Popular posts 6: A brilliant summary of orthodontics and Obstructive Sleep Apnea
This week’s popular post is a bit of a classic on this blog. This post was a simple summary of the AAO winter meeting of 2018 that looked at obstructive sleep apnea and orthodontics. I thought that this summary was great and is very valid today. All orthodontists and dentists should read this.
Obstructive Sleep Apnea is a serious disorder. The role of orthodontists in its treatment was the theme of the recent AAO Winter meeting. This post is a great summary by Dr Greg Jorgensen, who attended the meeting.
Dr. Jorgensen is an orthodontic specialist who has been in the private practice of orthodontics since he graduated from the orthodontic department at the University of Iowa in 1991. He has been certified by the American Board of Orthodontics and is active in organised dentistry. Jorgensen currently serves on the AAO’s Council on Communication. However, he wrote this summary merely as a service to those not in attendance at this historic meeting.
The AAO Conference On Obstructive Sleep Apnea And Orthodontics
In light of all of the information (and misinformation) that has appeared in the dental community in recent years, the AAO commissioned a task force in 2017 to examine obstructive sleep apnea and the role that orthodontists play (or don’t play) in the prevention, diagnosis, and treatment of this serious medical condition.
The task force gathered experts from sleep medicine, otolaryngology, pulmonology, pediatric medicine, neurology, oral surgery, dentistry, and orthodontics to look at this issue from every possible angle.
After two years of work, this group of unbiased experts drafted a 20-page “white paper” (that will be published as an upcoming AJODO article). This report was the framework for this 18-hour program.
Don’t Kill The Messenger
In this post, I will summarise the information they presented at the meeting on January 25th, 26th, and 27thof 2019. I write merely as a note taker of the presentations, not as an expert on obstructive sleep apnea or as a representative of the AAO. I hope you find the information as valuable as I did. Because I am not an expert on OSA, I will not debate those who take issue my interpretation.
My only goal is to share this timely information with those who did not attend.
Interest In OSA Sold Out The Conference
Interest in this topic was so great that every seat in the auditorium was filled. All 1,000 delegates stayed fully engaged from the minute the lectures began at 8:00 AM on Friday until the last questions were answered at noon on Sunday. The attendance was a testament to the interest in and importance of obstructive sleep apnea to our profession.
Obstructive Sleep Apnea (OSA)
Obstructive sleep apnea (OSA) is a severe and life-threatening disease. Undoubtedly, it deserves the attention of healthcare providers from every branch of medicine touched by its wide-reaching effects. It is not a new condition, but changing population demographics and discussions within and outside our speciality have forced it to the forefront in recent years.
OSA is a multi-factorial disease that is not caused by any single factor. Neither is it cured by a single approach in every patient. Importantly, OSA is more than a simple anatomical condition that can be prevented, induced, or treated by changing the dentofacial complex’s shape, size, or position. Instead, it is a complex interaction of neurological, muscular, and physical variables that results in the collapse of the oropharynx (upper airway).
Furthermore, this collapse is caused by a decrease in the tonicity of muscles of the upper airway and not merely a reduction in the size of its lumen. Because it is not just a size issue, procedures that increase the size of the “pipe” (both orthodontic and non-orthodontic) will not cure the disease.
A realistic review of the most current data suggests that orthodontists cannot predict, prevent, diagnose, or correct OSA.
Why Is Obstructive Sleep Apnea Important?
OSA in adults causes daytime sleepiness, cognitive impairment, vehicular accidents, and relationship strain. It also causes nighttime snoring with intermittent pauses, restlessness, and frequent trips to the bathroom.
Finally, it can result in hypertension, strokes, decreased life expectancy, and even death.
Children exhibit daytime behavioural problems (ADHD), learning disabilities, and inattention. At night they present noisy, laboured breathing, restlessness, mouth breathing, unusual body positions, and bed wetting. OSA can also cause failure to thrive and a host of other heart and circulation issues in affected young people.
What is the prevalence of Obstructive Sleep Apnea?
Recent studies suggest that the prevalence of OSA is 1-4% in children of healthy weight. But those numbers climb to over 50% of children who are obese. 10% of the men and 3% of the women between the ages of 30 and 50 have OSA. Those numbers rise to 17% in men and 9% in women over 50 as their overall muscular tonicity decreases. The prevalence of OSA in obese men and women rises to over 75%.
What Are The Causes Of Obstructive Sleep Apnea?
There are many causes of OSA. We can summarise these as;
- Decreased or altered neuromuscular tone in the upper airway,
- increased volumes of soft tissue around the airway (obesity),
- old age (general loss of muscle tonicity throughout the body),
- neuromuscular conditions,
- the presence of abnormal adjacent structures that narrow the airway (like enlarged tonsils, adenoids, pharyngeal pillars, and the uvula).
There is no evidence that the following cause OSA;
- the position of the teeth,
- the width of the arches,
- the size of the nasal cavity,
- the length of the lingual frenum
When we look at any influence of orthodontic treatment. There is no evidence linking orthodontic procedures (headgear, extractions, or so-called “backwards pulling mechanics,” etc.) to the development of OSA.
Additionally, there has been “no direct causal relationship between craniofacial structure and pediatric SDB”. OSA is not merely an anatomical disease.
What Are The Risk Factors For Obstructive Sleep Apnea?
Decreased muscle tonicity of the upper airway, which allows its collapse is the cause of OSA. Importantly, anything that causes, reduces, or contributes to that condition can be a factor. Obesity is the #1 risk factor as decreased muscle tonicity, in combination with a reduction in the lumen of the airway due to fat deposits, makes obturation much more likely. Other factors are aging, injury, neuromuscular disorders, being male, having a larger neck circumference, smoking, and genetics.
In children, tonsil and adenoid hypertrophy is an essential factor. It is important to note that no direct causal relationship has been identified between craniofacial structure and pediatric SDB (i.e., arch constriction, dental extractions, headgear therapy, or retraction of the anterior teeth).
I will post the second part of this blog post next week.
Emeritus Professor of Orthodontics, University of Manchester, UK.
Final nail in the coffin. No more claims of extractions causing sleep apnea or expansion “preventing” it. No more “So much we don’t (want to) know”. Any Prosthodontist who wants proof that orthodontic extractions do not cause harm, should first be required to prove that mounted casts doesn’t cause Global Warming or resin cements don’t cause cancer.
I love that we orthodontists curse general dentists who “take a weekend course” and practice orthodontics but we will attempt tinker with someone’s airway after doing the same and we don’t see the irony! If an orthodontist really cares about breathing issues then they should go to medical school and get a proper degree. To do otherwise is hubris.
Amazingly, I find myself in complete agreement !
If anyone desires a copy of the screenshot I just took of this conversation, then I will happily provide it.
Why will orthodontic “experts” not wait for the evidence before jumping on the latest flower to suck nectar than does not exist. After 35 years of practice I have watched some of the most respected leaders (you know who they are) jump on the newest and best every two years. So after 40 years of practice they have 2 years of practice twenty times.
I second that!
#me too
I think it’s fair to say that the treatment of OSA lays at an intersection of Respiratory Medicine and Dentistry.
I agree with Ben when he suggests that treatment of airway conditions should be informed by a physician, and in my opinion that would be a specialist in respiratory medicine or ENT Surgery.
On the other hand, I think orthodontists can assist in the care of patients with OSA when asked to do so by colleagues.
In short: its a team game.
I don’t see how we could possibly assist since anything we can do with our orthodontic skills has no effect on the problem. Am I missing something?
Since we see young patients and sometime more frequently that them seeing their paediatrician. I have been asked to help screening patients who might be at risk of OSA and make the appropriate suggestion to parents to seek help. In addition, orthodontist has the training to provide OAT to OSA patient should those patients opt not to have MMA and cannot tolerate CPAP. Just doing whatever we can to help.
I have had a moderate OSA diagnosis for ~4yrs, and use a CPAP every night. 5’11” 180lbs (not obese) male 48yrs old with a family hx of OSA. My care for apnea is provided by Neurology – not respiratory or ENT. Neuro can determine the quality, length, and type of sleep, as well as the number of interruptions in sleep patterns. Compliance is usually the biggest challenge (not mine). I would encourage dentists / orthodontists to examine how using a CPAP with forced positive (humidified) air flow may affect dental health. I find (as an intermittent mouth-breather using a full mask) myself waking up with dry mouth every morning, and if there are any extra precautions I could take to ensure continued good dental health.
Just so I am clear ,do you or anyone on this blog interpret this data in a way that suggests OSA appliances and or surgical bimax.advancements have no validity ?
I have no axe to grind ,just curious .I would appreciate any and all responses. Thanks.
This summary is a wonderful contribution by Greg Jorgenson. It brings to mind a quote from Leo Tolstoy ca. 1828, “The most difficult subjects can be explained to the most slow-witted man if he has not formed any idea of them already; but the simplest thing cannot be made clear to the most intelligent man if he is firmly persuaded that he knows already, without a shadow of doubt, what is laid before him.”
“There is no evidence linking orthodontic procedures (headgear, extractions, or so-called “backwards pulling mechanics,” etc.) to the development of OSA.
Additionally, there has been “no direct causal relationship between craniofacial structure and pediatric SDB”. OSA is not merely an anatomical disease.”
Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences.
Conclusion: Pediatric OSA in non-obese children is a disorder of oral-facial growth.
J Appl Oral Sci. 2011 Apr;19(2):161-8.
I realize that this author may have missed this study, and there are others if one wants to “really” look into the subject. Guess some of us will be taking the nails out of the coffin just as fast as some are swinging the hammer.
