7 Ways to Speed Up Aging

If you don't know Steven Park yet, now's a good time to get familiar with him.  An ENT who focuses on sleep and breathing issues, he authored "Sleep Interrupted" here, runs a biweekly webinar on sleep issues, teaches at Montefiore, and wrote this clever article last year that should be read by all.

7 Ways to Speed Up Aging | Doctor Steven Y. Park, MD | New York, NY | Integrative Solutions for Obstructive Sleep Apnea, Upper Airway Resistance Syndrome, and Snoring

On Early Treatment and Sleep Apnea

Here is a Letter to the Editor of the AJODO (orthodontic's premier journal) about two articles on sleep apnea. One article extolled the virtues of using appliances to treat sleep apnea and the other jaw surgery.  While both have their place, both miss the point, as you shall see...

Point/CounterCounterpoint: 

Treating obstructive sleep apnea:  The case for early treatment.

by Dr. Barry Raphael, Clifton, NJ

I was thrilled to see sleep apnea being discussed in the October 2012 (142:4) issue.  This is a timely topic that needs to be seriously considered by all orthodontists.  Many of our patients are victims of sleep disordered breathing.

We know that the underdeveloped maxilla  is a primary risk factor for obstructive issues (Dempsey, et.al., 2002), and that a majority of malocclusions, including Class II’s, have an underdeveloped maxilla (McNamara, 1981).

Connect the dots backward from the adult sleep apneic to the growing child to see the connection:  if a child’s face grows poorly from the beginning, s/he will be more susceptible to airway restriction as an adult.

While Drs. Jacobson and Schendel drew appropriate recognition to this issue by recognizing the importance of maxillomandibular advancement to relieve the airway in children, they quickly jumped to discussing surgery in craniofacial anomalies completely skipping over the vast majority of children with similar but less severe problems.  They were completely on target, however, in stipulating that “the orthodontist can play a major role” with interceptive therapy at early ages.

I would like to propose two issues that bear immediate discussion in our profession :

1. We need  the diagnosis of Bimaxillary Retrusion in our thinking.  Most Class II malocclusions are maxillary retrusive.  And just because the dentition is Class I doesn’t mean it is properly placed in the face.
2. There are approaches to orthopedically correcting bimaxillary retrusion in the growing child, but they must be started EARLY.  Waiting for the facial skeleton to be 90% grown before we commence therapy, as the ongoing discussion on early treatment is leading many of us to, is much too late.  By then, the maxilla has collapsed transversely, vertically and sagitally and the mandible has compensated for its partner’s limitation.  Dental compensation doesn’t help (and may hinder)...only orthognathics does.

The American Academy of Pediatrics (Marcus, et.al. 2012) issued guidelines regarding OSA in children.  Though T&A is now (finally) the first line of defense in children with OSA, at least one of the panel members (Sheldon, 2012) has stated publicly that dentofacial orthopedics (in his case, Biobloc Orthotropics) will likely be the future of pediatric sleep medicine.

I urge all of us to take a second look at these issues in light of the coming epidemic of sleep disordered breathing.  The children require it.  And we need to be the ones treating it. 

References:

Dempsey, Jerome, et.al, Anatomic Determinants of SleepDisordered Breathing.  CHEST 2002;122(3), 840-851.

Marcus, Carol, et.al, Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome -Clinical Guidelines. Published at http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1672 

McNamara, James,  Components of Class II Malocclusion in Children 8-10 Years of Age, Angle Orthodontist, 1981;51(3):177-202.

Sheldon, Stephen, Children and Airway: Issues and Interventions,  at NYU, October 6, 2012

Getting Healthier

I just started a "Detoxification Diet". Why? Just 'cause it's another step I want to take toward healthy.  Here is my first post on the CleanProgram.com blog.... Thought I would share.

I'm Day 3, but this feels like I've been doing this all along....

I'm here because I'm going through "professional" changes.  Not really a new job, but a revitalization of something I've loved all along.  I'm just taking things to a new level.  

I'm asking my patients to become healthier.  Here I am, over a year ago,  lecturing.  Notice my belly?  I realized I'd be a poor role model for health if I looked like that and was on BP meds and was out of breath from walking stairs.

