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.