What do I think of the AAO white paper on sleep-disordered breathing?
I have decided to review the AAO paper on sleep-disordered breathing. This follows our earlier post from a few weeks ago, where we highlighted the main recommendations of this significant AAO publication. Since then, I have had the opportunity to read the report more thoroughly. I will focus on the sources they used to make their recommendations.
This post is rather long, but I want to cover a lot of information. I will not be posting much about this subject in the next few months, unless a useful research paper is published.
Introduction
First, I would like to examine the definition of a white paper. This varies between countries. The definition for the USA is:
“An authoritative, in-depth report that analyses a specific health issue to educate stakeholders, propose solutions, or influence decision making. They are positioned between peer-reviewed research and marketing.”
Importantly, it is not a high-level research paper or systematic review. It is worth noting that the authors do not adhere to systematic review methodology.
Therefore, we should remember that a white paper presents a series of conclusions based on our best available research. It is important to recognise that these are recommendations, not mandatory requirements, and are therefore not compulsory. Nonetheless, this paper offers guidance for the future, as it contains solid clinical advice.
Is this important?
I also wonder how significant an issue sleep-disordered breathing and orthodontics are worldwide. As with many aspects of orthodontics, the push for “new” treatments and changes seems to originate from the USA. This is probably due to the greater number of orthodontists in the USA compared to other parts of the world.
I am also aware that some of the most vocal social media outputs and groups are USA-based. Subjectively, when I have seen comments from other countries, they tend to be more conservative, traditional, and possibly more grounded in science.
Therefore, we must keep in mind that the content and focus of this white paper are likely more relevant to the United States than to other parts of the world. Certainly, when I consider the UK, there doesn’t seem to be a strong drive to implement airway-focused orthodontics, apart from a few of the “usual suspects” who adhere to the mantra of orthotropics and other fringe treatments.
As a result, we need to be careful not to become dominated by USA-based orthodontics, as there is a risk of wasting a considerable amount of time.
In this context, I have decided to review this white paper.
The panel
It is evident from the information on the panel members that this is a carefully assembled group of experts. The panel comprises a mix of practitioners, representatives of the AAO, and research academics.
The Introduction
This was well written and clear. I was particularly impressed by the way they described the somewhat confusing situation of sleep-disordered breathing (SDB), its medical and surgical treatments, and the role of orthodontics. Importantly, they pointed out that sleep-disordered breathing is a continuum, ranging from snoring to obstructive sleep apnoea (OSA).
They also emphasised that SDB is a medical condition. Consequently, only a physician can diagnose SDB in the USA and Canada (and in the UK). This means that the diagnosis would fall outside an orthodontist’s scope of practice.
Nevertheless, orthodontics does have a role in the interdisciplinary management of SDB, particularly in children. This includes conventional orthodontic treatment, screening, referral, and some interventions.
When we consider the nature of the disease, SDB is a heterogeneous condition with variable treatment responses. It is influenced by both anatomical and non-anatomical factors. The former include soft-tissue volumes, such as enlarged adenoids or palatal tonsils, fat infiltration, and potentially reduced skeletal volume. Non-anatomical factors include the neuromuscular function of the pharyngeal musculature.
Importantly, prepubertal OSA tends to resolve naturally during the transition to adolescence. This, of course, coincides with orthodontic treatment. As a result, we believe that orthodontics can help treat SDB.
Now I would like to review what I consider the most important recommendations and the underpinning research.
Craniofacial form and OSA.
Traditionally, we think that OSA is associated with certain craniofacial features, such as increased facial height, mandibular retrusion and craniofacial disharmony. It is often stated that these are aetiologic factors in OSA. As a result, some suggest that correcting these skeletal problems will cure SDB.
The panel pointed out that there is limited evidence for these concepts. The source of their evidence was 2 systematic reviews.
One of these studies was published in the AJO-DDO in 2013. This review incorporated data from nine trials, of which eight were prospective case-control studies. The authors highlighted a potential association between craniofacial disharmony and paediatric sleep-disordered breathing. However, any differences were unlikely to be clinically significant.
The Journal of Clinical Sleep Medicine published the other study in 2022. The authors identified nine studies. Four were cross-sectional, four were case-control studies, and one was a prospective cohort study. Both reviews were conducted with sound methodology. Nevertheless, they were limited by a small number of studies and high levels of uncertainty in the data. As a result, the AAO panel concluded that there was limited evidence for a connection between OSA and certain craniofacial features.