It is always interesting how some in the field look to research for the answer that is really only provided by the established field that will not do the research and then proclaim there is no research. As someone that has been in the field of DSM for the last near 25 years and treated thousands of patients, significant numbers having had serial extraction, I guess the result is just serendipitous. The studies that I have reviewed proclaiming that ortho. has no impact on the airway do not take into consideration tongue level, mouth breathing, head position, swallow pattern, etc. yet they stand on their soap box proclaiming innocence. For example, I contacted the author of article written, from one of our progressive dental schools here in Texas and happen to be a senior instructor (actually head of the dept.), about the fact that there was no consideration of the prior mentioned issues taken into consideration in his article. After trying several times to discuss the matter and never a phone call or email returned, I gave up. So much for open discussion and exchange of ideas, but no big deal since the “prevailing” research supported him, right?
It might do well for some in the ortho. field to sit in my office occasionally and see all the patients with nice flat faces, bicuspids missing, tongues laying on top of the occlusal surfaces of the lower teeth, low resting tongue level, may or may not be tongue tied, forward head position (some up to 4 inches), reverse swallow patterns, etc. and then say there is no chance that the box size impacts the airway. But hey, they have a nice class 1 occlusion with straight teeth. Maybe size does matter when we look at the space between the cheeks.
The article you reference here is an excellent piece and almost a review of literature on the subject. It was a “call to action” piece from the authors who are passionate about orthodontists being involved in OSA. Thanks for sharing the reference! Every orthodontist should read it.
Thanks for the reference!
OSA is a link between the medical field and the work that orthodontists do every day. As we all know, the teeth and developing jaw structure are highly adaptable to the environment. Breathing, tongue position, habits, etc all effect tooth position and jaw growth in 3 dimensional space. This is well known. Add to that the fact that OSA is hard to study. Discovering certifiable direct links to causes or cures is probably a long time in the making. Some times, we get more questions than answers when studies are done well. We need to be vigilant in this realm and follow the rules as we know them today. The issue is long from being settled definitively. What I advise my various referral sources on this is, “If you see something, say something.” Crooked teeth and narrow palates can be a symptom, but are not always. There is a reason that children with diagnosed sleep apnea are twice as prevalent in orthodontists’ offices as in the general public. The same patients with crooked teeth are also more likely to have OSA. Orthodontists can provide a valuable service to these OSA patients and their families, and we are the only providers who are experts in orofacial growth. This is our realm. We should own it.
I love that we are talking about Muscle Tone and its role in OSA. But what therapies are there to address that and who provides those therapies… that’s assuming that there is a therapy that experts agree on.
Citing abysmal data and meaningless terms as proof only drives the nails deeper into the coffin. The time for far-fetched theories, unsupported rhetoric, and specious reasoning is over.
It’s quite amusing to see the ideas that are concocted by those who have never been burdened by the rigors of attending an orthodontic residency program.
I’m sure “The Fringe” has many theories about many things….however, these do not even survive basic scrutiny or common sense let alone higher levels of evidence.
Is it any wonder that these ideas were cast aside (as they should). We have heard these complaints for way too long…it’s time to put up or shut up.
Simply put, the plural of your anecdote does not rise to the level of data. In the meantime, four on the floor it is.
Citing abysmal data and meaningless terms as proof only drives the nails deeper into the coffin. The time for far-fetched theories, unsupported rhetoric, and specious reasoning is over.
It’s quite amusing to see the ideas that are concocted by those who have never been burdened by the rigors of attending an orthodontic residency program.
I’m sure “The Fringe” has many theories about many things….however, these do not even survive basic scrutiny or common sense let alone higher levels of evidence.
Is it any wonder that these ideas were cast aside (as they should). We have heard these complaints for way too long…it’s time to put up or shut up.
Simply put, the plural of your anecdote does not rise to the level of data. In the meantime, four on the floor it is.
Maybe we should clean the air a bit for these kids….
I agree Charlotte!
And the healthiest/cleanest air possible is ‘processed’ air…..processed via the nasal cavity/ turbinates, paranasal sinus complex (PSC) and laminar flow through the posterior choanae into the nasopharyngeal corridor to the alveolar sacs and finally the bloodstream. If ambient air is inspired orally, it will forgoe the aforementioned mechanical (nasal hairs, etc.) and chemical (nitrogen-oxide (N-O) from PSC’s mucosal lining is a powerful anti-microbial, anti-oxidant and vasodilator) ‘processing’; and furthermore Charlotte, nasally-inspired air also confers elevation of ambient air’s temperature and humidity to levels bio-compatible and conducive to maintaining homeostasis and optimal somatic and neurological G&D, which is especially important for young/very young children with LTS.
Children with LTS who have specific ‘physical’ malocclusion phenotypes:
e.g., deep-vaulted and narrow hard palates, lack of deciduous interproximal spacing, grade 3-4 (Kotlow) ankyloglossia, chronic open-mouth posture, vertical growth sensitivity (thank you Gerry Samson)/high angle and/or skeletal retrognathia, etc.,
AND, also display scientifically-validated (by U Michigan’s Chervin PSQ) ‘behavioral’ traits/symptoms that have been identified as being indicators of increased risk for SRDB co-morbidity:
e.g., snoring, mouth-breathing, diaphoresis, bedwetting, bruxism, restless sleep, etc.
will absolutely benefit from orthodontist-otolaryngologist collaboration, as had been common ‘best practice’ over the course of nearly 8 decades preceding WW II (again, some reference’s below).
I think it will soon be medically-indefensible for pediatric health professionals to look parents (of kids with LTS and predictable malocclusion) in the eyes, and tell them to,”better save up your money for braces”. To marginalize these children relative to how they could achieve neurological and somatic health benefits from optimization of the intimately connected craniofacial and respiratory complexes, is tantamount to not prescribing /appropriately referring for, glycemic control to pre-diabetic/diabetic children, spectacles or hearing aids for visually- or hearing-impaired kids with LTS.
Please consider/reconsider (Nicky)your expressed lack of interest in reading some of the historic papers below as they just might at some point be inspire you to better help some of the children in your current surgery/clinic.
Kev
References:
Bogue, E.A. ‘The Relations of the Dental Arches to Pathologic Affections of the Nasopharynx’.
Amer Med. Assoc., Transactions of Section on Dis. of Childhood, 58:110 (1907).
Zentler, A. ‘Relation To, and Influence Upon, Respiration During Childhood of Normal and Abnormal Dental Arches’; Archives of Pediatrics, 30(7):42 (1913).
Brown, G.V.I. ‘The Application of Orthodontia Principles to the Prevention of Nasal Disease’; Dental Cosmos (precursor to JADA), 45(10):765 (1906).
Haskin, W.H. ‘The Relief of Nasal Obstruction by Orthodontia—A Plea for Early Recognition and Correction of Faulty Maxillary Development’; Laryngoscope, 22(11):1237 (1912).
Weeks, S.M. ‘Relation Between Abnormal Breathing and Malocclusion’; Archives of Pediatrics, 30(1):46 (1913).
Kenzie, D.M. ‘Some Points of Common Interest to the Rhinologist and the Orthodontist’; International Journal of Orthodontia, 1(1):9 (1915).
I agree Charlotte!
And the healthiest/cleanest air possible is ‘processed’ air…..processed via the nasal cavity/ turbinates, paranasal sinus complex (PSC) and laminar flow through the posterior choanae into the nasopharyngeal corridor to the alveolar sacs and finally the bloodstream. If ambient air is inspired orally, it will forgoe the aforementioned mechanical (nasal hairs, etc.) and chemical (nitrogen-oxide (N-O) from PSC’s mucosal lining is a powerful anti-microbial, anti-oxidant and vasodilator) ‘processing’; and furthermore Charlotte, nasally-inspired air also confers elevation of ambient air’s temperature and humidity to levels bio-compatible and conducive to maintaining homeostasis and optimal somatic and neurological G&D, which is especially important for young/very young children with LTS.
Children with LTS who have specific ‘physical’ malocclusion phenotypes:
e.g., deep-vaulted and narrow hard palates, lack of deciduous interproximal spacing, grade 3-4 (Kotlow) ankyloglossia, chronic open-mouth posture, vertical growth sensitivity (thank you Gerry Samson)/high angle and/or skeletal retrognathia, etc.,
AND, also display scientifically-validated (by U Michigan’s Chervin PSQ) ‘behavioral’ traits/symptoms that have been identified as being indicators of increased risk for SRDB co-morbidity:
e.g., snoring, mouth-breathing, diaphoresis, bedwetting, bruxism, restless sleep, etc.
I want to thank Dr Jorgensen for his opinions and perceptions of the conference. His comprehensive report needs to be viewed with a touch of healthy skepticism. For example, it is agreed that the conference confirms that “Recent studies suggest that the prevalence of OSA is 1-4% in children of healthy weight”. In contrast, a study undertaken by Larsen et al. reported that in patients treated orthodontically, about 10% received a diagnosis of OSA. That’s up to ten times higher than expected. Are the conclusions of the conference sound?
Larsen et al. Evidence Supports No Relationship between Obstructive Sleep Apnea and Premolar Extraction: An Electronic Health Records Review. J Clin Sleep Med. 2015 Dec 15;11(12):1443-8. doi: 10.5664/jcsm.5284.