Then one of my colleagues (Thanks, Gwen!) gave me Dr. Junger's book.  I started the Elimination Diet right away....Slowly right away.  I'd known from multiple attempts at losing weight that if the effort stressed me out it either wouldn't work or wouldn't last.  

So I took it slow.  I ate only foods from the Elimination Diet (Whole foods. No sugar. No wheat. No dairy. No red meat)  that I liked and ate as much of them as I wanted.  It was a qualitative diet instead of a quantitative diet.  And it began to work.

Then I saw "Forks over Knives", and read "The Omnivore's Dilemma", and William Davis' "Wheat Belly", and studied Joel Furman's "Eat to Live" program.  Each time, I picked up on something new, maybe dropped something off my menu.  I got a Health-master blender for my birthday.

And little by little, I lost 30 lbs over 9 months.  Here's me in August.  Better right? And over the summer I maintained just by eating good food - real food- only.  I also started lifting ("The Power of 10") and walking Casper, my white lab.

But now it's time to take my eating to the next level.  And that's why I'm here. 

Day 3: It's been pretty easy.  Actually, I'm kinda stuffed after lunch.  I've been pretty much eating this way all along.

Come 21 (days on the whole program), I hope to feel like I know what I'm talking about when I tell the kids that they need to make a change in the way they eat (and breathe and stand and sleep...) and they CAN do it. 

Wish me luck!

Dr. Barry Raphael

Another Ortho asks me about "Trainers"

I am completely new to the technique and am very open minded but as you might understand think it is a bit too good to be true. You will not hear me say it is as easy as it sounds.  It's more than just the trainers. But the approach covers aspects of treatment and health that classic ortho just ignores. Once you learn what that is, it will be hard to stay ignorant of these issues.  

I am not sure what the situation is in the US but as a UK ortho specialist something like this would not be considered mainstream and many orthos would frown on this.  If mainstream means what everybody else does, then I agree, it will not be readily accepted since it requires intellectual retooling and some new protocols.  However, it will not replace tooth alignment techniques. It will only broaden our capabilities to guide the child to not only a beautiful smile but to better all around health as well.  Many of these concepts are well accepted if not totally well documented.  It will be the public that will demand this from us eventually.For instance, one issue you must learn about is how teeth get crooked and how that affects the airway.  With the increasing incidence of chronic diseases, like malocclusion and sleep disordered breathing, there will be a huge demand for our service soon.

I have a couple of questions please:

1. How long have you been treating cases with this and what has been your experience of long term stability and are there any side effects of the treatment documented?  Like any treatment, there are limitations, both short term and long term. There is no magic bullet.  In the past 4 years of involvement, I've had my successes and failures.  Most failures stem from my inability to garner understanding and cooperation from the family and patients.  Yes, that damnable "C" word. Ortho has been drifting toward non-compliance techniques for good reason.  And here I am trying to get people to take responsibility for their own health.  Sometimes I think myself the fool.  But what would you want for yourself (as an analogy): to prevent a heart attack or to have open-heart surgery?  What would you want for your child (as a fact): to grow with a balance between the teeth, face, spine, airway and heart, or to have one problem fixed to the detriment of others?  Were are health care practitioners, or so we say.  We have a bigger game to play than just straightening teeth.

2. In terms of getting it out there I am looking at mainly the general dental market in the UK. I think UK orthos will be late adopters to this if it works. Any thoughts on this? Go to the parents.  they will know what is better for their child.  Once they understand it, that is.  And yes, many of the GP's already understand the link between the mouth and the body.  And many wonder why it's taking ortho so long to find out.  You'll see once you start talking about this subject with conviction, your circle of influence will expand rapidly.

3. Do you have any tips on getting started as the number of appliances is a bit confusing and the types of cases I should start with? It's not the trainer so much as it is the training.  Buying a piece of exercise equipment alone will not make you fit.  You have to learn to use it properly. Soon, you can exercise without the crutch. Same with the trainers.  They teach certain specific principles of health: 1) Breathe through the nose, 2) Keep the lips together without strain, 3) keep the tongue on the palate when at rest, and 4) learn to swallow without using your facial muscles.  The trainer is just an aid to that.  The MRC concept is there to make it easier to implement this teaching.