Their overall conclusion was that, due to the very low to moderate certainty level, ‘an association or lack thereof, between craniofacial morphology and paediatric OSA, cannot be supported by the data.’
Use of imaging in SDB
The panel concluded that imaging of the upper airway using CBCT or lateral cephalograms has no diagnostic value for SDB risk assessment or diagnosis. Furthermore, using changes in upper airway dimensions to suggest the efficacy of orthodontic treatment is scientifically flawed.
They based these conclusions on an International Consensus Statement on Obstructive Sleep Apnoea, published in July 2023. This was a large consensus meeting that evaluated OSA in great detail. The paper included 176 pages with just over 2000 references. I did not have time to read it in detail. However, in addition to the section on imaging, there was a section on the treatment of paediatric OSA. The authors pointed out that the first-line treatment was adenotonsillectomy. Importantly, I did not find a mention of orthodontic treatment.
I thought this paper was very important because it addressed one criticism that the AAO viewpoint was not based on medical research. I wonder if our collection of airway-focused orthodontics has read this paper?
Palatal expansion
The panel concluded that orthodontists should only provide palatal expansion for sleep disordered breathing management in patients with a clear orthodontic indication alongside a confirmed SDB diagnosis. I found this somewhat vague, and I interpreted it to mean that expansion should only be performed if a crossbite with a potential skeletal discrepancy is present.
They based this recommendation on two publications, one of which was a 2023 meta-analysis that found that RPE alone did not significantly reduce the apnea-hypopnea index. This included data from five randomised controlled trials and four non-randomised controlled trials, which together provided information on 595 patients. Most of the trials were rated as high risk of bias due to issues with blinding participants. The meta-analysis revealed limited evidence of a positive effect of rapid maxillary expansion.
The other study was a crossover randomised controlled trial examining the use of adenotonsillectomy and palatal expansion on AHI. I have written a blog post about this trial. I found it well-conducted. Its overall conclusion was that adenotonsillectomy is the primary treatment for OSA, and RPE may not provide benefits.
Again, these were good sources of evidence.
Functional appliances and growth modification
The panel concluded that there was no evidence to support the prophylactic use of functional appliances as a preventive measure for sleep disordered breathing. This is a logical conclusion because there are no studies showing that functional appliances can meaningfully change or alter the skeletal pattern.
Can we help in the treatment of sleep-disordered breathing?
A key message from this research and discussion is that treating sleep-disordered breathing primarily falls to our medical colleagues. We clearly have a role in screening for sleep disordered breathing and referring patients. Once the physician has made an accurate diagnosis, we can contribute to relevant treatment, but we must collaborate closely with sleep specialists and other experts.
We can also offer care with maxillary expansion, but only in a few carefully selected cases. This is when there is a clear skeletal discrepancy, most often accompanied by a crossbite. It is absurd to expand maxillae simply because “we feel they are not wide enough” or that we need to increase the width by 3 to 5 mm to some hypothetical ideal imagined by an advocate who does not understand the existing research in this area.
What did I think?
I did not have the space or time to explore all aspects of this white paper, so I decided to focus on perhaps the four most controversial areas. I believe the evidence they used to support their recommendations was entirely relevant. The studies they selected were generally of good quality. The most striking finding, in my view, was that there were very few studies they could include. This is because there appears to be a lack of high-quality research.
This reinforces my opinion that, across this entire field, there is a surprising lack of evidence. This is a significant finding because, if evidence of benefit is absent, we cannot ethically promote or provide treatment that claims to address a disorder.
FInal thoughts
This is an extremely useful and valuable source of information for all orthodontists. The recommendations are very clear. Importantly, they provide straightforward guidance on what we should and shouldn’t do. This means that if we perform treatment that disregards these recommendations, we may be acting unethically.
The response by some to the white paper has been unbelievably arrogant. Some detractors even suggest that their personal viewpoint or that of their ENT colleagues is more important than anything included in this document. Alternatively, some suggest the White Paper is flawed but do not specify where these flaws lie. Others have claimed that the AAO is protecting organised orthodontics. I don’t even understand what this means.
I have been an orthodontist for 40 years. Over this time, I have witnessed several “waves of nonsense”. These include orthodontic TMD treatment, non-extraction approaches for everyone, orthodontic vibrators, localised trauma to speed up tooth movement, orthotropics, and self-ligation. All have gained momentum, generated profit, and preyed on vulnerable patients. However, when science and the truth catch up with these claims, the new treatments vanish and we return to conventional, sensible orthodontics. This paper by the AAO is a significant step in the right direction.
