Think Pieces - The Orthodontics Professors

JAWS – Dr. Proffit and Dr. Ackerman Review a Sensationalist Book

6/22/2018

The ultimate thesis of the book is that deficient jaw growth - a disease of civilization - is causing pediatric sleep apnea.

BY WILLIAM R. PROFFIT, JAMES L. ACKERMAN, & TATE H. JACKSON

This book is the result of an unusual interaction between a private practice orthodontist with ties to an English “orthodontic philosopher” and a prominent evolutionist / cultural anthropology professor. Its basic idea is that dental crowding and jaw relationship problems are a disease of civilization, and that the changes in behavior and jaw function produced by civilization are largely responsible for problems secondary to deficient jaw growth, with pediatric sleep apnea as the hidden epidemic.

The thread running through the book is roughly:

Civilization was made possible by the descent of the larynx during evolution and the unique human trait of spoken communication, but that put the point of connection of the mandible to the skull in a vulnerable position that could affect jaw growth.
Jaw size is largely a function of the forces on the jaw during chewing. It is not determined by inherited facial proportions.
Malocclusion is a modern phenomenon because with modern diets, jaws no longer receive the functional stimulus to grow large enough to accommodate the teeth. For this book, malocclusion is crooked teeth; improper occlusion and accompanying jaw relationships are called growth distortions, not another type of malocclusion. Growth distortions lead to other functional problems, with a path from lack of breast feeding to improper swallowing to mouth breathing that culminates in sleep apnea.
Treatment for malocclusion and growth distortion of the jaws, therefore, should focus on increasing the growth of the jaws, which can be assisted by removable orthodontic appliances but successfully accomplished only by exercises to develop the proper muscular environment.

As with all good stories (and this is a good one, well told), the thread contains elements of truth. The book is written in a sensationalist “the truth has been revealed” style that offers no discussion of points of difficulty in either the theoretical development above or the recommendations for orthodontic treatment with which it ends. What are the points of difficulty? Let’s examine them in the sequence above.

One major problem with the theory outlined in the book: cooking, and therefore decreased stress on jaws from chewing, began well before an increase in malocclusion was seen.

Disease of civilization?
Labeling malocclusion as a disease of civilization goes back to two parallel discoveries in the early 20th century: burial mounds with multiple human skeletal remains from the previous millennium, and observation of the dentofacial characteristics of previously unknown aboriginal groups who were found at the same time. It was observed that crowding of the teeth (this book’s narrow definition of malocclusion) was much less prevalent in remains from European populations from more than 400 years ago, and rare in most aboriginal populations. More recently, it was also noted that malocclusion is more prevalent in at least some large and crowded cities in India than in adjacent less-developed rural areas.
Given that, is malocclusion a disease of civilization? Not a bad description, if you don’t take it too far too fast.

Jaw size: function vs. heredity
Some studies by physical anthropologists suggest that dental crowding is due largely to environmental, not genetic control. Even if you accept this, which is the justification in this book for assuming that stress during function determines jaw growth, there are two difficulties in extending the concept of environmental control that far.

The first is that almost surely, chewing force decreased gradually over a vastly larger time scale than the more recent increase in dental crowding. An anthropological theory posed recently (and either overlooked or ignored in this book)(1) is that a key step toward civilization was learning how to produce and control fire. That allowed proto-humans to come down out of the trees, protect themselves from predators by gathering around a fire, and use it to cook food to make it more readily consumable. Data indicate evidence of cooking 200,000 years ago, and it was widely adopted by ice-age Neanderthals. The amount of stress on the jaws from chewing one’s food presumably began to decrease when cooking made food easier to chew, not when malocclusion increased just a few hundred years ago. With that difference in the time frame, can you realistically claim that a rapid decrease on stress from chewing occurred recently and that jaw size decreased rapidly because of this? Almost surely not.

The second difficulty is data that refute environmental rather than genetic control of jaw growth. A major point not acknowledged in the book is that the jaws of current Europeans are quite similar in size to those of the burial mounds. Direct evidence of genetic control can be seen in the remarkable similarity of the facial proportions and jaws of identical twins, in whom minor deviations in jaw width appear in a mirror image. It also is seen in the large but internally-consistent differences between aboriginal groups. Examples are the large and protrusive mandibles of Melanesian islanders, which have not changed although their diet has; the same is true for the X-occlusion (buccal crossbite) of Australian aboriginals. In short, even if you conclude that dental crowding is largely due to environmental influences, there is good evidence of genetic influence on both jaw size and jaw relationships.

