A Work in Progress

This is from a letter I sent to a colleague who was unfamiliar with what is going on in Integrative Orthodontics....


"For years, I stayed within my circumspect orthodontic circles.  Now I'm meeting people ffrom all the healing arts with whom I have common goals: searching for the etiology and allowing the body to heal itself by removing blockages and bad habits.  

For me, it's mostly removing bad habits.  I'm firstly concerned with resting tongue posture in the growing child.   Since the tongue is the scaffold on which the maxilla and upper teeth take their support and guidance, having the tongue on the palate at rest is fundamental.  So teaching oral posture and proper swallowing habits is the central strategy.

But I also have to look at what may keep the tongue away from the palate.  Open mouth posture at rest and especially during sleep is an endemic problem.  This may be secondary to upper airway distress, allergies, asthma, chronic hyperventilation (over breathing), swollen lymphoid tissue, environmental stressors (both physical, like in food, and toxic substances, and emotional stressors). There are also the postural issues of ascending and descending musculo-skeletal imbalances and habits that I'm sure you are all too familiar with.

So my program (still in the developing stages) takes a broader approach: it includes Oral Myology (for tongue posture and function), Arch Expansion, (to undo previous damage to jaw growth), Breathing Correction ( to slow down breathing and improve oxygenation of tissues), Postural Training (straight body:straight teeth) and Nutritional Coaching (to lessen the toxic and metabolic load, if possible).   At least that is what I'm working toward.  

And what I find is that if I start early enough, the teeth will improve before we even have to talk about braces.

I look forward to further conversation and to learn about your way of thinking,

Sincerely,

Barry 

--
Barry Raphael DMD
1425 Broad Street
Clifton, NJ 07013

Every Breath You Take: a theory of Sleep Disordered Breathing

My introduction to Obstructive Sleep Apnea has been through the early orthodontic technique that recognizes that open mouth postures lead to deformation of the maxilla and, hence, crooked teeth.  Part of the deformity is poor forward growth of the mid-face leaving the airway smaller.  I've come to understand that these kids will be more susceptible to OSA since it will take less obstruction to stop the breath.

Mouth breathing has other effects as well.  

The theory is this: chronic open mouth posture allows  excess escape of  carbon dioxide (CO2) lowering both lung and blood CO2 levels.  Medullary breathing triggers (in the brain, stimulated by CO2)  are eventually lowered to accomodate these chronically lower levels.  Lower triggers are tripped sooner in a feedback cycle and in time breathing rate rises.  Hence, a state of chronic hyperventilation ensues.   Instead of 8-10 breaths/min, mouth breathers are 20 or more bpm.

Further, according to the Bohr phenomenon, lower blood CO2 raises blood pH and inhibits the release of O2 from hemoglobin lowering availability to tissues.

Finally, CO2 is responsible for regulating the tone of smooth muscle.  Lower levels lead to spasm in vessels and organs with multiple effects, including hypertension, behavioral effects, and more, too numerous to mention here.

 

Regarding sleep, open mouth postures are often at maximum during sleep, allowing even more CO2 escape.  Breathing may actually stop when blood levels are acutely low.  Breathing stoppage however allows a quick buildup of CO2 until the patient begins breathing with a start.  This is Centrally-mediated Sleep Apnea.

 

CPAP (continuous postive airway pressure), may be helping with OSA by physically opening the airway under pressure. But it may also be helping with CSA by preventing the excess release of CO2, allowing proper build-up and breathing triggering.  

It seems to me that this distinction has gone largely unrecognized by a burgeoning Sleep Medicine establishment.  You can see the relevance of this thinking is huge: to the extent mouth breathing is the cause of centrally mediated phenomenon, a transition to nasal breathing and a lowered breathing rate may be the FIRST line of defense against sleep disordered breathing, especially in the young.  Furthermore, mandibular advancement appliances,  airway clearing surgery, and even jaw surgery will be fruitless unless proper breathing is achieved simultaneously.

(I would like to thank Dr. John Flutter for helping me understand these concepts)

Sleep tight! (you lips, that is....)

Snake Oil?

My family is constantly chiding me on my fixation with mouth breathing.  Evidence of its importance to health seems to be everywhere I look and yet they don't have a context to understand my every mention of it.  They just roll their eyes.   Wait 'til they read this post....

