Moving my Blob, I mean Blog

My very few friends and fans,
I want to thank you, all 19 of you, for having been fans of this blog, but I must move on to greener pastures.   Oh, don't worry. You can come along with me.  Just click below and subscribe to my blog in it's new location on my website.  And yes, you can bring your friends.

Integrative Ortho News

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.

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.