In the book, pediatric sleep apnea is said to develop because the mandible doesn’t grow forward enough and doesn’t bring the tongue forward with it, so that makes the pharyngeal airway difficult to maintain. Dr. Kahn’s lengthy discussion of the path from lack of breast feeding to improper swallowing to mouth breathing to poor oral posture to sleep apnea is simply not supported by data. There are weaknesses or contradictory findings at every step, especially the part about lack of jaw growth as a cause of sleep apnea, and none of this is discussed.

100 years ago, Alfred P. Rogers presented the same theory laid out in the book.

Orthodontic treatment by growing jaws
Dr. Khan calls herself a proponent of Dr. John Mew’s approach to orthodontics, which is built around the goal of stimulating growth to correct growth distortions. A long series of studies has shown that increasing the long-term size of mandibles beyond 1-2 mm very rarely occurs even though temporary acceleration of growth was achieved. Despite that, she suggests that orthodontists who follow current treatment recommendations fail to understand that “basic evolutionary theory makes it crystal clear that claims of a dominant role of genetics can be ignored in almost all cases.”

All of this is a remarkably selective resurrection of ideas that have been totally discredited. The bottom line is that Khan and Ehrlich's theory is not at all original and has been shown to be incorrect over the years. Exactly 100 years ago, Alfred P. Rogers, a graduate of the Angle school, posited the same theory as Khan and Ehrlich. Rogers was not an obscure person in American orthodontics, having served as chairman of orthodontics at Harvard and as president of the AAO. His first and most important paper, in which he coined the term myofunctional therapy to describe an elaborate set of exercises that would straighten teeth and correct jaw relationships, was published in 1918 in the International Journal of Orthodontia. He published a follow-up paper 32 years later in the American Journal of Orthodontics saying essentially the same thing but presenting no evidence that it worked, and by a few years later his methods had largely been forgotten in this country. His claims had been examined and could not be confirmed. Ballard in the UK revived a similar theory in the 1960s and promoted it with Tully’s help, but once again the claims could not be substantiated. Mews’ theories are a direct knock-off of Ballard and Tully’s work. Perhaps if you don’t know the history, you really are destined to repeat it.

Dr. Kahn distinguishes orthodontists who (in her view) only straighten teeth from dental orthopedists (also called orthotropists). This is a small group who are oriented to treat children starting at age 4 or 5 and use appliances and exercises to attempt to guide growth. She sees this, based on her own experience, as occasionally successful but potentially harmful. She now practices “forwardodontics”, a term she introduces in this book. It is based on Mew’s “orthotropics”, defined as application of the “tropic premise” that if therapy is properly directed and accompanied by stimulation of the jaw muscles, jaw growth can be stimulated.

What makes it forwardodontics? It is Dr. Kahn’s conclusion that “In practically every person in modern society, both the upper jaw (maxilla) and lower jaw (mandible) are well behind their ideal forward locations for airway development,” so the major goal of treatment for everyone would be to cause both jaws to grow forward. How is this accomplished? With a combination of a removable appliance that postures the mandible forward and a series of exercises. How well does this work? Despite all the claims of effectiveness, there have been only isolated case reports of treatment outcomes for patients treated with Mew’s methods, and there is a total lack of data for results with Dr. Kahn’s suggested methodology.

One aspect of cultural anthropology is the evaluation of how a group’s behavior is based on their beliefs. Perhaps that is the link between cultural anthropology and orthodontics. Dental orthopedists (and forwardodontists, if there are any others besides Dr. Kahn) treat patients based on their beliefs, not on evidence of treatment outcomes. That’s a cultural decision, certainly not a scientific one. In the real world of orthodontics and health care in general, even the best treatments work well in some patients, to some extent in others, and not at all in some. Only in a fantasy world can you promote the idea that your chosen treatment approach is the best for everyone, and that those who don’t use it should be condemned because they have refused to understand. In this book, the cultural anthropologist / evolutionist seems to have been misled by the orthodontist’s fantasy world.