I came across an ad from the 1930's, pictured here.  I saw it some time ago and sloughed it off.  Today, I read it again and it didn't seem so funny.  Read it yourself....

People on another blog were making fun of it.  So, I just had to add my two cents as follows:

"I can't believe I'm actually making this post, but after 28 years in the dental profession and now becoming fluent in the realm of sleep apnea and it's ravages, I can tell you in all seriousness that this somewhat inelegant method has merit!  Mouth breathing is still considered a deterrent to longevity.  And that's from day one of life.  

• Mouth breathing affects oxygen balance and metabolism (with lowered oxygenation of tissues).

• It allows unfiltered air to irritate the respiratory tract (hence, allergies, asthma, URT infections and swollen lymph tissue).

• It affects the tone of smooth muscle (like in blood vessels and organs).

• It leaves the upper jaw unsupported during growth (hence, crooked teeth).

• In fact, both obstructive and centrally-mediated forms of sleep apnea are aggravated by mouth breathing. 

 I've never considered selling snake oil, but I just might like to see this product make a return...."

And there you have it.  I said "snake oil".  Now they'll really think I'm off the deep end.  And, hey, at $3.00, it couldn't hurt...STEP RIGHT UP!....

What I'm telling the GP

Before I begin treatment, I write a letter to the dentist (GP, general practitioner) to explain what I'm going to do. The letter I wrote today was exemplary enough (as in: a perfect example), that I thought I might share it with you.   You may use it yourself....(p.s.: I'm using a fictitious name....)...

"Dear George,  Hi. It's Barry Raphael, orthodontist for Stephanie.   Below is a summary of my treatment plan for Stephanie and attached are copies of records.  Please review and consult with Stephanie's father and mother with your opinion.

First some background.  Before I move teeth, I like to look at the cause of the problem.  Orthodontics has long been plagued by trying to treat and maintain teeth when the etiology has not been rectified.  I particularly look at muscular habits,  especially during breathing, swallowing and sleeping.  Mouthbreathing and tongues not positioned on the palate are, I feel, responsible for many of the malocclusions we see, Stephanie included.  

Her narrow palate, posterior crossbite and anterior openbite are typical of such issues.  As such, my preliminary treatment is aimed at eliminating the harmful habits.  Once reduced, straightening the teeth become much simpler.  More importantly, however, these habits and the poor growth patterns that ensue are associated with the sleep disorders that adults are now often struggling with.  No matter the orthodontic protocol I choose, she will be predisposed to sleep disorders if the habits are not corrected.

Correcting harmful habits, unfortunately, is like giving dance lessons - many will participate but only those that are motivated and work at it will succeed, and even then to varying degrees.  Without Stephanie's and her parent's understanding and participation, the results will diminish, and she will be likely be subject to typical orthodontic regimines like extractions and retractive mechanics - something I try to avoid whenever possible.

Stephanie's treatment will begin with a removable (by her choice) expander to widen the palate and establish room for the tongue.  Then myofunctional training to 1) keep the lips closed, 2) keep the tongue on the palate, and 3) breath through the nose, especially at night, will begin.  Again, her cooperation with these exercises is paramount to success.

Should she have difficulty with the exercises I proscribe, a referral to an Oral Myologist will be made for a more specific and individualized therapy.

Finally, when she is on the way out of the mixed dentition (estimated age 11-12), I will re-evaluate for fixed appliance therapy.  If the myofunctional work is effective, only alignment will be needed.  If it is not, then more complex treatment will have to be considered.

If you are not familiar with the above approach, or would like to learn more about it out of curiosity, I will be happy to forward some links to more information. You can start here.

Sincerely,  Dr. Barry Raphael "

Is Early Treatment Necessary? An ongoing battle....

I know that in orthodontics there is a move away from early treatment.  Tulloch and similar studies have been used to vilify early treatment since the results of two-phase and one-phase treatments seem to be the same. And since two-phase treatment is less economical to both the patient and the orthodontist, then why do it?  Reasonable argument.  Especially since new approaches to fixed appliances have resulted in better arch development, better facial appearance and less extractions. 
However, the AJODO (the most revered juried journal in the field) recently published a systematic review(1) on the efficacy of functional appliances.  In summary, the review found statistical significance but little clinical significance to the way functionals could make a mandible grow.  And it also concluded that the data supports “that 2-phase treatment has no advantages over 1-phase treatment.”

