Marc Bernard Ackerman, DMD, MBA 

“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!

 

 

 

 

 

 

11 thoughts on “Letting The Air Out of Sleep Orthodontics

  1. Although Dr. Ackerman has made some valid points, it is interesting that this article makes no mention of the iatrogenic aspects of orthodontics as a cause of Upper Airway Resistance and resultant Obstructive Sleep Apnea. Many orthodontists are unaware or choose to ignore the effects of their treatment outside of the occlusion. Because of this, objections to the long standing practice of removing bicuspids and aligning the remaining teeth, although not as popular these days due to many factors, may fall on deaf ears, and provoke a defensive reaction with our orthodontic specialist colleagues. The general dental field seems to be ahead of many orthodontic specialists with the understanding of upper airway problems, perhaps because they see the lifetime results of some traditional orthodontic approaches that don’t consider the airway. Thankfully the four on the floor mentality is going the way of the dinosaur. While trying to avoid excessing verbosity, I must mention that I have successfully eliminated OSA (verified with before and after sleep studies) on even adult patients with the use of Slow Palatal Expansion (SPE) with removable appliances such as a Swartz or a Sagittal.

  2. Dear Kent
    Thank you for taking the time to read this post.
    Do 4 congenitally missing premolars predispose that individual to sleep disorders?

    1. Dear Marc,
      Missing teeth by themselves do not predispose an individual to a sleep disorder, but an underdeveloped maxilla can. An underdeveloped maxilla can result in dental crowding potentially ‘trapping’ of the mandible causing it to develop posteriorly. This can lead to deep overbites, TMJ Dysfunction and even forward head posture compensation. All of this, including the constricted maxilla, can cause a lack of tongue space which will reduce airway space, leading to airway restriction causing sleep disorders, including Obstructive Sleep Apnea. If this condition is not addressed during orthodontics, i.e.with maxillary expansion and non-extraction treatment, then extractions followed by closing these spaces can intensify an already tenuous situation which can lead to sleep disordered breathing intensifying as a person ages.

  3. Or even better surely every patient that has full dentures or no teeth without dentures must have OSA.
    We all have patients that have improved after a twin block , RME , SME , but if you think it happens in all patients then you need to go back to dental school for some remedial tutoring. Remember a good number of the kids get better by simply observing.
    That’s why most of us except the likes of the above responder don’t go running around telling people look what happening on this case n =1 means just that …….

    1. Sorry Dr Oz,
      I didn’t mean to imply that the missing teeth were the problem, just that an underdeveloped maxilla with dental crowding should not be treated with removal of teeth, The problem is not that there are too many teeth; the problem is that the jaws are too small. The maxilla can be expanded to normal size and eliminate the need to remove permanent teeth to get alignment. This works toward opening up the airway, since the nasal passageway is increased, as well as the tongue space enlarged. I hope my previous statements make more sense to you now.

  4. Thanks ,very ,very interesting comments.Is there an implication that dentists ,of all stripes ,are becoming involved in the formal diagnosis of sleep pathologies ?In Canada ,this is definitely not the case.Formal diagnosis is left to the ENT,s or better {in my view }to the Boarded Sleep Specialists.
    The comment is made that sleep issues are more related to soft tissue issues than hard.Could you kindly refer me to evidence,whether anecdotal or Cochrane level re this comment.My own feeling {and it is just that!}is that both areas play a major part.
    Again ,thanks for a very interesting set of comments!

  5. Dr. Michael Major of the Inter-disciplinary Airway Research Clinic at the University of Alberta: http://iarc.ualberta.ca/en.aspx

    1. The article discusses adult and pediatric sleep disturbances as if they were the same.
    While there is some overlap, adult and pediatric sleep apnea are different entities. Adult sleep problems are typically one dimensional – the patient has narrowing in the oropharynx. Narrowing is most commonly caused by a retrognathic mandible and obesity. Because muscle tone decreases as we get older, age is a risk factor. And because of the differences men and women gain weight, being male is a risk factor. Those 4 risks – retrognathic mandible, obesity, gender, and age – are the main 4 characteristics evaluated in the STOP BANG questionnaire.
    In contrast, sleep disturbance in children is usually in the nasopharynx. Tonsils, adenoids, chronic allergic rhinitis, asthma, and allergies all pay a massive role here. This largely encompasses the classic “adenoids faces” kids we learned in ortho residency. However, there are 2 additional subtypes. Obese, mandibular retrognathic kids who’s OSA presents almost identical to adults is one subtype. The other sub-type are mid-face deficient, short anterior cranial base, CPAP dependent, growth stunted children. Our team’s working hypothesis is they have a collagen mutation
    Without a proper understanding of each patient’s etiology, treatment will always fail.

    2. “If you want to kill your husband send him to an orthodontist.”
    This cheeky statement is absolutely true. But it does nothing to educate unless it is properly explained. In adults who are treated with oral appliances, it’s rare for follow-up sleep study to be complete. The patient may stop snoring, but still have apnea. This is the “silent killer”, and dentists are as bad as orthodontists for “killing” their adult patients. The lack of follow-up used to be a huge problem in the pulminology world until CPAP machines became auto-titrating.
    In kids, orthodontists make the mistake of thinking “expansion cures sleep apnea.” As I outlined above, pediatric sleep apnea is a extremely complex, multi-disciplinary disease. Simple-milded thinking most certainly does make orthodontists “killers.” However, I will be clear: Correctly targeted orthodontic treatment can provide MASSIVE therapeutic benefits for children with sleep apnea… however, NEVER can it be done without a multi-disciplinary team.

    3. So, what role does an orthodontist have?
    Orthodontists have two major roles: 1) early detection and appropriate referral, and 2) appropriately targeted treatment. The next logical question becomes, “what is appropriately targeted treatment?” Again, it must address the underlying etiology.
    As a rule of thumb, if orthodontic treatment is to have therapeutic benefit for sleep apnea, it MUST be skeletally directed. For adults, this means orthognathic surgery. For children this means orthopedic treatment.

    MOVING TEETH DOES NOT TREAT SLEEP APNEA

    If every orthodontist could simply learn that statement, 90% of the false claims would disappear.

    http://iarc.ualberta.ca/en.aspx

  6. With the Damon Smile System, Dr. Lyles provides patients of any age:

    Treatment without tightening
    Faster treatment times
    Fuller, wider smiles
    Greater comfort

    Are you sure that none of these qualify as false claims?

    1. I took the information above directly from Dr. Lyles website.

      1. The airway information is straight from the multi-disciplinary adolescent airway clinic at the University of Alberta with many cases of experience as described by the orthodontist on the team. What does that have to do with my web site?

        Working to put a team together with Texas Children’s Hospital so the same service can be available in my community. The results in Edmonton show that it works and it requires a team. They have and are making very significant life long changes for these kids. If it were your child, what would you want?

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