However it happened, the result is a deliberately misleading book that introduces an element of unwarranted fear to promote itself. The metaphor of the killer shark in the movie Jaws – an unseen and unbelieved danger until it is too late – could have been the real model for Ehrlich and Kahn as they wrote this book together. Often, collaboration of individuals from different scientific disciplines can create great synergy. In this instance, it has instead produced an exercise in mutual delusion.

References:
Sandra Kahn and Paul R. Ehrlich. Jaws: The Story of A Hidden Epidemic. Stanford, CA: Stanford University Press, 2018 (Apr.) https://www.amazon.com/Jaws-Hidden-Epidemic-Sandra-Kahn/dp/1503604136
1. Wrangham R. Catching Fire: How Cooking Made Us Human. New York: Basic Books, 2009.

102 Comments

Arnold J. Malerman, DDS link

6/22/2018 06:05:10 pm

Drs. Ackerman and Proffit have been collaborating in the Orthodontic literature since the '60s when I was priveliged to be one of Dr. Ackerman's post-graduate students. As has always been the case their conclusions are based in sound investigation, and presented in a clear and cogent manner.

James Ackerman

6/23/2018 08:24:07 am

What a lovely compliment from a very competent man!

Mihir Shah

6/23/2018 12:52:43 am

So if that is the case, then one can claim that Functional Matrix Theory is also wrong. Function has no role in Form. Going to Gym will never help to grow Muscles & Jaws, Genes will determine wether if one can have strong muscles and bones

Laz S

8/16/2018 08:01:54 am

Well put. The functional matrix has been proven and this old reviewer needs to retire - he is stuck in the 60s when he started

Bennett Mui

1/13/2019 07:49:57 pm

Going to the gym can help me grow more muscle but cannot make me taller. So I cannot see how exercise can cure a Cl II malocclusion by making the mandible longer.

Prof Dave Singh link

1/14/2019 09:46:40 am

Hi Bennett: Going to the gym is (predominantly) muscle hypertrophy whereas bone growth is (essentially) hyperplasia based on a viable population of stem cells. If you fracture the mandible (e.g. during surgery) it 'grows' back because of stem cell differentiation (e.g. distraction osteogenesis). The holy grail according to Sandra Kahn's book (back inside cover) is "develop stronger jaws that fit all 32 teeth" But the front cover shows impacted wisdom teeth! Talk is cheap, I guess. I have not seen any of Sandra's cases with 32 teeth fully erupted in occlusion - but I have seen this in my own experience.

Mihir Shah

6/23/2018 12:54:42 am

So if that is the case, then one can claim that Functional Matrix Theory is also wrong. Function has no role in Form. Going to Gym will never help to grow Muscles & Bones, Genes will determine wether if one can have strong muscles and bones.

REPLY

Gurkeerat Singh link

6/23/2018 08:18:05 am

Fact and fiction are two different things, who ever may be the propose and/or disposer. Fads in Orthodontics have existed since the very science evolved. Having had the opportunity to have practiced myofunctional l/ functional / alignment only etc etc orthodontics for over 20 years and it has taught me but one thing: no two malocclusions are the same and we as orthodontists don't treat malocclusions alone but individuals with similar malocclusion, so no two appliances will give the same result irrespective of the similarly of the malocclusion. The diagnosis is the key...experience helps and evidence will be forthcoming about newer modalities of treatment, hopefully soon....

sandra kahn and Paul Ehrlich link

6/24/2018 10:39:15 am

Over the past 10,000 years there has been a huge self-administered set of changes in the human environment. People began to reduce the amount of breast feeding, move to a more liquid diet, and move indoors where they are exposed to more allergens. Over that period there has also been a decline in human jaw size and a resultant increase in malocclusion and failure of the last molars to erupt. The evidence, documented in the hundreds of scientific references in JAWS, strongly suggests that reduced chewing pressures and mouth-breathing as a result of softer food and stuffy noses disrupts normal jaw development. There is some evidence to support the belief that the shrinkage is still occurring, but data on trends in food chewability are largely lacking, and it is not clear how much of the increase in brace use and sleep apnea is due to need or to diagnostic or technological factors.