But wait.  It concludes: “several benefits must be attributed to the early treatment …”

1. prevention of trauma to maxillary incisors associated with a large overjet, (ed: every one agrees with this one)
2. psychosocial advantages for the child during an important formative period of life,(ed. kids and mothers,  especially, appreciate this)
3. interception of the development of dysfunction, (which is why teeth get crooked in the first place)
4. stable dentoalveolar correction (ed. stability: the holy grail of orthodontics)
5. improved prognosis and shorter duration of treatment with fixed appliances.(ed. Better Faces: Less Braces!

So given those five reasons, why wouldn’t you want to do early treatment for our children??? Since when is money and efficiency more important that the health of our children?

(1) Marsico,E, et.al. Effectiveness of orthodontic treatment with functional appliances on mandibular growth in the short term, AJODO,  2011, 139:1, 24-36.

The way I want to change the world.

I am thinking about orthodontics as a health service, not only an esthetic service...

Up until recently, I’ve felt that ortho was mainly an esthetic service, and that just few people really NEED it. Crooked teeth don't hurt. No one ever dies of a bad bite. But they WANT it.  And there are many benefits from a pleasing smile in our culture.  Better self-esteem.  More confidence smiling and speaking.  Pride in accomplishment.  Improved dental awareness and care.  All good things.  But like plastic surgery, it is a discretionary service, maybe even a luxury.  

From my new point of view, however, orthodontics, if and when it broadens its scope, can be a health oriented service that IS NEEDED by thousands of children.  When you look at alignment of teeth as merely a product of, a symptom of, or a solution to, a larger ailment that has health consequences well beyond just those of a pretty smile, then orthodontics takes on a greater significance.  

If crooked teeth are a symptom of early feeding and nutrition, then it is a health related matter.  If crooked teeth are a symptom of imbalanced musculo-skeletal alignment which contains vertebral subluxations and cranial strains, then it is a health related matter.  If crooked teeth are a symptom of suboptimal respiration where oxygen is not being processed efficiently and tissues are not being nourished as they should, then it is a health related matter.  If crooked teeth are related to mouth breathing, snoring, airway restriction, asthma, allergies, frequent upper respiratory infections, and sleep disorders, just to name a few, than orthodontics is certainly a health related matter.

What I am suggesting is that there is the possibility of a whole new line of concentration within our specialty.  One that is crying out for our attention. One that provides us with tremendous opportunity for improving the health of our children, now and into their future.  

Of course, we should still concentrate on the esthetic benefits of a beautiful smile.  But I also suggest that it is time to forgo esthetic goals when they are accomplished at the expense of health. Or when they are performed in ignorance of the health ramifications to our children. Ideally, our children have the right to enjoy both enhanced esthetics and enhanced health.

And that what I want to see happen in my lifetime.

...and how I discovered it.

I was looking at the description of this blog and realized how presumptuous it sounds that I "discovered" anything.  The only thing I discovered is the man who discovered all of what I now know before I did, and took it upon himself to tell the world about it.  Without Chris Farrell, I would not be writing this blog.


Dr. Farrell practices myofunctional dentistry in Helensvale, on the east coast of Australia.  Like me, he credits others for his knowledge, but he did three things that may yet change the face of orthodontics as we know it.   


First, over the past 20 years he's been developing a practical protocol for helping children change their bad oral habits.  Secondly, he developed the engineering techniques for producing a series of prefabricated appliances that can be used as part of this protocol.  And lastly, he is so passionate about the benefits of this treatment that he wants everyone - and I mean the entire planet - to know about it.  


He was well on his way to making it all happen before I ever heard of him.  Us Americans - so proud of our abilities with braces - are the last to know.


As my own dreams are beginning to align with his, I can only admire the big game he is playing.  So this blog is dedicated to Chris, with a big thank you for all you've done for the children of Earth.  May your success grow as others "discover" it, too.


Learn about his work here.

A Milestone

Milestones...things you pass along your way that let you know how far you've come.  I passed one today.  One I've been waiting for, and hope will be the first of many.