The conference also concludes that “There is no evidence that the following cause OSA; the position of the teeth, the width of the arches, etc”. I agree with the findings of the conference that CPAP is the gold standard. But, why do sleep physicians refer non-CPAP compliant patients to orthodontists and general dentists (with advanced training in DSM) for treatment with mandibular advancement devices, which are empirically identical to orthodontic devices for class II cases (e.g. Herbst, Twin-block, etc)? Furthermore, why are these oral appliance procedures approved by the American Academy of Sleep medicine practice guidelines as well as the FDA, ADA, etc., and reimbursed thru medical insurance? Is it a placebo effect or should we ignore these cases (and just let these patients die) since they don’t need orthodontic treatment? Referral to a maxillofacial surgeon can also be considered, but what if the patient can’t afford orthognathic surgery? Although rapid results can often be dramatic and effective in the short-term, about 15% of cases are left with residual OSA. The longer-term outcome is less predictable, simply because of the ageing process. Repeated surgeries are often more complex and the guarantee of getting the desired outcome is lessened.
The good news here is that it appears that the screening, diagnosis and treatment of OSA does not fall within the remit of the specialist orthodontist per se. Forward planning for this pervasive condition in the 21st century may lie in the hands of a new dental specialty with advanced training for the screening, diagnosis and treatment of OSA, leaving any orthodontic finishing in the hands of the orthodontist, if needed.
Dr Singh,
In Dr Larsen’s study, the subject are adults, so it is inappropriate to compare that 10% figure with the prevalence of POSA which is 1-4%
But, why do sleep physicians refer non-CPAP compliant patients to orthodontists and general dentists (with advanced training in DSM) for treatment with mandibular advancement devices, which are empirically identical to orthodontic devices for class II cases (e.g. Herbst, Twin-block, etc)?
I’m confused by this statement. Are you saying that the patient should have a twin block or Herbst to wear full time. What is the orthodontic treatment that would result in this force of pulling the mandible forward and open while sleeping, after the orthodontics is completed. With an oral sleep device, the patients jaw is held in this position all night. When you correct the teeth orthodontically, what is holding the patients jaw forward throughout the night. Surely you are not saying that patients remain in maximum intercuspation at all times during there night. In which case the patient would require some type of appliance at night to maintain this position. At that point it is the device that is helping and not your teeth, or bite. To the best of my knowledge most patients presenting with OSA have an open mouth posture when sleeping and teeth touch during swallowing, with some evidence that there are possible bruxism events following an apneic event.
It would appear that once the device is removed the benefits would not remain.
I have seen bite changes occur in some patients wearing OSA oral devices, and subsequent orthodontics to allow proper function and contact of the teeth after this has occurred may be warranted. But only as a correction of a side effect of OSA treatment, not as a treatment itself.
Dr. O’Brien, Thank you so much for posting this. There seems to be a surge of patients in my area being told they need orthodontics to correct their OSA. Most of which have not even had a sleep study. I am also seeing some of my patients return from multiple specialists with a request for me to consult with them about orthodontics to manage their airway. I look forward to reading the second part of Dr. Jorgensen’s Summary.
Well said Dave Singh
If a mandibular advancement appliance helps OSA in 40 -50 year olds
How the hell can extracting upper premolars to reduce overjet , rather than expansion and mandibular advancement in kids be defended, or taught as treatment technique . Its simply inappropriate, most of the time.
The conclusions of the Larsen study are unimpeachable. Conflating the findings of two different papers, one comparing children of healthy weight, and the other comparing adults with or w/out extractions, depicts an inability to understand the scientific method.
In addition, are we supposed to use unverifiable referral patterns or FDA device approval as existence of a cause-effect relationship when there is data to the contrary?
In what universe does that make sense? That’s akin to correlating unicorn flatulence and tsunamis.
This sort of discombobulated speculation doesn’t even rise to the level of anecdote. Time to accept the facts, and reconcile our beliefs accordingly. No need to create a specialty
What Nonsense. Extraction of upper premolars to reduce overjet is a perfectly reasonable Tx option. Well taught, and superbly defended. Questioning treatment modalities with no knowledge or understanding of the specialty. is what is truly indefensible.
Martian Denbar, I have a similar experience. Others have claimed that the earth revolves around the sun. To them I say, come spend a day sitting in my back yard and you will observe clearly that the sun rises from behind the mountains to the east, and clearly moves across the sky as it circles the earth. Others may have “proof” that this is not so, but I know what I see and I will stick to the truth that is right in front of me. I am with you all the way, what you see in your patients represents the only truth anyone needs to see.
Well written
Thank you Gerry Samson for your quote of Tolstoy. To Richard Pilley’s mention that ‘Tx of OSA lays at the intersection of Respiratory Medicine and Dentistry…..’, I’d like to provide some peer-reviewed support for this speculation of yours (references below); these articles, while of course not based upon an EBM framework because EBM didn’t really begin until after the post WW II Trials at Nuremberg, had all been published not long after Tolstoy published his own not-so-new hypothesis:
Bogue, E.A. ‘The Relations of the Dental Arches to Pathologic Affections of the Nasopharynx’.
Amer Med. Assoc., Transactions of Section on Dis. of Childhood, 58:110 (1907).
Zentler, A. ‘Relation To, and Influence Upon, Respiration During Childhood of Normal and Abnormal Dental Arches’; Archives of Pediatrics, 30(7):42 (1913).
Brown, G.V.I. ‘The Application of Orthodontia Principles to the Prevention of Nasal Disease’; Dental Cosmos (precursor to JADA), 45(10):765 (1906).
Haskin, W.H. ‘The Relief of Nasal Obstruction by Orthodontia—A Plea for Early Recognition and Correction of Faulty Maxillary Development’; Laryngoscope, 22(11):1237 (1912).
Weeks, S.M. ‘Relation Between Abnormal Breathing and Malocclusion’; Archives of Pediatrics, 30(1):46 (1913).
Kenzie, D.M. ‘Some Points of Common Interest to the Rhinologist and the Orthodontist’; International Journal of Orthodontia, 1(1):9 (1915).
I have many more references from medical and dental literature dating back as far as the Tolstoy era that specifically report on the powerful alliance and collaboration between orthodontists and otolaryngologists in preventing and resolving co-morbidities of skeletal malocclusion and naso-respiratory compromise with bi-maxillary expansion……and most often done in the deciduous and early mixed dentition
So, rather than continuance of a debate as to whether, as Prof. O’Brien opines, ‘….there has been no direct causal relationship identified between craniofacial structure and pediatric SDB (I think he means ‘negative Tx-effect upon naso-respiratory competence), why don’t we all drop the debate framework and adopt the more useful and productive form of discourse known as ‘dialectic’? This statement, “It is important to note that there has been no direct causal relationship …….”, is indeed on solid scientific terrain I think and anyone who attempts to claim otherwise will be on the wrong side of the controversy.
But, so as not to be distracted by the veracity of the aforementioned statement, and pretty much become discouraged from engaging in further constructive discourse, please consider omitting the words ‘no direct causal’ from this proposed non-relationship between craniofacial structure and naso-respiratory compromise, and substitute it with ‘a direct co-morbid’. By doing this little wording modification you should see the problem with using terms like ‘risk factor’ or ‘direct causal relationship’ rather than ‘comorbid’ disease phenotypes.
Fantastic comment!
Thank you very much for this post. Cordial greetings from Portugal
The Mandible advances all by itself most of the time without a functional . I cant for the life of me think why you would extract and retract if you can expand and advance. Its a complete no brainer to me .
Upper Premolar extractions =unnecessary blood and pain and distressed patients and parents ,collapse of canine eminence , premature aging of upper lip , loss of upper arch lip support significantly reducing facial attractiveness , the lost opportunity to advance the mandible , longer treatment time, and dead stop to further lower facial growth as the patient ages . Mandibles continue to self correct and overjets continue to reduce as patients age if the upper arch is well developed and held . This happens over decades . This opportunity is lost with premolar extractions.
Add to this mandibular entrapment and mandibular distalisation , admittedly less common but when it occurs causes completely debilitating migraines , neck ache and back ache , and finally OSA, as the patient ages and puts on weight.
Either I (and many of my colleagues) are magical placebo inducing miracle workers , or orthodontics and mandibular position are vitally important to patients long term well being , OSA only being one small part of these considerations .
Hoping not to cause offense to those who don’t share my position , from this soup of lack of hard evidence , but I have masses of clinical examples of freeing entrapped mandibles and increasing posterior vertical that result in removing ;- migraine , depression , neurological attention deficit disorder, back ache and atypical facial pain, in practice. I’ve been doing it 30 years and every now and then I get completely blown away by the positive body impact a corrected mandibular / maxillary relationship and good orthodontics can have. Its not placebo .
Perhaps you should audit and publish some of your “masses” of examples…?
Dr. Doyle , Nicely stated an completely agree with your statement. And you should publish your massive case positive results to releasing mandibilar joints due to extraction cases. Good luck to you.
I must also agree with Dr. John McDonald. Of what use is research if it doesn’t support our fervently held beliefs?
One must simply discard all the evidence-based data if it conflicts with fondly espoused pet theories. Elementary, really.
Of course the mandible advances by itself by just merely wishing it were so. Isn’t it amazing how these “specialists” are not aware of how jaw growth occurs?
Upper premolar extractions also cause loss of cerebro-spinal fluid, distressed teachers, rising oceanic water levels, suicidal ideation and death (of course).
A new procedure called Geno-expansion ® gently stimulates the hemi-maxillae and the hemi-mandible to slide away from each other thus creating room for teeth, tongue, tonsils, etc. In some cases, there is adequate space for a second or third tongue.
This in conjunction with Premolarogenesis® will allow us to meet the genetic potential of our hominid ancestors who had four premolars per quadrant. I totally agree that we must discard the evidence when it does not support our hypotheses…of what use is data if it doesn’t support what we do?