What is clear is that claiming the dramatic change in jaw size and malocclusion since hunter gatherer days is ¨genetic”
is nonsensical. Even if there were strong selection favoring small jaws (which seems unlikely to say the least) there haven’t been enough generations. The idea that migrations have led mobs of big-toothed men to inseminate small-jawed women hardly needs rebuttal. We were very clear in JAWS to state where our conclusions were based on research, clinical results, or speculation. Those who say we are wrong need to present a coherent argument for another explanation of the epidemic and, to the degree possible, cite the scientific literature to back it up.

Kevin Boyd link

6/26/2018 01:56:17 pm

I think Dr. Proffit and Ackerman's review, while certainly a negative appraisal of Dr. Khan and Ehrlich's constructive work, should be viewed as mostly a good thing I think in that it will likely draw much needed attention to a problem that has plagued the American dental and medical educational curriculums since from their humble beginnings; that is, within commisioned summary documents, the AMA's Flexner Report (1910) and the ADA's Gies Report (1926), there is absolutely no mention that either curriculum should include the subject of Evolutionary Biology (EB) as a pre-requisite basic life science for being admitted to the undergraduate training program. According to Randolph Nesse, who along with evolutionary biologist G.C. Williams, is one of the co-founders of the newly emerged educational discipline of Evolutionary Medicine, 'pre-doctoral students who lack basic education in EB, would be comparable to engineering students who hadn't been required to take courses in physics.' A good example of how incomplete understanding of fundamental EB principles can lead to erroneous conclusions can be seen in what the good professors misstated about how control of fire, according to them some 200 kya (oops....evidence of fire control by 'proto-humans' suggests that it had happened way before 200,000 years ago), seemingly somehow refutes Kahn and Ehrlich's claim that modern (industrial) feeding regimens over recent centuries are epigenetically impacting phenotypic expression of genes that are involved in coding for structures of the craniofacial and respiratory complexes. But when one understands that the first cooked meats consumed by our 'pre-human' ancestors still then actually required extended chewing time and tremendous masticatory force to fully process(chew), swallow, digest and absorb macro- and micronutrients contained therein. So, over the course of 100's of thousands of years our so-called proto-human ancestors gradually assumed a more gracile (vs. robust) skeletal form. The process of gracialization, a.k.a., 'feminization' is very slow and gradual, which allows for allometrically-scaled size reduction of anatomic structures, that is, not only did the jaws reduce in size, shape and density, but so also did the teeth (proportionally) shrink (i.e., no appreciable malocclusion yet gentlemen)......allometry is the key for grasing of this......and believe me Dr.'s Proffit and Ackerman, I did not learn about allometric scaling in dental or pedo school. When events preceding the Industrial Revolution began to impact nursing, weaning and lifelong chewing practices, well, that's precisely when we see what occurs when genes that modulate expression of survival mechanisms (e.g., the masticatory and
respiratory apparatuses) are no longer stimulated by pressures similar to what previous ancient environments had exerted (i.e., first appreciable appearance of
malocclusion phenotypes in industrializing societies). So gentlemen, the fact that malocclusion didn't coincide with first mastery of fire, but indeed did coincide with first industrialization, it becomes understandable when/if viewed within the framework of allometric scaling.

Thank you for your careful, albeit somewhat uniformed, critique of Jaws.

Roger Price link

7/1/2018 11:28:05 pm

Reading Kevin O'Brien's sarcastic introduction to this topic conjured up an image of of wide-eyed hobbit prancing about in glee, rubbing its hands and giggling uncontrollably that yet again someone else had validated his own intractable position.

The noted British economist, John Maynard Keynes famously stated
"Worldly wisdom shows that it is better for the reputation to fail conventionally rather than to succeed unconventionally",

On another occasion he also stated that "it is better to be roughly right than precisely wrong".

When working with something as complex and unpredictable as the human body there is only one correct treatment, and that is an outcome that is stable and functional.

Mechanical orthodontics, which forcibly drags teeth from a stable position - albeit dysfunctional and aesthetically unacceptable - to an unstable position which has to be retained mechanically - is not a functional or stable outcome.

It also flies in the face of Newton's Third Law which states that "for every action there is an equal and opposite reaction".

What are the equal and opposite reactions as a result of mechanically rearranging a person's mouth and jaws - often removing 4 impacted wisdom teeth as well as 4 premolars?