One of the issues with myofunctional therapy is that it requires the commitment and cooperation of the child.  Another issue is that it is new enough (in this part of the world) that not many people have heard of it.  And when you try to get a kid to do something new, it can be very difficult if he or she has never heard of it before...They'll say, "My friends don't have this, why do I need it?!"(drag out the word "I") or "You (if you're a parent, drag out the word YOU), YOOUUU told me I was getting braces with colors. What's this?!?".  Perception is everything, right?


So, today I was working with young girl, adjusting her light-wire expander and I said "So, now that you are used to your "wire thingy" (I call it), would you like to get your trainer this visit or next ?"(I always give choices)


"Oh, this visit!" Her face lit up so, that it took me aback.


"Why is that?" I asked, almost afraid to press my luck.


"Because Katie already has hers.  Can I have one in pink?"


Yaaaaaahhhhhooooooooooo! ( Drag that one out...).

Newton's Tongue

Every orthodontist is familiar with Newton's Third Law of Motion: For every action, there is an equal an opposite reaction.  When you push on one tooth, you have to be pushing on something else (tooth, appliance, bone, neck) in the opposite direction.  We call this the problem of "anchorage" and it is a consideration in every treatment.



But there is one situation in the mouth that, I am guessing (based on my personal experience), very few orthodontists have thought about regarding equal and opposite reactions - that is the  tongue thrust swallow.  The tongue thrust (or reverse swallow) has the tongue pushing against the front teeth during swallowing instead of up on the palate where it belongs.


We all know that a thrusting tongue pushes the teeth enough for them to move, sometimes dramatically, causing them to flare forward or even creating a huge space between the upper and lower teeth.  But what is the equal and opposite reaction to that?


The tongue and other structures used for swallowing are tethered to the lower jaw bone by some of its muscular fibers (genioglossus, mylohyoid, geniohyoid). So when the tongue pushes forward against the teeth, it also pushes back against the lower jaw.  This pushes the head of the jaw joint back into its socket.  This compresses the cushioning cartilage disk in the joint.  Between 1-2,000 times a day.  Microtrauma to a sensitive structure every time you swallow.  A damaged disk is what creates the clicking, popping, locking and pain of TMJ problems. 


And we wonder why people associate TMJ problems with malocclusion and orthodontic treatment?  Tongue thrusters and mouth breathers have already predisposed their joints to damage for years before the braces go on...for years before all their teeth grow in.


This is yet another reason why early interception of soft tissue dysfunction is so critical.



That's not so hard to swallow, is it Issac?

The Missing Link

When orthodontists talk about the influences of heredity and natural processes on the way a child grows, they refer to "Growth and Development".  For instance, if we are unsure if a 6 year old is going to need braces, we might "wait for further growth and development".  Or if a child's jaw structure seem to be getting worse as he grows older, we describe it as "poor growth and development".  If we want to explain to a parent why a child's teeth are crooked, we say....you guessed it....G&D.


But this view of the way a person grows is limited because it is missing an extremely important element in the way a child grows and develops: Adaptation.  Neither growth (a change in size or mass), nor development (the genetically pre-determined maturing of a structure) leaves room for the interaction of the person with the environment.   The expression of genetic potential DEPENDS on how the individual and the environment interact. 


Not all of the details of our face and position of our teeth are predetermined.  The bones grow and the teeth erupt under the guidance of all the forces that surround them - from the muscles, airway, posture, swallowing, nutrition, habits, etc.  They ADAPT to the surrounding forces (Functional Matrices in Moss' terms).    And this element of change is every bit as important as growth and development.


It's not just G&D. It's G,D&A! And THAT is the missing link in our thinking.

Physicians of the Face

First read this and then look up John Flutter at the link below.  Dr. Flutter practices a more comprehensive kind of orthodontics in Australia than we have been used to in the US.  He was gracious enough to share some slides with me for an upcoming lecture, and here is my thank you note:

John, I consider this a terrific gift. Thank you very much.

Of all the things that have opened my eyes to the importance of what we do, it is this issue of airway.  The food we eat, the way we stand, yes, they are important, too.  But I really get the sense of how fragile we are - and how adaptable we are - when dealing with the airway issue.  

Before this, I could never really get past orthodontics as just an esthetic treatment.  And frankly, when you treat the mouth symptomatically, it really is just that.  But when dealing with breathing, posture, and diet, suddenly we are physicians of the face.  And that's how it should be.

Learn more about Dr. Flutter's work.