Enjoy the journey,

Barry 

The Challenges Ahead

The Challenges Ahead for Orthodontics and the 

American Academy of Physical Medicine and Dentistry

by Barry Raphael, DMD

The First Challenge: To see malocclusion as a symptom of a greater imbalance.
The Second Challenge: To understand these imbalances as being involved in the overall health of the child.
The Third Challenge: To recognize the condition of “Bimaxillary Retrusion” as an endemic condition of modern life and learn how to treat it.
The Fourth Challenge: To understand the relevance of orthodontics to the formation and maintenance of the oronasopharyngeal airway and proper breathing, both day and night.

Background
Most people understand that there are two approaches to health. One - described as “Western” or “allopathic” medicine - focuses on the elimination of symptoms, whether chronic or acute. The other, described as “Eastern” or “holistic”, focuses on the elimination of etiologies on a broader scale and attempts to promote health as opposed to eliminating disease. Currently, we’re seeing a trend toward Integrative Medicine which takes the relevant aspects of both approaches.

In orthodontics, we call the allopathic approach “Corrective”, that is, the straightening of crooked teeth.  We call the holistic approach “Preventive” and “Interceptive”, where we ameliorate a problem by intercepting the cause.

Throughout its one-hundred-plus years of organized effort, the practice of orthodontics has also seen attempts at integrating both approaches.  Leading figures in the profession such as Edward Angle, Alfred Rogers, Thomas Graber, Robert Ricketts, and Donald Woodside, among many, many others, promoted the idea that the face takes its shape from developmental influences that are identifiable and reversible.

Yet, efforts made in clinical practice to take advantage of this knowledge have waxed and waned.  For economic, political, practical, and intellectual reasons, there is pressure on practicing orthodontists to forgo efforts at preventing malocclusion and to favor mechanical solutions for alignment of teeth.  When crooked teeth are considered “the problem” to be solved, there is validity to the idea that “braces” (or any form of tooth moving mechanics) has become the simplest, quickest, most predictable, and most economical(?) method of solving the problem - much like taking an ibuprofen is a solution for a headache.

Yet just as pain pills do not guarantee a headache won’t return, orthodontics has struggled with the long term instability of its results, resorting to methods of permanently holding teeth in place despite what the body’s attempts at equilibrium might be dictating.  Furthermore, there is some evidence that certain orthodontic techniques either ignore or aggravate preexisting conditions requiring additional treatments, orthodontic or otherwise,  later on.  Especially relevant to this discussion is the provision of adequate space for the tongue to be housed within the “fence” of the teeth without being forced back into the pharynx where it may block the airway, especially at night.

An ounce of...
There is also some pressure for orthodontists to start looking at integrative solutions, too.  The overall movement toward health and wellness in our society has increased awareness that prevention is far better for health than waiting to treat symptoms.  

There is growing evidence, especially from the field of anthropology, that malocclusion is not genetically predetermined, but is rather a modern phenomenon created by the dramatic mismatch of our genome with our rapidly changing environment.  The study of epigenetics is attempting to pinpoint some of the triggers that send development awry.  Many of these triggers have already been identified and are in fact, "intercept-able".

The alarming rise of chronic non-communicable diseases of lifestyle (CNCD) is pushing us toward integrative approaches as well, since Western medicine, despite all its new techniques and pharmacology has failed to stem the tide.   Malocclusion can easily be grouped in this category.  More significant is the rise in sleep disordered breathing (SDB) - very much related to the shape of the face - which is now being shown to be extremely deleterious in its effect on body systems.  To the extent that orthodontics can contribute to, or alleviate, conditions leading to SDB, there is an imperative to pay attention and act where we can.

Meeting the Challenge
There are many who think that orthodontics as a specialty is unable or unwilling to face the challenges ahead.  Many thought leaders and professional societies are seen as entrenched and bent on protecting turf.  Evidence-based Dentistry is being seen as being used to protect the status quo.

However, there is no “one” way of thinking within the profession, which has been seen to polarize frequently over many issues over the years.  There will always be a portion of the profession that is forward thinking enough to incorporate change when it seems warranted for the benefit of our patients.

One purpose of the AAPMD will be to give a forum and a voice to those in the profession that see that there is a real opportunity now, in our time, for a positive change to the kind of care we provide and the way we deliver it.  Membership will give you a personal stake in our mission.  Presence at meetings and on forums will give us the benefit of your knowledge and experience.  Differences of opinion will help us iron out the details and give direction to future research.  Most importantly, your voice will help spread the word of our mission.