If we accept and adhere to the recommendations of the White Paper, we can deliver a valuable service to our patients. This should also keep us sufficiently occupied.
What are your thoughts? Would you be interested in discussing this further in the comments?
Emeritus Professor of Orthodontics, University of Manchester, UK.
I’ve been orthodontic provider for over 40 years and have tried hard to follow the Evidence Based Practice starting with the cassette tapes (then CDs) the series ‘”Practical Review in Orthodontic ” plus being an avid follower of your blog. Everything you listed, especially extraction vs. non-extractions, TMD, self-ligation and now SDB will continue to be argued long after we are both gone. Keep up the good work of “Science and Truth”.
Thank You
Thanks for the supportive comments
The entire field of “Airway-Friendly” Orthodontics is based on specious research and in direct contravention of the scientific evidence. The proponents of this scam not only do not care what the science indicates, they actually concoct their own ludicrous explanations for why the science is wrong.
Most, if not all, of them have significant financial conflicts of interest and thus these types of findings are anathema to their revenue stream.
Be it expansion for all, universal frenectomies, or non-extraction at all costs, these fringe practitioners do not let facts get in the way. Instead of providing scientific evidence, they love to challenge folks to a verbal debate on podcasts hosted by them or their acolytes. There is no debate to be had, when one side has no data. It is way past time that we stop indulging these people.
Yes, you are right. We must keep challenging them
“Be it expansion for all, universal frenectomies, or non-extraction at all costs, ” – Dr. Raj – I couldn’t agree more! There is no treatment in any arena that should be universal.
When I see any treatment modality that is exactly as you describe – expansion for all or non-extraction at all costs or 4 premolars extracted for every Class II – then it raises warning flags of a failure to diagnose.
It reminds me years ago of the question someone asked “What Class II corrector is used in XXXX” and my response was “Well there isn’t any magic Class II corrector, it depends on the issue – is it skeletal, dental, maxillary, mandibular” Many times people that advocate “systems” and “efficiencies” to drive higher volume are leading others to perhaps gloss over diagnosis. It’s the same things I teach my residents every year – there are cases that “look” easy that are actually tough. Bottom line: do the right thing for the right patient at the right time. Sometimes that’s extractions, sometimes it’s expansion, sometimes frenectomy, sometimes orthognathic surgery, and more and more I find it’s things that I need to learn more about whether it’s overlap with medicine or mental health (the increasing number of people with body dismorphing disorder seeking orthodontic care where they should NOT be treated orthodontically). Thankfully we are committed to life long learning.
Thank you, Kevin. You are a pillar of strength to those of us who advocate for the proper care of our patients.
Thanks for your supportive comments
Kevin
Well done on keeping us well informed and defending science and proper evidence, even for long retired like me.
Ray
Thanks Ray, I hope all is well with you. Best wishes Kevin
Always interested in how CBCT is applied because it’s so much added value for surgical planning, craniofacial anomalies, and underlying pathology (e.g. finding periapical pathology that others missed due to only having a pano).
Working with radiologist consistently, I’ve always understood and emphasized that static imaging is just that – static. But sometimes static observations lead us to investigate dynamic systems further. So I pulled up the article referenced under the imaging section to review and it seems to say the opposite of your summary in this section.
International Consensus Statement on Obstructive Sleep
“Similar to cephalogram, CBCT can be of value as an adjunct in the anatomic evaluation of OSA and for surgical planning in orthognathic surgery.”
So for sure, as always, no one should diagnose from a static description. Adjunct is definitely a key word. However, it should be observed, noted, and referred when appropriate for further evaluation by a sleep specialist / ENT. That’s the same standard and process with all OMFS / ENT training programs as well.
In addition, SDB is no less important than a full health screening – a comprehensive medical history etc. (which many people gloss over). I have discussions with families all the time about vaccine decisions and frankly tell them that I watched children die regularly while serving overseas for 8 years from preventable diseases such as tetanus. Same goes with obesity. There’s an epidemic in western culture of overeating and skipping on nutritional counseling neglects treating a patient. Yes it takes time. It’s about embracing the core of doctor which is to educated and teach and not just be a tooth mover for as many mouths as possible in one day.
Well said, Chad!
Hate to be the party pooper but I found this link interesting –
Beyond RCTs: Real world evidence and the future of sleep research by Dr Ellen Stothard PhD, hosted by orthodontist Dr Mike DeLuke
Am I right in thinking that a you tube video is a better form of evidence than the AAO white paper?