In general, premolar extraction is a brutal and medieval travesty akin to amputation. Do we remove limbs when we are trying to enhance function?
No. After all, esthetics, function, stability, periodontal and TMJ health are not everything. Who is to say that Bimax. protrusion, lip incompetence, drooling, loss of attached gingiva, uncoupled incisors etc. are undesirable?
One simply has to do a better job of explaining to patients why their appearance has worsened substantially – once they understand our concept of Atavistic© Orthodontics, they will leap on board like our primate ancestors.
If malocclusion is a modern development, would harkening back to better times not surely resolve malocclusion by removing the cause? In the famous words of James Hetfield (father of down-picking) “ It’s all fun and games till someone loses an eye… then it’s just fun you can’t see.”
The most common cause of Sleep Apnea is obesity; treating a symptom of Sleep Apnea—snoring—is putting the cart in front of the horse. Treat the CAUSE not the SYMPTOM.
Providing Orthodontic Jaw Wiring Weight-Control (OJW®:Weight Control) as Part of A “Healthcare Team”—A New Service in the Dental Professional’s Office
Video of my Powerpoint presentation to the Tri-county Orthodontic Study Club in Portland, OR: https://youtu.be/451mmOSsSRI
My work demonstrates that Dental Professionals (DPs) are welcomed by the public and as providers of weight control services as part of a Healthcare team that includes dietitians, physicians, psychotherapists and bariatric surgeons. OJW is a fixed intra-oral, bio-mechanical appliance and protocol for controlling compulsive overeating in carefully selected patients who are obese/heading toward obesity, that help them start regaining control over compulsive eating habits with potentially grave health consequences. Patients are wired into the physiologic rest position- “Rothstein’s OJW position of Mandibular Weightlessness” thereby limiting the extent they can open their jaw. Permission to begin a liquid diet is obtained from their physician. The clarity of speech is unaffected.
Seemingly extreme, after seventeen years providing OJW, it is arguably rather a benign non-invasive, safe and effective method, when using my protocol. Under my protocol, the DP is responsible for maintaining the health of the TMJ, Dentition and Gingiva. The PATIENT is responsible for losing weight by dint of their passionate dedication and adherence to a long-term, low-calorie, liquid diet authorized by their physician or proxy (psychotherapist) with guidance from dietitians and nutritionists.
My presentation will enumerate the myriad consequences of obesity, and the DPs function as a member of a Healthcare team. I will describe the appliance and how-why it works. Then demonstrate how to wire the jaws and tell you about the position the jaw is wired into. I will outline the scope of the service including its application to the treatment of OSA/Sleep apnea. I will address safety and effectiveness by referencing to a questionnaire I mounted in 2009. Documents will include the Informed Consent, Poor candidates; how to address problems, and a list of the ten most important elements of the OJW Service.
Submitted to the AAO and PCSO in application form to present work at future meeting.
Peter Doyle, my daughter, who is 16 now wishes to be taller than her current height of 5 feet two inches. After reading you post, it occurred to me that she may be suffering from “dermal entrapment” i.e. her skin is restricting her skeletal components from reaching their true potential. I am considering expanding her dermal envelope using subcutaneous air bladders to stretch her skin in order to “release” her skeleton’s true height potential. Could you please forward me relevant clinical articles about mandibular and other “releasing” studies to support my proposed treatment of my daughters height deficient syndrome? I am having trouble finding a surgeon to insert the dermal releasing bladders.
“CDermal Entrapment”……I like it
Just read your post Ted. Yes obesity does play a major role in OSA, but it is not the only role. About half of my patients have totally normal BMIs or close to. Just as I have patients that do not snore or exhibit EDS having significant apnea. Virtually every patient will have a myriad of cofactors that play into their disease, whether they are skinny or over weight, and there is seldom a single magic bullet.
John, to your point about what Peter commented on, I have had cases where ortho. treatment has artificially trapped the mandible behind the upper anterior teeth. With the use of the MAD the patients jaw becomes advanced. I have had Cl 1 cases when they start and become end-on or mild class 3 cases in a very short period of time. Like Peter stated, not often but have seen it. I have never monitored associated symptoms such as migraine for improvement but will now be on the lookout. I can tell you that I have significant numbers of patients that have improvement with their migraines and AM headaches and bruxism once their treatment is finished.
Kevin, if you want this to be a legitimate thread, how about controlling some that respond with kindergarten like responses. It does tend to devalue the discussion and to make those that would like to exchange ideas simply back away. There is no need to use bullying comments to push a point. As I would say to some on the thread, “Me thinks they doth protest too much”. Selectively choosing one’s research serves no purpose and by yelling louder than the next guy does not make a case stronger.
Sometimes we decide to take sides instead of a middle ground. What this should be about is that if any of us is interesting in managing (in a multidisciplinary team) these patients the conference discussions suggested that additional training is encouraged. These are complex cases where there is not likely a unique cause for the disease (i.e. anatomical obstruction). Hence thinking that any individual measure will “solve” the problem is naive. Also the first line of action (and quite effective in overweight/obese) patients is weight management more than “treatment” approaches. Finally, the pathophysiology of OSA in children and adults is quite different. It seems that we have a better grasp of what MAAs could accomplish in adults but we have a lot more limited information of the potential of adjunctive orthodontic approaches in children and adolescents. We are neither trained nor legally qualified to diagnose OSA. Additional training would not change that legal fact. So a qualified physician has to be part of any treatment approach to handle this disease. For my part I am quiet happy to use either the PSQ or the Stop Bang to refer my patients to the sleep medicine specialist when there are indications of high risk. That in itself is one of the greatest services, likely quality of life altering, I can make to such patients.
Hi Carlos,
A point well-made thankyou.
Rather than providing a dental home for our patients we act as a component of a medical neighbourhood.
I was involved in removing two CPD presentations, related to OSA , from our Australian Dental Association site a couple of years ago. One by a US “Orthodontist” (who turned out not to be an Orthodontist), on expanding kids beginning by 5. The other screening signs for OSA including Tori, scalloped tongue and bruxing but no mention of STOP BANG or other validated screening methods.
Ideologies and belief systems ( desert cults aren’t confined to “The Life of Brian”) coupled with lack of training in EBD at least for baby boomer dentists, a post modernist approach to equivalence in ideas and the way we form up our everyday approaches to patients [1, 2] will persist as a basis for patient management for many.
Another interesting phenomenon in this issue relates to the diffusion of innovation theory and curve[3]. Those who jump on issues such as early dental treatment of OSA see themselves as innovators and early adopters. When new evidence becomes available which is compelling but questions these methods, they become late adopters and laggards but retain their original self-image.
Overtreatment and overdiagnosis with the associated medicalisation of the usual is a big issue in medicine now. This is more complex and confronting again but seems to be a non-issue for much of our profession.
Thankyou Kevin this is a really helpful blog.
Paul Beath
1. Gabbay, J. and A. May, Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. BMJ Br Med J, 2004. 329.
2. Gabbay, J. and A. May, Practice-based evidence for healthcare: clinical mindlines. 2011, Abingdon: Routledge.
3. Rogers Everett, M., Diffusion of innovations. New York, 1995. 12.
One can’t just make claims, and then feign affront or claim to be “bullied” when asked to prove them. It doesn’t work like that.
Where are these findings of the “ hapless mandibles trapped by predatory maxillary incisors” published? What journal?
And pray educate us on where one might find data on a “MAD”, whatever that is. There is no discussion to be had when one side is all emotion and no evidence.
Show us the published data, or quit saying it. Nothing else will even come close to being enough.
“Finally, the pathophysiology of OSA in children and adults is quite different. “ You are missing the point. Children grow into adults so the initiation of disease in childhood predisposes the child to what occurs as an adult. One cannot parcel the end result without acknowledging the etiology.
Great point Martin. When you observe a tall leaning tree, as a sapling, it had likely begun the upwards journey towards our sun, with an ever so slight tilt.
I find it difficult to imagine that, if post-graduate orthodontic training curricula required their trainees to demonstrate competence in pediatric behavior guidance, child psychological development and appropriately managing child anxiety, there would still be such resistance to Dx/Tx of subtle/not-so-subtle malocclusion phenotypes (sapling tilts) in the deciduous/ early mixed dentition.
In a previous response I posted some references to peer-reviewed papers that describe how physicians and orthodontists, from the mid-19th thru early 20th-Centuries, had enthusiastically collaborated with one another on ‘spreading the arches’ under age 7, for the primary purpose of improving, reversing and preventing health problems associated with chronic mouth-breathing and recurrent apnea after adenoidectomy surgery. I wonder if Nicky et al might be even curious about these articles. I will be presenting on these and other papers this summer to The American Thoracic Society and also to The Academy of Dental Sleep Medicine.
Here they are again if interested:
Bogue, E.A. ‘The Relations of the Dental Arches to Pathologic Affections of the Nasopharynx’.
Amer Med. Assoc., Transactions of Section on Dis. of Childhood, 58:110 (1907).
Zentler, A. ‘Relation To, and Influence Upon, Respiration During Childhood of Normal and Abnormal Dental Arches’; Archives of Pediatrics, 30(7):42 (1913).
Brown, G.V.I. ‘The Application of Orthodontia Principles to the Prevention of Nasal Disease’; Dental Cosmos (precursor to JADA), 45(10):765 (1906).
Haskin, W.H. ‘The Relief of Nasal Obstruction by Orthodontia—A Plea for Early Recognition and Correction of Faulty Maxillary Development’; Laryngoscope, 22(11):1237 (1912).
Weeks, S.M. ‘Relation Between Abnormal Breathing and Malocclusion’; Archives of Pediatrics, 30(1):46 (1913).
