“The greater the ignorance the greater the dogmatism.”
Sir William Osler
An aggravated wife walks into the family Doctor’s office with a complaint about her husband’s snoring:
“Doctor, I haven’t slept in months and I don’t know what to do about my husband’s unbearably loud snoring!”
“Mrs. Jones, if your husband doesn’t mind, I would like to examine him and with his permission I’ll be happy to discuss my findings with you.”
“Oh Doctor, that would be wonderful.”
The doctor follows up with the husband:
“Mr. Jones, your wife is very concerned about how your snoring is affecting her sleep and her quality of life.”
“Doc, I don’t snore.”
“Mr. Jones, it’s very difficult for patients to know whether they are snoring during sleep. Let me take a brief history and examine you.”
“Ok Doc, but I don’t think you’re gonna find anything wrong.”
Finally the doctor consults once more with the wife:
“Mrs. Jones, I’ve had an opportunity to find out a little more about your husband’s snoring and have examined him. I have concluded that he probably snores. I can’t find a physically detectable cause but since there is clearly a marital problem, my gut says it needs to be addressed.”
“So Doctor, what can I do?”
“Well Mrs. Jones, it really depends on what outcome you’re looking for. Are you looking to cure him, merely get a good night of sleep, or kill him?” If you want to cure him, the first step is to get him a sleep study. If you merely want a good night’s sleep, move to a different bedroom. If you want to kill him, send him to an orthodontist!”
The burgeoning interest in sleep apnea treatment by some orthodontists is rather curious and may have something to do with the general busyness problem in the specialty. If the lay public believes that orthodontists are experts in craniofacial growth and are effective at growth modification, then by extension they would believe that orthodontists are well-suited for treating and curing the spectrum of sleep disordered breathing (e.g.-snoring, sleep apnea, and upper airway resistance syndrome). If the lay public believe that orthodontists are just glorified teeth straighteners, they would be stupefied to learn that orthodontists are treating sleep disordered breathing.
Physicians who are expert at treating and curing sleep disordered breathing (e.g.-otorhinolaryngologists, pulmonologists, and neurologists) have been dumbfounded by the diagnostic and therapeutic regimens utilized by orthodontists to treat sleep disordered breathing. How do I know this? I have participated in the Program for Sleep Apnea and Sleep Surgery (PSASS) at Boston Children’s Hospital for the past 6 years. The PSASS team evaluates patients that have had an initial sleep study, previous adenotonsillectomy, an inability to tolerate continuous positive airway pressure (CPAP) therapy, and one or more repeat sleep studies confirming persistent sleep disordered breathing. Many of these patients have also had some type of orthodontic or dental intervention purported to cure sleep disordered breathing, such as rapid palatal expansion. If a child, adolescent, or young adult gets referred to the PSASS team, it means that a very competent clinician put their ego aside and wants a fresh pair of eyes to look into the patient’s refractory sleep disordered breathing.
Many PSASS patients have had insufficient diagnostic testing or misdiagnosis prior to the initiation of the first line therapy. Some of the diagnostic errors include invalid sleep studies (missing leads, inadequate sleep duration, or non operational thermistors), a “home” sleep study, a pediatric sleep study read and scored by an adult pulmonologist, failure to appreciate obesity and its contribution to airway obstruction, lack of examination via flexible nasal endoscopy, lack of drug-induced sleep endoscopy (DISE) when indicated, and primary diagnosis via 2D or 3D radiographs (lateral cephalometric radiographs and cone-beam computed tomography). An effective method to locate the level and cause of the airway obstruction (nasopharynx, oropharynx) is to utilize a dynamic type of examination. This is achieved by examination of the patient with either awake flexible nasal endoscopy (assessing turbinates, adenoid tissue, lingual tonsils, tongue base, laryngomalacia), cine MRI, or the DISE procedure to assess these tissues in a realistic sleep state while also looking for glossoptosis. Static 3D volumetric reconstruction of the soft tissues of the airway via cone-beam computed tomography is akin to describing the extent of coronary artery disease in a cadaver by means of gross dissection.
For the most part, patients with refractory sleep disordered breathing have more soft tissue problems than hard tissue problems. Orthodontists commonly point to the outliers like severe retrognaths or syndromic patients with micrognathia that would benefit from orthognathic surgery. Or they will point to high vaulted palates with normal transverse relations and claim that the patient’s palatal depth is indicative of increased nasal resistance.
I wouldn’t in my wildest imagination purport that I am an expert in diagnosing and curing sleep disordered breathing. However, I would argue that from my experience working with experts in this field, my understanding of the topic, and my own hands-on experience employing the “recommended” sleep orthodontic interventions, patients benefit the least from orthodontic machinations. Orthodontists have traditionally adopted a can’t cure ‘em can’t kill ‘em mentality, however in the instance of sleep disordered breathing it’s not inconceivable that they couldn’t achieve the latter!