Another passive-aggressive response, Kevin. Don’t shoot the messenger if you don’t agree with the content of your peers when the caste-like, self-appointed hierarchy of orthodontics is challenged. As a keynote speaker at the International Association for Orthodontics next month, it’s important for me to include all viewpoints.
Thanks for posting, Dave. Ellen is a sleep and circadian scientist who focuses on patient-centered healthcare. She earned her dual doctorate in Integrative Physiology and Neuroscience from the University of Colorado Boulder. She is a brilliant researcher who participated in research funded by the National Institutes of Health, the US military, universities, and commercial research and development organizations.
But I’m sure orthodontists like Kevin know more than she. After all, what she says is on YouTube. Lol
In a guideline/ white paper context emphasizing RCTs and systematic reviews is standard. Provider “real world evidence” can complement but does not replace well-controlled evidence for causal claims about interventions.
Here is just one more of many examples of flaws of the update to the Wt paper. The authors state, “No currently known craniofacial phenotypes can identify the presence of SDB.”
Yet in reference #34 (the aforementioned International Consensus), it states, “Craniofacial anomalies that are common in patients with OSA include mandibular deficiency, narrowed posterior airway space, steep mandibular plane angle, and long anterior facial height.(234,1184)
Based on this and the discrepancy pointed out by Chad Carter above, it seems both you and the authors should have read the entire document. I’ll post another example momentarily.
The ICS statement about anomalies being “common” is real. But “common”/ associated does not mean “can identify presence” diagnostically.
They also failed to mention this part of the Consensus (again, their ref. #34):
“Benefits of maxillary expansion include increased nasal cavity volume, improved ability to breathe through the nose, and increased width of the palate, resulting in enhanced oral cavity volume. This allows the tongue to posture appropriately (antero-superiorly) at rest and while swallowing. An additional benefit of maxillary expansion is the increased tension of the palatal tissues, reducing laxity and tissue collapse in the OP [oropharynx]. RME is effective in teh treatment of OSA, with improvements/reductions in the apnea/hypopnea index, or AHI.
The authors clearly cherry-picked quotes from this document, and didn’t do their due diligence.
Here’s another one. The Wt Paper update stated, “…prepubertal OSA tends to resolve naturally during the transition to adolescence. Primary snoring and mild SDB do not appear to be strongly associated with progression to more severe SDB; in other words, there is a tendency towards spontaneous remission of SDB from preschool years to adolescence.”17,18
Ref #17 has numerous flaws, including:
It’s a prospective longitudinal cohort study, so it does not prove that children “outgrow” SDB or OSA.
Remission is defined by AHI cutpoints alone, which we know is flawed for mild disease.
The strongest claim for remission (100% remission of AHI ≥ 5) is based on N=6.
Made the OSA scoring rule more stringent w/age.
Defined apnea as ≥ 5s if <16 y.o., but ≥10s if ≥16 y.o.
Only 60 % of initial subjects returned (authors acknowledged possible selection bias).
A nontrivial fraction persist or worsen – especially snorers w/mild SDB.
-30.3% persisted as snorers
-25.8% worsened to AHI 2 ≤ 5
-12.4% worsened to AHI≥5
Ref #18 states this in their conclusion:
"Moreover, SDB in preadolescents may not spontaneously remit, and a significant number will develop SDB when they are adolescents."
Either that's the best the authors could do, or they didn't actually read and critically analyze the documents they cited. Either way, it is well beneath the standard our professional association should be held to.
And another one:
The authors state, “Evidence on the effect of extractions on oral cavity dimensions is mixed, with no evidence to support a causal relationship between extractions and the development of SDB.” 52
Guess what the authors of ref #52 used to make that conclusion? You guessed it – CBCT imaging! Can’t make this stuff up! Lol
You may recall that, as mentioned in Chad Carter’s previous post, the authors of the Wt Paper previously stated, “Imaging of the upper airway using CBCT or lateral cephalograms has no diagnostic value for SDB risk assessment or diagnosis.”
Can you imagine what the anti-airway crowd would (and should!) do to a pro-airway article if it were this fraught with issues??? I just wish you were consistent and called balls and strikes instead of praising the authors for this deeply flawed and poorly researched document.