In subsequent articles, I will address the specific challenges outlined at the beginning of the article.

A Future of Orthodontics

Every profession likes to justify its existence by comparing itself to another it feels inferior.  Orthodontists complain about general dentists doing incomplete orthodontics.  GP's complain about orthodontists with a narrow point of view.  Recently, an ortho colleague sent me an article about encouraging GP's to do orthodontics.  Here is my reply:

Over the past couple of years, I've met a number of dentists doing orthodontics. I've been unpleasantly surprised to find that many are very accomplished.  Even more so, some have a conception of facial growth, tooth movement, and mechanotherapy that is very different from ours.  For instance, as orthodontists, we generally see malocclusion as the problem to be solved.  However, many look at malocclusion as a symptom of a greater problem, and seek to solve THAT.   Their view takes a broader view of the face to include the formation and the function of "functional matrices" that Moss talked about: swallowing, chewing, breathing, sleeping, etc. This point of view comes closer to looking at a "medical" view of dentistry, and frankly, that is probably where dentistry is moving.  As techniques become simpler and "mid-level providers" come into play, which I believe they will, dentists will have to play more than must a mechanical role in oral health.  We see that in perio. We see that in TM problems. We see that in sleep medicine.  I believe we are going to see that in ortho, too.  Unfortunately, unless something changes, it may not be the orthodontist leading the way.  

Snoring Infants and Behavior Problems

My wife still chides me, "Is everything related to mouthbreathing?".  She is the director of a preschool program.  She sees the best and the worst of children ages 4,5 and 6.  Here is a study that relates the nighttime breathing patterns of infants to their daytime behavior.


This study, out of Einstein, where I now lecture to the ortho residents, created quite a media splash and deservedly so.   Take a look at it here.


Then take a look at my online comment to see what they are missing in their study here.


Yes, my dear, it all starts with mouthbreathing.

Untangling the Mess

Untangling the Mess

I guess you have to start out by saying, "There are no accidents" when you look at how our children are growing.  There is a reason for everything.  The reasons are a balance of genetics and the expression of the genes after exposure to the environment.  If you've read my blog, you know that I am concentrating heavily on the effects of non-genetic factors in the development of crooked teeth.

I consider crooked teeth to be a symptom, the end result of a number of interactions of various body systems that occur throughout one's young life.   I look at the difference between what the genetics is SUPPOSED to produce (straight teeth, a full healthy face and jaws)  and what has eventually come to be (underdeveloped facial bones and crooked teeth.  This is the basis of "Darwinian Dentistry" and "Evolutionary Medicine".

The interactions between our bones, our muscles, our breathing, our eating, and all of our habits within the "experience" of life makes us who we have become. It has shaped our bodies and faces. It determines our overall fitness and health. That makes common sense, no? This is true of all the various Chronic Non-Communicable Diseases of Civilization (cardiac disease, diabetes, obesity, etc.)

My challenge, as an orthodontist, is not just to look at crooked teeth and try to untangle them, but to find all those interactions that have led to the crooked teeth and try to untangle THEM.  If we untangle the REASONS the teeth get crooked first, we can help them grow straighter in the first place, and then once straight (with or  without braces) we can help them STAY straight for your lifetime.

This puts my work at the end of a list of issues to be handled: 

• the bones (chiropractor, cranio-sacral, podiatry)
• the muscles (physical therapy, body work, posture, fitness)
• breathing (Buteyko, ENT, sleep hygiene, asthma, heart rate variability), 
• eating (nutritional selection and routines, allergies)
• habits (myofunctional therapy, TMJ, parafunctions)
• and then....straightening the teeth.

So when a patient comes in, what I am looking at is the end product of 4 or 8 or 12 years of development in the presence of one or more noxious habits or exposures that have blocked normal growth.  It is over breathing? Sensitivity to milk products? A chronic stress reaction? A forward head posture?  

In order to "see" something on a medical/dental exam, you have to know it exists. That's the beginning of diagnosis.  Then we have to know where the signs and symptoms come from. And then assign the appropriate symptom to the appropriate cause.  And then treat the cause.

Well, is there any wonder why this will be an interdisciplinary effort?   We have to help each other "see" what's there.  We have to be open to allowing others to help us establish the treatment plans and protocols we use.  An that's how we are going to untangle this mess called crooked teeth.