Losing 8 teeth represents a loss of 25% of the occlusal structure. Might there not be a compensatory 'equal and opposite reaction' to this? Might this not manifest itself in other areas of the body - like the airway, head and neck posture, jaw joints and the ability to breathe in the way that nature intended us to breathe - with an open airway - compliments of 32 well positioned teeth in wide jaws which sit forward of the airway?

It might be wise to remember that if an assumption is fundamentally flawed, and you specialise in it, all that makes you is a specialist in a flawed assumption. It does not make that assumption any more valid because many people are doing the same thing.

This kind of snide sarcastic commentary does nothing to promote the health of future generations. Research can be cherry-picked by anyone and outcomes can be manufactured by the use of selective data to support a position.

It is indeed sad that ego makes people say and do things which from an outside perspective, serve no useful purpose whatsoever.

Sam Whittle

7/2/2018 12:03:34 am

Clearly identifiable 3rd molar distoangular impaction and severe ectopic mesio-labial positioning of the LL3 in a Neanderthal teenaged male skull specimen in the Neus Museum, Berlin. Seems to me, on this sample size of n=1, that malocclusion, and more specifically dental crowding, has been around for a while. Indeed, viewing representations of many ancient people's profiles suggest a class 2 hypoplastic mandible was rather common in BCE times.

Kevin Boyd link

7/2/2018 02:34:32 am

Thank you Sam for your comment.

Yes indeed, an impacted Neanderthal 3rd molar might certainly serve as a proxy for some sort of malocclusion phenotype in this particular Neanderthal individual ....good find; and it’s a good thing I think that you present this as maybe evidence to refute those hypotheses which posit large scale skeletal malocclusion in H. Sapiens as a ‘recent’ post-industrial epigenetically-modulated phenomenon coinciding with changes (cradle-to-grave) dietary strategies/practices often associated with shifts from hunting-gathering and intensive agriculture. As to your mention of ‘having observed ‘representations of many class II hypoastic skulls
of ancient peoples....’’, will you please post some images and/or links or references to published articles that support your statement? And, as to your n=1 H. neanderthalis skull with the impacted wisdom tooth, will you please post images of the entire occlusion?

Again Sam, so pleased that my EvoDent comments inspired you to dig deeper.

Kev

Fenris Ulfr

7/2/2018 03:35:56 am

The question is not if a theory or technique works, but more importantly, like the authors note, Can you prove that it does not? For example: Epigenetics can prevent Migraines, Zika and Helminthiasis, and releasing restricted lingual frena can prevent spina bifida. Where is the clear evidence that it does not do all of the above?
Our allegiance MUST be to our theories – regardless of if they work or not, and ESPECIALLY if they don’t work. For instance, have “conventional orthodontists” ever had a patient whose previously normally inclined incisors are now parallel to the floor after Biobloc or Orthotropic Pneumopedics? Or created bimaxillary protrusion in patients by gently pushing the teeth forward?
The tears in their eyes, their now unfettered tongue and their endearing lisp make it all worth it, Evidence or Not! If that doesn’t make one a 100% believer, what will?
We must indeed address the cause of malocclusion…normal arch development does that. If only the arches can be “fully developed” to their genetic potential – but they can! A new procedure called Geno-expansion ® gently stimulates the hemi-maxillae and the hemi-mandible to slide away from each other thus creating room for teeth, tongue, tonsils, feet etc. In some cases, there is adequate space for a second tongue. This in conjunction with Premolarogenesis® (Iatrogenically increasing overjet and adding premolars) will allow us to meet the genetic potential of our hominid ancestors who had four premolars per quadrant. I totally agree that we must discard the evidence when it does not support our hypotheses…of what use is data if it doesn’t support what we do?
Premolar extraction is a brutal and medieval travesty akin to amputation. Do we remove limbs when we are trying to enhance function? No. After all, esthetics, function, stability, periodontal and TMJ health are not everything. Who is to say that Bimax. protrusion, lip incompetence, drooling, loss of attached gingiva, uncoupled incisors etc. are undesirable? One has to do a better job of explaining to patients why their appearance has worsened substantially – once they understand our new concept of Atavistic© Orthodontics, they will leap on board like our primate ancestors. If malocclusion is a modern development, would harkening back to better times not surely resolve malocclusion by removing the cause?