Kenzie, D.M. ‘Some Points of Common Interest to the Rhinologist and the Orthodontist’; International Journal of Orthodontia, 1(1):9 (1915).
Perhaps you should audit and publish the success of your treatments, Kevin…?
That would be interesting to read.
Dear Nicky(et al)
After having been an invited lecturer there on two different occasions, the chairman of the Orthodontic Dept. from a university in another US state, will be sending one or two of their post-doc fellows to my Chicago practice this summer for the sole purpose of observing our assessment, diagnostic, Tx-planning and Tx-execution (IRB-approved) protocols; they will also be collecting retrospective data from my records for an IRB-approved (from their own institution) study protocol designed to support or refute two research questions/hypotheses.
As I am not a full-time academic Nicky (et al), and see approximately 50-70 patients per day/4 days per week, and am lecturing 1-2 weekends per month in the US, Canada and your neck of the global woods, it is difficult to also publish, but I thank your for your encouragement to do so and am grateful that I will get some much needed research assistance this summer.
So Nicky(et al) let’s get back to my question that’d been specifically aimed at you and a few others on KO’s forum. As most children referred to me by pediatric health professionals in the Chicagoland area who hold staff appointments at tertiary care children’s hospitals with dedicated pediatric Sleep Medicine laboratories, consist of kids who are LTS with co-morbid SRDB and specific malocclusion phenotypes, are you even curious about the references I’d posted citing evidence, albeit circumstantial (as RCT rules did not exist until after the post-WW II Nuremberg Trials) from over 100 years ago that support this practice….i.e., of orthodontists and otolaryngologists (then called ‘rhinologists’) collaborating together? I am anticipating another terse response from you Nicky (et al) that will likely criticize the quality of retrospective study design and pre-WW II research …..but hopeful for something a bit more substantial this time Nicky (et al).
Proctoring a few courses in Evolutinary Medicine (U Durham, UK), anthropology and/or evolutionary biology, maybe reading a few articles about the emerging academic discipline of Evolutionary Medicine or just visiting the NHM in London(I could try to arrange for you to meet with a PhD Anthropology Scholar there who had helped me with my pos-doc data collection at the NHM few years ago if you’d like), might help you think more critically Nicky (et al) about
how/why you might be able to do more to help, rather than ignore, LTS kids with co-morbid malocclusion and SRDB. I am looking forward to collaborating with you someday….soon I hope.
Good luck in getting that work put together and published. I’m sure it will be an interesting read.
Am I interested in spending time reading case reports from the early 1900s…? No.
I find it an interesting situation that nobody on this elite forum seems to be curious about how/why RPE, mandibular protrusion, MMA surgery, etc., as a Tx effect often produces improved naso-respiratory ability in little kids and adults…..loads of published papers in peer-reviewed med-dent literature on this dating back to the mid-19th Century. And furthermore, why is nobody apparently curious about how/why jaws and faces have gotten more and more narrow, retrusive and vertical coincident with cultural industrialization……and how come nobody here wants to talk about Dx/Tx in the deciduous/early mixed dentition (why are so many of you waiting, waiting, waiting? Are orthodontic residents in the UK exposed to didactic and clinical training in managing anxiety and expectations of young children….and their parents when in clinical settings? Just curious about why orthodontists in the UK, US and elsewhere avoid mitigating predictable malocclusion traits when they first become evident.
The conversation here is mostly centered around the controversy of ‘iatrogenic airway disease’ and whether or not retractive and extraction strategies, etc. are contributory. The claim by Dr. O’Brien is that there is no solid evidence to substantiate the claim (that the aforementioned retractive and extraction interventions do indeed ’cause’ airway problems)…..and he’s 100% correct; so why not then change the discourse here and discuss how/why non-surgical and surgical expansion and protraction can often reverse airway disease …in children and adults?
I am a Pediatric Dentist practicing for almost 50 years. From the start, I have been frustrated with the orthodoxy of orthodontic treatment protocols which seem to be more interested in treating the symptoms and not searching for the causes of malocclusion. More interested in the mechanics of moving teeth with success defined as “plaster on the table” as opposed to health and wellness.
Sleep apnea is the end stage of a disease that essentially is a first world problem like hypertension. It is not the normal result of our genetic potential. It would than seem important to see if we can identify the causes of sleep apnea and sleep disordered breathing ( or better defined as breathing disordered sleep) to see if we can reduce the incidence and better treat the disease.
What i see missing in the back and forth discussion about this topic is the understanding that there are multible factors inviolved in developing this disease and no one treatment choice that can fix it by itself. To say that expansion or tonsillectomy or a myofunctional appliance by themselves does not cure the problem is evidence that they do not work is missing the point.
People do not catch crooked teeth, narrow jaws, retracted lower jaws etc. They grow that way because of disfunction. There is a reason that the teeth in skulls in museums from 1000 years ago or in people untouch by modern life have wide jaws and straight teeth. There is also a reason that future generations of those same people that come in contact with “civilization” develop malocclusdions. We are geneticly destined to have straight teeth, so why do so many people have malocclusions? Why do we see relapse after a beautiful orthodontic treatment result ? Were the teeth not moved in to the correct position or is there still untreated muscle disfunctioin pushing everything around?
Orthodontics is not like wood shop. The teeth and jaws are part of a complexed system connected to a living human and not to be moved around witrhout understanding how they interact with and are influenced by the rest of a functioning living organism. The best results are only accomplished when we consider the big picture and not just plaster models or beautiful photos of stright teeth.
I can understand how one of the orthodontists in this chain was frustrated when patients showing up in his office with a “trainer’ from a GP or pedodontist (we changed our name many years ago) after taking a weekend cource. However, the attempt to learn new information about the causes and possible treatment for malocclusion should not be dismissed as quackery even though the myofunctional appliance was never ment to be the only treatment necessary
One of the major concerns for Pediatric Dentists is growth and development. We started providing early orthodontic care to our patients because the orthodontists did not see the need in the early mixed dentition. We knew that we were better starting early because we could use natural growth to correct potential problems. We knew that when we saw a 4 year old with a deep bite, gummy smile and no spaces in the lower incisors, the need future ortho correction was certain. What i didnt fully understand was the reason for the condition of that 4 year old. I also didnt understand the cause of kids presenting with long sad faces, narrow palates,crowded teeth, shinners under the eyes, chapped lips, histories of snoreing and grinding and restless sleep and ADHD were connected to disfunction and airway issues that could be addressed.
One of the most exciting moments in my professional history was when i understood the causes of malocclusion and problems of general wellness was directly related to proper nasal breathing, proper tongue posture and proper swallowing habits and that i could help. I never thought i would discribe mysef as a holistic dentist but that is what i have become because I now can make a difference in kids dental and physical well being.
The answer, I believe, is that no one approach can solve this problems but an approach using both mechanical orthodontic techniques and appliances in combination with myofunctional treatment can produce the results and health we desire for our patients. We can eliminate or greatly reduce the risk for sleep apenia if we see kids with symptoms early and provide treatment early especially if we work with other medical provider.
I hope we can all be open to understanding how new information and working together can expand the scope of what dentistry can provide and add to the overall overall health for our patients
I’m a dual-trained pedo-ortho and have been practicing for more than 55 years. I have seen a lot of claims made over the years, including Ricketts, Roger Price, Mew etc.
My own study and experience has allowed me to make certain observations if I may – Myofunctional therapy and all these “environmentally-based” protocols are unfortunately bordering on junk science.
I have followed these “protocols” and have seen the horrendous results they have produced. I had to re-treat hundreds of these patients with premolar extractions. Similar to Dr. Tweed (who I used to criticise).
For all these myofunctional and sleep apnea people I say – shame on us for being so gullible and naïve and to discredit good orthodontic researchers like Dr. Johnston.
I am 82 years old and still follow your blog Kevin. Keep up the good work!
Dr. Lozano, as a 72 year old Pediatric Dentist, I have incredible respect and admiration for your ability to still be in the trenches. Like you, i’m sure you are a G.V. Black educated dentist and you have seen an incredible number of ideas and gimmicks come and go in you time in practice. We all have closets full of materials and appliances that didn’t past the test of time.
I do have to disagree, however, with your feeling that treating breathing and swallowing dysfunction makes us gullible and naive and discredits good orthodontic research.
The evidence for breathing with your nose and not your mouth to promote good health and development has been well documented from ancient to modern times. The evidence that we have evolved, as we have become “civilized”, to humans that have trouble sleeping, breathing and need machines to force air down our throats to stay alive should be concerning to all of us.
The problem is not how we treat the end stage of disease but what can we do to help prevent it and asking ourselves are we doing anything to make it worse.
Making the mouth smaller by extracting bicuspids, headgear to push the dentition towards the throat, not having a sufficiently wide palate for the mandible to advance and both A and B point back and down from its normal genetic potential makes things worse not better. It also contribute to relapse and re treatment because of muscle dysfunction and no place for the tongue except down the throat
I’m sorry you have had negative experiences with the myofunctional appliances you have used. There is nothing magic about them. They are exercising devices that help teach proper function. I tell the parents that when you go to the gym, you have to pick up the dumbbells not just look at them for results. All I can say is that with experience and training and good systems and people they work and change lives .And when we finish with
traditional bands and brackets, we have healthy beautiful kids that have smiles that last a lifetime.
I hope I make as long as you have.