AAO’s CBCT claim concerns diagnosis and risk assessment. Reference 52 uses CBCT to measure airway volume (anatomic endpoints). Using CBCT for anatomic measurement is not logically inconsistent with “CBCT cannot diagnose OSA”
One more, b/c it’s too easy to pass up.
The authors also state, “After a review of extensive epidemiologic assessments, it is concluded that no substantive evidence supports a causal relationship between orthodontic extractions and airway obstruction.” 53
Article 53 is the vaunted Larsen article. Guess how many patients out of the 5,584 included in the study had orthodontic treatment? You don’t know? Well, with good reason, b/c neither did the authors! Previous ortho tx was NOT a prerequisite for inclusion! You only needed to be missing at least one PM in all 4 quadrants. So a subject could be edentulous and never had ortho for all they care, as all they did was a chart review for missing PMs. As a result, there was no imaging used, no determination of incisor movement pre/post-tx, etc. They just did a dental chart review for pts w/missing PMs, and a medical chart review for a Dx of OSA (w/no explanation of how they even reached that diagnosis, I might add), and compared the two. In the conclusion, the authors slyly stated the absence of PMs was a “presumed” indicator of past extraction orthodontic treatment. The devil is in the details…
Again, can you imagine if I cited a study like this to “prove” that extractions DID cause airway issues? I’d be mocked, and deservedly so. You all call for an RCT for us to say anything to support our claims, yet use THIS as “evidence” to support yours? At least I have the clinical data to back up my assertions, which, per Sackett (the founder of EBM), is what you should defer to in the absence of an RCT. Y’all don’t even have that!
And here we see the loud, painful and futile protestations of all those financially-conflicted individuals concocting their own spurious explanations for continuing to pursue pseudo-science.
The burden of proof is on them that make the claim and not on the rest of us to disprove them.
These folks not only do not have that, they honestly expect us to “accept” clinical evidence from – A. Individuals that don’t even practice or never practiced orthodontics and B. Those that depend on keeping this Airway nonsense alive so they can sell courses?
They are not fooling anybody but counter-intuitively, they are instead steeling the resolve of all of those who oppose this nonsense. Some of the things that all these people have in common include A. Denial of sound scientific evidence B. Claiming to be a Guru, but with ZERO scientific expertise or appropriate academic experience C. Proposing alternative hypotheses that are clearly unproven or implausible D. Appeals to emotion and request to take their course/view their podcast/attend their lecture.
There is no chance that we will accept anything as true from these folks UNTIL they put up the data. They clearly do not understand how science works
For the sake of completeness, I’ve just heard that my article on this topic has been accepted for publication in a medical sleep journal. The Reviewers commented it was an “intellectually rigorous” manuscript.
Singh GD. Craniofacial endotype of obstructive sleep apnea: Spatial matrix hypothesis. Sleep and Breath, 2026 (accepted).
Aloha Dr. O’Brien,
Thank you for your blog. I’ve genuinely enjoyed reading it over the years, and your last two issues on RPE and the AAO’s white paper were no exception. They did, however, compel me to put pen to paper. Consider this both a reply and a friendly public health warning.
Tread carefully, Doctor. There’s an outbreak afoot.
I’m referring to what I’ve taken to calling “Sinclair Syndrome”, a condition I freely admit I invented, but one that fits our world in dental sleep medicine with uncomfortable precision. The name comes from Upton Sinclair’s most famous quote:
“It is difficult to get a man to understand something, when his salary depends upon his not understanding it.”
I, Candidate for Governor: And How I Got Licked (1935)
I’ve watched this syndrome spread through my practice over the past couple of years. It apparently originated on the mainland, hopped the Pacific to Hawaii, and has since gone international. Not a day passes without a fresh case crossing my desk. The WHO has not yet been notified, but I’m monitoring the situation closely.
Jokes aside, the underlying concept is well established in psychology and behavioral economics, even if my branding of it is not:
• Upton Sinclair bias: the informal term for resisting information that threatens one’s financial or personal interests
• Motivated reasoning: reasoning toward a preferred conclusion rather than an objective one
• Conflict of interest bias: distorted judgment driven by personal stake in an outcome
• Willful ignorance: the deliberate choice not to know something, because knowing would be inconvenient
There is, of course, no formally recognized medical or psychological diagnosis called Sinclair Syndrome. I made it up. But given how rapidly it appears to be spreading, perhaps it’s time we submitted it for peer review.
Keep your eyes open, Dr. O’Brien — this one is contagious.
Warm regards,
Steve Wilhite, DDS
Oh these comments got SPICY!! Loved them though!