Rob Wakefield

7/2/2018 04:29:53 am

Well I suppose as the saying goes 'Never letvthe facts get in the way of a good story'. I have been around long enough (sigh!!) to have seen this come and go and come again. The whole sleep apnoea is the latest gravy train to stop at the station of the credulous and financially motivated charlatan. Now that bleaching has become bon- non profitable then a new cash cow was needed and hey presto!!! All the antivaxers and 'food intolerant' parents will be batering these peoples doors down. Quite frankly they are welcome to them.

David McIntosh

7/2/2018 06:07:16 am

Sleep apnoea is a gravy train that’s a fad? Are you genuinely aware of the research and massive push into getting this disease identified and treated and the widespread consequences of not treating it?

Paul M Thomas

7/3/2018 07:03:09 am

So you are suggesting there is a large body of legitimate research reporting the results of sleep studies on pre-adolescents before and after treatment with some whiz-bang appliance? Lysle Johnston said it best (paraphrasing) history has come full-circle. The "activator" originally developed to help manage Pierre Robin sequence has now morphed into a gadget for managing undocumented sleep apnea in contemporary pre-adolescents. Rob Wakefield's post should only be offensive to those presented with the possibility that the emperor may indeed be naked.

Fenris Ulfr

7/2/2018 05:22:32 am

As famously stated by the eminent father of down-picking, James Hetfield, “It's all fun and games until someone loses an eye. Then it's just fun and games you can't see.”

Mechanical orthodontics, is all about science and evidence, whereas, we in the fields of Orthotropics, Epigenetics, Myofunctional therapy and Scientology believe in so much more!

The possibilities are endless…one just has to shut off the part of the brain that is responsible for cognition, and turn on the part of the brain that embraces delusion.

For instance - Let’s ignore the fact that Newton’s third law dealt with motion, and not fantasy. After all, were Newton alive today, might he not create a corollary to the third law specifically due to the consequences of premolar Denticide???
If losing 8 teeth leads to decreases in the airway, should gaining 8 teeth not lead to stupendous increases in airway, and the ability to fly?

Edward Angle was right! However, along with expanding the arches limitlessly, one has to also apply gentle external forces to the maxilla and mandible so the nose and chin are obscured and the teeth protrude excessively beyond lips stretched in a rictus of appreciation!

It might be wise to remember that alternative facts are also facts, as are specious facts. Australopithecus had awesome posture, 40 teeth, jaws that sit forward and no sleep apnea! Why then can we not use mechanical orthodontics to recreate our healthy ancestor?

Roger Price link

7/2/2018 07:13:18 am

Not sure if anyone has picked up that Fenris Ulfr - translated from the Norse as 'Swamp Wolf' likes to hide behind anonymity so that it's (I'm gender neutral) biased, sarcastic and ill informed comments save it from the embarrassment of people knowing who it really is. Cowardly is not an adjective that I would like to have associated with me.

Fenris Ulfr

7/2/2018 07:33:13 am

An ill-suited adjective like cowardly would fail to capture the enormity of the delusional granduer that emanates like a miasma of puerile observations from the self-appointed prince of the absurd. Only a Norse wolf would ever want to engage with one mired in such asinine thought. Perhaps this manufactured outrage would be better spent trying to wrap one's mind around conceiving a cogent thought?

David Turner

7/4/2018 03:38:33 am

I am a Cambridge University graduate in mathematics and am well aware of the naivety in drawing conclusions from small sample sizes. With this in mind, I am not going to claim that Orthotropics is devinitively superior to standard orthodontics. However, when both of my daughters started to suffer from crowding of the teeth, I researched the alternatives and decided to try Orthotropics as practiced by Professer John Mew and his son Mike. I am very pleased with results they have achieved, not only in relation to teeth, but also facial appearance.

James To

7/4/2018 10:18:40 am

Unfortunately, the plural of anecdote is not data. I have 5 children, 8 nieces and 7 nephews all treated with extraction of teeth and they look great. Should I now conclude that all patients would benefit from the same therapy?