Peace and Good Health
Dear Dr. Lozano
With all due respect sir, per your several decades of practice….and especially for having had the courage to try some ‘alternative’ (to your conventional orthodontic training) intervention strategies, I would be appreciative if you might post records of some of your stated Tx failures that resulted from your having utilized/implemented concepts learned from John Mew and Bob Ricketts. And, as you are only human, might it be a possibility that you’d made some errors (i.e., you did not stay within the outlined guidelines of Mew’s and Ricketts’ protocols) in executing treatment of some of these admitted failures? And please tell me/us how early in a child’s life you are/were comfortable treating a mouth-breathing child with co-morbid malocclusion.
Thank you for considering.
“Children grow into adults so the initiation of disease in childhood predisposes the child to what occurs as an adult” – Yes. That is what usually transpires.
What disease is “occurring”? How will you “prevent” this? You cannot make claims of “preventing” something which would have never occurred. Where is the RCT which would support these statements?
Dr Mulroney asks “how can you prevent a disease that has never occurred?” The answer , I believe, is prevention is all about preventing a disease before it occurs. A large part of prevention is recognizing potential problems and behaviors that will lead to disease if we do not intervene. That means we teach oral hygiene and proper nutrition to prevent dental disease. The same goes for bad habits and muscle dysfunction that can lead poor growth and poor health.
The kids we see early with open or deep bites, gummy smiles, narrow jaws, no spacing in the primary teeth, tongue tied, dark circles under the eyes, chapped lips and caries are in most cases not healthy. If you ask the parents about these kids you will many times get histories of snoring, grinding, restless sleep, ADHD concerns, bed wetting and being tired . These kids are good candidates for breathing disorders, sleep apena, diminished physical and cognitive growth and early death from cardiac disease from poor sleep and breathing.
If we can see these problems early than we can save these kids from the inevitable with the combination of myofunctional and traditional orthodontic treatment.
Nothing is 100%, but this works and changes lives. We can help children maintain good health and a smile that lasts
Dear Richard
I think what you are asking is important. Will you please describe proposed RCT protocols that might be designed to support or refute ‘What disease is “occurring”? and how will you “prevent” this?’
Thanks for considering
Hello Dr. Lozano and Kevin.
I’m a general practitioner who did orthodontics for many years.
I used these technics of Ortotropics, myotherapy even the Biobloc, ALF and DNA.
They seemed to work ok for a few patients, but failed miserably in a lot of the others. The relapse was almost 100%. I had to refund several and referred patients to three orthodontists who were nice enough to accept and help re-treat these patients.
One of them told me about Dr. O’Brien. When I attended to Dr. O’Brien’s lecture, I began to realize that the stuff I believed in was not based on good science and a lot of it was just made up!
I wish these therapy worked, but in fact, to my sorrow, it does not. Even though traditional orthodontics is more effort and discomfort, there is no doubt it works and very stable compared to myofunctional and orthotropics.
I no longer do orthodontic treatments…only general dentist. But, it was painful learning experience. Lesson – Learn to listen to wise people.
Thanks for your humility James!
I have followed this discussion with interest. With regard to Martian and Kevin Boyd, I had similar thoughts and ideas. I am a standard orthodontist of 47 years.
I too began my career with Begg and Tweed and then turned towards Mew, Hang, Singh, Guilleminault and others.
They has convinced me to consider alternative therapies such as the Biobloc, DNA appliance, ALF. I treated every case with this new approach because it seemed to be more preventative and less invasive.
It took 5 to 9 years to see the relapse of patients treated with this philosophy. I had sold the office by then, and the new orthodontist shared all these records of collapsed arches, protruded teeth and worse. It was very humbling.
A lot of effort went into fixing this the second time around. I have since realized that if it sounds too good to be true, it probably isn’t. I see the same issues with the Sleep Apnea claims . I used to think the same things and used the same approaches, but I was wrong.
Orthodontics is a very complicated science and one cannot treat every case with the same treatment plan.
After 47 years, I have noticed that I’m extracting even more than ever….this is in contrast to what I used to do.
And now I have learned from my failures. Hope my experience can prevent other people from the same folly.
I know this comment is old but this was a very interesting read! Would you be willing to share more about what you saw happen to these airway patients? Do you mean that the collapsed arches and protruded teeth were caused by the expansion treatments but took several years to actually appear? I’ve been recommended to do an expansion treatment (DNA) as an adult so I’m gathering as much info on it as possible. I’m finding it highly suspicious that most people I’ve talked to are either current patients or providers who’ve been doing it for less than 10 years…it’s impossible to find anyone with a long term success story.
I got this message in my email today “Hello Dr. Singh, My name is xx, I live in xx and have just recently been diagnosed with moderate sleep apnea after a sleep study. I have had orthodontics (twice) have been told that I swallow incorrectly and have sinus congestion and ear fullness and pain. I am also seriously claustrophobic and am not interested in wearing a CPAP mask at night.” (I have also seen patients who were previously surgically-treated with similar outcomes.) Based on the discussion on this forum, my dilemma is both ethical and practical.
A few evidence based comments need to be brought to bear in this conversation. In 2005 Stanford University Center of Excellence for Sleep Disorders, published an American Academy of Sleep Medicine Report entitled “Practice Parameters for the Treatment of Snoring and Obstructive Sleep Apnea (OSA) with Oral Appliances: An Update for 2005
In this report it was stated that “Oral appliances (OAs) are indicated for use in patients with mild to moderate OSA who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP.” Reference for this lengthy report was Kushida CA, et al, Practice parameters for the treatment of snoring and OSA with oral appliances: an Update. Sleep 2006; 29(2) 240-243
Shortly after this report came out I was contacted by the Sleep Center located in the local hospital in my community and ask if I would be interested in providing care for patients who fit the criteria indicated in the Stanford report. Their request was somewhat in the form of a plea related to their many less than stellar CPAP results (mostly based on the lack of patient compliance). After a bit of research on my part I agreed and for the next several years I provided oral appliances for several patients referred to me from the sleep center. All of these individuals had previously been subjected to a sleep study at the hospital and had consulted with a sleep physician. I had 17 successes (patient responses and sleep study results) In my review of the literature during this time, as to the efficacy of oral appliances, I was made aware of 1475 references but only 14 RCTs. The majority of these studies showed improved subjective outcomes with MADs (mandibular advancement devices) reason being that the main causative factor of adult OSA is age related loss of tenacity of oral structures, mainly the tongue. A large portion of tongue musculature attaches to the lingual surface of the mandible and thus any MAD that holds the tongue forward a sufficient amount, such that, while sleeping, the tongue in its relaxed state, cannot fall back and block the airway, is beneficial in helping to treat OSA. A student of the refereed literature on this topic will be made aware that the recent AAO conference provided very accurate information along these lines. Awake individuals do not suffer from OSA, only while sleeping does it occur. While awake, if nasal breathing is difficult as the result of allergies, sinus infection etc. oral breathing occurs, no matter what is occurring or has occurred in the oral cavity. That same oral breathing occurs while sleeping. It is the age related lack of muscle tonicity that allows the tongue to fall back blocking or partially blocking the airway. Obesity with fatty deposits (mostly men) in the neck contributes to the problem.
The down side of oral appliance therapy is that the MAD devices act as functional appliances resulting in forward mandibular tooth movement which can have very undesirable impacts on the occlusion. The patients I was treating did not seem to mind, out of desperation I believe, but I eventually ceased providing this care as I came to believe that CPAP (or mandibular advancement surgery) is the best long term modality of treatment for OSA.
OSA in children is a totally different issue as it relates to tonsillar and adenoids tissue.
Providing Weight-control in your office, be it for Weight-control per se, or eliminating Sleep Apnea (Snoring) by eliminating the Major, Most Common CAUSE of it, seems more sensible than the devices we currently offer. I speak from EXPERIENCE having tried not less than four different types of them and finally the CPAP—UGH to all of them. When my wife decides she’s had enough of my snoring (BMI 26) she heads off to the guest bedroom.
Below find my criteria for providing my Weight-control service. *
Here’s some good articles:
https://www.ncbi.nlm.nih.gov/books/NBK441909/
Apnea, Snoring And Obstructive Sleep, CPAP
Jawedulhadi Memon; Susan N. Manganaro
The major predisposing factor for sleep apnea is excess body weight. It has been estimated that 58% of moderate to severe OSA is attributable to obesity. The etiology of OSA involves both structural and nonstructural factors, including genetic factors. Structural factors related to craniofacial bony anatomy that predisposes patients with OSA to pharyngeal collapse during sleep, e.g.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5181619/
Obstructive Sleep Apnea without Obesity Is Common and Difficult to Treat: Evidence for a Distinct Pathophysiological Phenotype Emma L. Gray, et al
Results: Twenty-five percent of the participants with a diagnosis of OSA had a body mass index (BMI) within the normal range (BMI < 25 kg/m2) and 54% had a BMI < 30 kg/m2 (nonobese).
My work demonstrates that Dental Professionals (DPs) are welcomed by the public and as providers of weight control services as part of a Healthcare team that includes dieticians, physicians, psychotherapists and bariatric surgeons. OJW is a fixed intra-oral, bio-mechanical appliance and protocol for controlling compulsive overeating in carefully selected patients who are obese/heading toward obesity, that help them start regaining control over compulsive eating habits with potentially grave health consequences.
I currently provide this service in Brooklyn NY and have done so for the past eighteen years. I have treated 200+, patients most of whom have come from everywhere in the United States. I recently opened a second office in Salem, Oregon to provide the service. Moreover, I teach Dental professionals how to provide the service in accordance with their state’s code of dentistry.
I ardently believe that OJW: Weight-control is a service that dental professionals will and should provide with pride and pleasure in their own communities. And that the overweight will applaud our efforts to help them. My experiences providing this service have demonstrated that the patients are deeply grateful for the opportunity to begin regaining control of their compulsive eating habits.
