last to posts.

    I think some people are misinterpreting (again) the data obtained by not so well designed studies. Far from being nailed shut down, this coffin is more open than never and a lot of questions arise.

    I hope Prof. O’Brien will bring some light. I look forward to reading his posts, as always.

  17. I have a patient that transferred to my practice. I obtained start/progress/final records. He was a Cl I skeletal average patient who had 2 jaw surgery ONLY to correct a diagnosed sleep apnea condition. The patient was not over weight and was unaware of any health issues. His post surgery blood oxygenation level showed absolutely no improvement. It’s just one case nonetheless I feel these results are worthy of reporting.

  18. Richard Mulroney says:

    Hello Dr. Boyd –
    I have to agree with the other posters on this and the other thread about the coffin being nailed shut specifically re: The extraction-OSA controversy.

    Any credible discussion has to begin with acceptance of that FACT. If not, I fear there is no debate to be had. There is no validity to the hypothesis at all, so like fruits of a poisonous tree, anything emanating from a logical flaw has no basis in reality.

    My partners and I have connected with the vast majority of programs in the UK and USA to obtain a consensus. The faculty are in agreement with the findings of the conference as it pertains to the extraction scenario. There are definitely other areas that need more research (such as the effect of SARPE or MMA) and would present interesting data. In our own offices (more than 2000 active patients in 2014), we are glad to report that the extraction rates have gone up significantly.

  19. Peter Bevans says:

    Regardless of how many teeth we are genetically equipped to have, there is simply no room to fit all of them in the mouth.
    Which is why 3rd molars are extracted, and premolars need removal. For crowding, protrusion, overjet, facial balance, periodontal health etc. Now those are important treatment goals.

    The least relevant is presence or absence of bicuspids. Shuck away as needed. Especially since there is such phenomenal data supporting it.
    CG is not to be taken seriously…after all his understanding of orthodontia is minimal. Leave OSA to the medical specialists. Refer appropriately and stick to the orthodontics. If expansion is warranted, it is very reasonable to consider it (not as an alternative to extractions, but for a completely different purpose).
    We have treated 1000’s of patients over the last 35 years and know what works and what fails. Stick to the science and discard silly beliefs.

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