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....)