*Good Candidates for OJW: Weight-Control:
BMI is between 28 and 38
Overall health is still good
Failed at previous methods of weight control
Are looking to jump-start an attainable weight-loss goal
*They consider weight-loss medications out of the question
and Weight-reduction gastric surgery too risky
Are eating "mindlessly" when not hungry.
… Or are experiencing Binge-Eating-Disorder (BED)
*They are DEDICATED to and PASSIONATE about Achieving and
Maintaining a weight goal
The way it is worded anyway Dr. McDonald, your ‘….OSA in children is a totally different issue as it relates to tonsillar and adenoids tissue.’ seems to imply that there are few, if any, structural mal-developments (e.g., retro-/micro-gnathia, deep/narrow palatal vaults, ankyloglossia, etc.) that might predispose a child (whilst in their primary/early mixed dentition) to increasing nasal disuse and habitual mouth-breathing; and, that ATH is the primary etiological component in the pathogenesis of pediatric SRDB. This ‘ATH hypothesis’ for Dx:peds- OSA is opposed by Christian Guilleminault, the discoverer of peds OSA in 1976, and others. Please review a recent paper on this controversey sir. https://www.ncbi.nlm.nih.gov/pubmed/30165336
For those that have responded on this blog that they have had relapses, I would be curious how many can go back to their charts and document the kid’s resting tongue position, normal or abnormal. Did you document their swallow pattern or side plumb line? How about severity of tongue tie. You know from the last 50 years. I see all the time the nice flat face of the post ortho. patient in the 30-60s with missing bicuspids, low tongue level, reverse swallow pattern, forward head position and tongue tied. Yet I am hearing how “the studies” that do not even take these issues into account are the gold standard at this point in time. Any study that does not document tongue level, swallow pattern or side plumb line cannot hold the validity it states it has. To many uncontrolled variables since it would be assumed these factors play no role. Doesn’t the word assume have another meaning?
To another point I read earlier, I have yet to hear that anybody say MFT is a cure all. It can be one part of a myriad of issues that can be corrected. There are no silver bullets here. I have had patients from age 6-70 go through the treatment with good results. It is only a part of the answer but in the end all the parts make up the whole. For those that naysay it, how many of you docs have had patients have it performed? How many naysayers are such from actual clinical experience or just from reading. In dental school we called these doc talkadontists. Our office does MFT over Skype using telemedicine and have had pretty darn good results over the last 4-5 years. My therapist is in San Antonio and my office is in Austin.
The biggest issue is this, the general public is not having access to this knowledge, whether you agree with it or not, that can have a significant impact on their personal appearance and other health consequences. Ken, myself and others post research and it is either ignored or told it does not meet muster with the “profession”. I would recommend the “establishment” open their eyes, whether they agree or not, and start to perform research that includes the input from individuals like Ken Boyd, Bill Hang, Barry Raphael and others. There could be forces in the future that move the profession quicker than it wants to move with the GP’s and airway centric orthodontists in a stronger position and taking a leading role. By the way, let’s not all be sanctimonious and point to failures of others using one technique or another when I know that conventional ortho. never has any failures or relapses. You know, when I was doing general dentistry all my patient’s flossed, I never had a shy margin and I never broke and endo file or root. Isolating a few cases, particularly when the doctor is not fully adept at a technique and then throwing the baby out with the was water is a bit disingenuous.
IT is quite amusing to be “lectured” about orthodontics by someone who know so little about it.
Even with 55 years of experience, I find myself learning from other knowledgeable professionals; however, extraordinary claims require exceptional evidence.
My experience and that of Dr. Murray and To is the complete opposite of Martian’s claims and the evidence.
So Martian, where can we find a peer-reviewed paper documenting your findings?
I find most of your claims to be unverifiable or unlikely. You would be better served by trying to publish your cases or at least show us something but words. Do not cast stones on things you do not understand.
Hello Dr. Kevin Boyd –
That depends on the “disease or condition” under study, and if there even is a suspected Cause/Effect relationship.
For example, as the data irrevocably shows, there is simply no relationship of that nature between extractions and OSA.
Martian and others have posited one, but have consistently failed to provide any sort of proof other than just their opinions. We are way past that in our field.
As Hitchen’s Razor states, ” The burden of proof regarding the truthfulness of a claim lies with the one who makes the claim, and if this burden is not met, the claim is unfounded, and its opponents need not argue further in order to dismiss it”.
In other words, we don’t have to prove Martian wrong. He has to prove himself right.
Now, going back to your point regarding design of the study, you would need a homogeneous patient population randomized to the intervention and a control group. With appropriate blinding and stratification.
The problem, of course, is how long should the follow-up last? 10 years? 20 years?
Which is why Larsen and Rugh conducted their excellent study looking retrospectively. And they found no relationship. Ventum Est Ad Arbitrium
Dear Richard-Thank you for your reply.
Just to reiterate the conversation so Kevin’s readership doesn’t have to scroll back and forth, on Feb 7 you made the statement, “– Yes. That is what usually transpires.” in response to Martin Denbar’s “Children grow into adults so the initiation of disease in childhood predisposes the child to what occurs as an adult”; and you replied to MD,
“What disease is “occurring? ” and, “How will you ‘prevent’ this? “You cannot make claims of ‘preventing’ something which would have never occurred. Where is the RCT which would support these statements?”
First off Richard, you mention early in your response to my question*:
“For example, as the data irrevocably shows, there is simply no relationship of that nature between extractions and OSA.”. I’d like to caution you against the usage of the word ‘irrevocably’ when attempting to support your speculation; please read CG’s paper on this topic (‘Missing teeth and pediatric obstructive sleep apnea.’
Sleep Breath. 2016 May;20(2):561-8), which concludes:
CONCLUSION:
Alveolar bone growth is dependent on the presence of the teeth that it supports. The dental agenesis in the studied children was not part of a syndrome and was an isolated finding. Our children with permanent teeth missing due to congenital agenesis or permanent teeth extraction had a smaller oral cavity, known to predispose to the collapse of the upper airway during sleep, and presented with OSA recognized at a later age. Due to the low-grade initial symptomatology, sleep-disordered breathing may be left untreated for a prolonged period with progressive worsening of symptoms over time.
And your suggestion that a prospective, 10-20 year(longitudinal) and blinded RCT might actually be an ethical endeavor (survive the rigors of IRB process) seems unrealistic sir…..and a retrospective study design I think is a good alternative, but professor O’Brien will tell you that it is far inferior (low level of evidence)to prospective RCT.
That said, I really appreciate this discussion with you and hopeful we can continue to work collaboratively towards productive solutions with problems that face the children whom we all care about
*(KB’s question for Richard: ‘I think what you are asking is important. Will you please describe proposed RCT protocols that might be designed to support or refute ‘What disease is “occurring”? and how will you “prevent” this?’)
Dr McDonald: I don’t understand your logic. You initially state that patients were referred to you because of a lack of compliance with CPAP – but you end your statement by saying that you prefer CPAP (inter alia). My dilemma remains unaddressed. What should we do for patients today, in the light of the AAO’s preliminary consensus, for those that are CPAP intolerant and can’t afford surgery?
Hello Dr. Boyd –
Just to elucidate a bit – I have actually treated 1000’s of patients in the decade and a half that I used all these modalities. Saw Mew, Hang and others multiple times over the years. Used ALF, DNA, Biobloc, MFT and some functional appliances as well. I have treated children as young as 4 ( IT does not work!!!)
One can claim error once or twice, but when 85 to 90% of the cases end up with protrusion, incompetent lips, mentalis strain, relapse and some with recession, one has to wonder! And then we had 5-7 other practitioners in our alumni association at LLU who all reported the exact same findings.
Nay Sir. The fault is in the baseless claims made by Mew and others that FOOLED me and several colleagues. I am very embarrassed that I got taken in by quackery.
I discovered Dr. O’Brien (not too late!) and re-discovered Prof. Johnston and I’m now doing penance for the years of uncritical subservience to now-debunked nonsense. I would like to publish my cases in the same journal as the successes that Martian and others claim. What journal is that?
Dr. Yarmosky –
That’s all well and good, but why believe it will occur? That’s like saying daily shin-kicks will prevent multiple myeloma. That does not approach the burden for even the most minimal level of scientific credibility. There is no connection whatsoever. If you think there is, prove it.
Dr Singh,
The patient that wrote to you seems to be suffering from a swallowing problem, sinus congestion, ear fullness, pain in an unspecified area and is claustrophobic. Furthermore, he/she is “not interested in wearing a CPAP mask”. (They do not say that they are unable, just not interested). I would suggest that you write back and suggest and ENT for the sinuses and ear fullness, Speech pathology for tongue training, and a mental health expert for the claustrophobia. Furthermore, suggest they follow the recommendations of the health professional that requested the sleep study. (Weight loss is probably involved since that seems to be generally recognized as the primary cause of OSA). Then explain that as an orthodontist, there are no treatments that you can provide that have been shown to be even mildly successful in the treatment of this life threatening condition. You can tell him/her that in fact a major conference sponsored by the AAO just confirmed that orthodontic treatment has no curative benefits relating to the treatment of sleep apnea. There is no ethical or practical dilemma here. You can offer an oral appliance informing them of the reported 65% success rate. Other proven treatments are outside the scope of you dental license. (with the possible exception of the jaw wiring treatment.)
Dr. McDonald, I was at the conference and participated in its design. This statement: “You can tell him/her that in fact a major conference sponsored by the AAO just confirmed that orthodontic treatment has no curative benefits relating to the treatment of sleep apnea” is misleading I feel. There is currently thin evidence, most of it performed without controls, anecdotal, etc that would lead one to believe that certain orthodontic interventions in certain patients are in fact effective. Our challenge is determining which patient needs our help and which ones don’t. There is no current study that lays that out with certainty. That does NOT mean that orthodontic intervention has no curative benefits. Two of the speakers were advocating RPE’s for narrow palates, not just crossbites. So, who’s right? Time will tell and studies need to be done. The question has not been decided, not by a long shot.
Dr McDonald:
Thank you for your reply. I can certainly follow your suggestions but experience is the best teacher. The patient has a diagnosis of moderate OSA. Are you saying that this should now be ignored and other associated signs and symptoms be addressed instead? You make the assumption that the patient is obese – but what if that is not the case? You stated that patients were referred to you because of a lack of compliance with CPAP – and ended your statement by saying that you prefer CPAP? I guess we could refer this patient for CPAP but what is the prognosis for success given the fact that the patient appears to associate two past orthodontic treatments with current craniofacial concerns? Doing the same thing again and expecting a different outcome doesn’t appear to be the best option. We could consider a mandibular appliance but what if the patient has a Class III profile? As an orthodontist you were taught to correct this condition not exacerbate it. The ethical/practical dilemma persists – since the first rule of medicine is do no harm.
Dr Singh,
You seems to be mixing up the two Dr McDonald’s. Maybe you should read the post and answer them separately. I do think that Terry and John are two different persons.
This conversation thread make me think of how many academic arguments have occurred since man/woman began to use their BIG and more developed brains . And I just can’t help but to think about those who used to argue about “if babies feel pain” (see below) and how tightly some held on to what they “knew” to be true based on what was likely the “most up to date medical literature” at that time. At the very least, shouldn’t we keep an open mind and admit that NONE of us know it all ? NO matter what residency program we completed? I think if we all got more comfortable (AND CURIOUS) with the idea of being the “dumbest person in the room rather than the smartest” we could continue to learn a thing or two and GROW our minds and do great things – isn’t that what innovation is all about. If no one ever questioned the “status quo” of the time, in medicine or dentistry, we would still be blood letting to treat the bilious humors and not washing our hands (thank you Louis Pasteur – I am SURE you were also considered to be on the FRINGE as well way back when. ) If one knows EVERYTHING already, what is left to even think about? Are we not at least life long learners? Are we always looking backwards and never forwards? Are we always proving WHAT we know and not asking ourselves what we DO NOT know? The very FACT that we even talking (or arguing) about the topic of our roles as dentists in airway issues MEANS that change is on the horizon. One can choose to look the other way, be an impediment to change or get CURIOUS, truly curious about some of the improvements to the QUALITY OF LIFE quite a few of us are making in some children’s lives, including our own. And with those QOL improvements, often “straight teeth” are at the bottom of the list.
http://www.bostonglobe.com/ideas/2017/07/28/when-babies-felt-pain/Lhk2OKonfR4m3TaNjJWV7M/story.html
Nicely said.
And there you have it. The last refuge for those devoid of data – The “There’s so much we don’t know” crowd.
When really, they mean there’s so much we refuse to accept. How “open” should our minds be?
Do we ever accept anything as true? Is the Earth truly flat?
Does “true learning” mean being in a state of stuporous denial punctuated by paroxysms of specious logic?
All these meaningless, meandering platitudes and aphorisms are a thinly-veiled attempt to discredit excellent science and pedal an agenda either due to financial or other motivations.
The only impediment we represent is to patients getting hood-winked by unscrupulous purveyors of serpentine unguents.
Sorry. That will not work either. No data = No dice.
Dr. Yarmosky – It can be difficult to accept the truth, but we have too. I too believed many things and was proven wrong when the science came out. Kevin is a unbiased reasearcher and there’s a reason he has this blog.
Autism and vaccines were something I thought were connected. Not so.
In the last few years, I have been traveling around speaking at orthodontic and pediatric residency about my experience. Many were amazed to hear that and they are all going to reinstate extraction therapy again. I feel vindicated for all the horrible cases I unintentionally mistreated.
Taking out bicsupids doesn’t do anything but tremendously improve breathing. Point A and B need to come back many times…and we do that all the time now. As you well now, all that making the mouth smaller stuff is just pure nonsense. And, several mouths need to be made smaller to appear human and not primate.
Now that both the evidence and our own experience shows that it is the best treatment. We will not listen to anybody else since they offer nothing of substance. These opinions you make has no basis in reality.
We have been fooled too many times by smooth talkers. I have my results to stand back on, both from times I did things wrong and from the times of the revelation. I hope you can learn from me. God Bless.
Dear Dr. Boyd – In case you didn’t know, as one poster noted, that coffin has been nailed shut!! Come sir, let’s move away from that sarcophagus!
I have zero respect for CG as an authority in orthodontics, especially after proclaiming us “Murderers” at the conference.
Larsen and Rugh , Sir. That is the data not CG’s maladroit attempt. There is simply no going back, or reason to revisit this graveyard.
Even Kevin O’Brien commended the Larsen and Rugh study, so your statement is inaccurate.
Regards,
Rich
Dear Rich
Will you please elaborate on which part of which statements contain inaccuracies.
Thanks for considering helping me understand where I may have gone astray
Kev
Dear Kevin – All the statements regarding extractions causing OSA or contributing to it, are just plain wrong. Larsen and Rugh proved it. Anything else may be up for discussion, but all productive debate will cease if efforts are made to rehash pseudoscience.
Cheers,
RM
Since my practice deals with the adult train wrecks with AHI’s of 50 and above, some over 100 with nadirs down to the 40% range, post stroke cases, Parkinson cases, heart failure cases, transplant cases, etc. I thought I would make another comment. I realize it is just coincidental that many of these patients are missing bicuspids, have low tongue levels, high palatal vaults, reverse swallow patterns, obligate or intermittent mouth breathers and forward head position. Dollars to donuts, I would bet that few if any of the orthodontists on this thread even check for swallowing patterns, tongue level, tongue tie or head position. Doing the same thing for 50 years just means you are doing the same thing for 50 years. I have yet to see any adult patients, maybe one or two, with normal palatal vaults that have apnea come through my office. That is looking at about 350+ apneic patients/year so I feel I do have a basis to make that comment. Sorry, no formal research so for some just forget that I said it as the comment is anecdotal.
I am proud to say that my office is a leader with Combination Therapy using an Interface. Having published case reports and lower level research, only high level can really be done at the university level, I have been told that “I was not supposed to do that” by one dental school. Patient’s family really appreciated academia’s support and that the articles I published about “untreatable” cases were realty worthless since they were considered anecdotal. If I had not opened my eyes to potential new therapies where would hundreds of “untreatable” patients be today.
Some of these comments remind me of a chapter from the book Century of the Surgeon. A practitioner would remove the thyroid and the patient’s thyroid issues would be cured. Patient went home cured and the doc felt he was a genius. One day one of his patients came back to visit but he was now a cretin. Good intentions and actions have consequences, sometimes not the best. This is not a simple subject, nothing being proven by a few studies that more than likely have not considered a whole host of contributing factors that were not considered. As Einstein said, “Don’t let your education get in the way of your learning”. I may not be an orthodontist, but since probably over 50% of my cases, all adults, are missing bicuspids, that duck is quacking awfully damn loud or I have cornered the market for outliers.
Dear Kevin – I have been a follower of your blog since it’s introduction. I think this is a very useful service. However, there have been several episodes of commentary notably by some of the supporters of these unfounded therapies, who present no data, yet levy allegations against the specialty.
These allegations are providing fodder for unscrupulous practitioners to instigate actions against evidence-based practitioners, while in reality, it should be the other way around! Martin has made several such statements but never has any proof.
This is a very dangerous trend, in my humble opinion, and should be looked at seriously. Please note the latest AJO editorial by Jim Macri. This is exactly the scenario that occurred.
There must be consequences for these type of inflammatory and inaccurate claims. Patients and the specialty are endangered when fringe practitioners make patently false allegations. I encourage the specialty, and the governing bodies to curtail non-evidence based practice.
I believe we can also use our common sense (if you are lucky to have it).
We know that when we expand the maxilla we lower AHI and our patients breathe better. We know that mandibular advancement surgery increases retroglossal airway and also diminishes AHI. IMDO surgery does it as well, and even in a better. Maxillomandibular advancement surgery is also an effective treatment for OSA.
The statistical methods in medical research can only show if differences between study groups are not explainable by chance within a predefined margin of error. Not finding differences does not mean that they do not exist. Study designs and avoiding biases are very important in order to find those differences.
And more importantly is to have common sense that allows to interpret all those data and also compare them to the rest of the scientific knowledge (like physiology, pathology, anatomy…)
Is it unscientific to think that we can also impair the airway and health of our patients if we make their jaws smaller by means of… extractions, for instance, or some appliances?
Is it unscientific to think that within the opportunity costs of refusing treatments proved to improve airways there is and increased chance of having an affected airway in the future, when our patient ages, gains weight and have less muscular tone in the muscles of pharyngeal wall?
Isn’t it unethical to withdraw all this information when explaining treatment options to our patients to increase our conversion rate and treatment acceptance rate?
Now that a dentist, who has described how forward growth prevents osa, has been put on trial, his you tube views are soaring at an exponential rate. His natural methods of tongue posturing and chewing are gaining popularity, and parents and children are showing each other how to chew like squirrels for alignment of erupting incisors. They have a good point: squirrels chew with precision, control, and the same number of strokes per side.