Of course not. I have seen Mew's and his colleagues results and they look horrendous. I have to admit I did not realize that until a few years ago. The biggest fool is an old fool

I used these technics of Ortotropics, myotherapy even the Biobloc, ALF and DNA. They seemed to work ok for a few patients, but failed miserably in a lot of the others. The relapse was almost 100%. I had to refund several and referred patients to three orthodontists who were nice enough to accept and help re-treat these patients.

One of them told me about Dr. O’Brien. When I attended to Dr. O'Brien's lecture, I began to realize that the stuff I believed in was not based on good science. Orthotropics was just a made up word!

I wish these therapy worked, but in fact, to my sorrow, it does not. Even though traditional orthodontics is more effort and discomfort, there is no doubt it works and very stable compared to myofunctional and orthotropics.

I no longer do orthodontic treatments…only general dentist. But, it was painful learning experience. Lesson – Learn to listen to wise people.

David Turner

7/4/2018 12:11:26 pm

For some reason I cannot directly respond to the response to my comment below, but I can respond to my own comment:

- have you seen the pictures of the identical twins where one was treated by standard orthodontical treatment and the other by John Mew? The difference in facial appearance is significant
- I don’t understand why anyone would consider that the extraction of 4 teeth to obtain a good look is commensurate with a good look obtained by the retention of those teeth. Am I missing something?
- perhaps I have been brainwashed, but I fail to see how any self respecting professional is content to treat to symptoms without any regard to the cause. Perhaps the Mews are wrong, but at least there is a logic to what they are doing. How do standard orthodontists justify their treatment?

James To

7/4/2018 12:31:12 pm

Yes! I have seen that MEW Twin paper. That was worst junk article I ever read! What a nonsense! No mention of what was done, no measurements, no superimpositions, pictures like taken by monkey at zoo. He used to show us all time and we believed him!

It was a total rubbish fest fiction. Nobody in right mind think that’s how science done!
You are missing many somethings. You have no understanding of dental science and limits of bone, stability etc. You have been brain-washed…like I used to be!

The Mews were my idols and I followed their teachings for years, but what a mistake! My family all treated with extraction...all look great. Two niece won beauty contest, daughter is model.

David turner

7/4/2018 12:39:29 pm

Thanks but you have responded to my second and third points, or perhaps you have by saying in an earlier post that you have reverted to being a general dentist. If so, that’s rather sad. Are any standard orthodontists willing to respond?

James To

7/4/2018 12:42:48 pm

No, no. I was never a orthodontist, just general dentist who was doing orthotropics, myofunction and epigenetics. But I have many orthodontist friends who showed me MEW and I were wrong! So now I no longer do orthotropics.

David Turner

7/4/2018 12:43:29 pm

Apologies, I’m typing on a phone and can’t easily see the first part of each message. There’s a typo in my previous one “have” should read “haven’t “

G. Murray

7/4/2018 12:52:11 pm

I have followed this discussion with interest. With regard to Dr. Turner - I am what you call a standard orthodontist of 47 years.
I too began my career with Begg and Tweed and then turned towards Mew, Hang and others. It took 5 to 7 years to see the relapse of patients treated with this philosophy.

A lot of effort went into fixing this the second time around. I have since realized that if it sounds too good to be true, it probably isn't. Orthodontics is a very complicated science and one cannot treat every case with the same treatment plan.

After 47 years, I have noticed that I'm extracting even more than ever....this is in contrast to what I used to do. And now I have learned from my failures. Hope that helps.

Sax Dearing link

7/2/2018 05:46:02 am

It seems to me that the orthodontic community as a whole is grossly over sensitive to commercialism and hugely under sensitive to not subjecting patients to unproven treatments.

Roger Price link

7/2/2018 07:20:56 am

As to the accusations of ethics being driven by commercialism, the latest forecasts for the growth of the orthodontics supply industry - please note - supply only - not fees - which are many multiples of the hardware - sometimes 10-15 times - is $6 BILLION by 2023. So we're looking at a $60 - $90 billion profession!!!!! No wonder 'the virgins protesteth too much - methinks'

Paul M Thomas

7/4/2018 04:57:30 am

Here we are in agreement. (I'm impressed! A response of only four lines of text). The "Holy Grail" of orthodontics seems to be moving teeth the fastest. No mention of stability which is another question. One only needs to stroll the exhibit floor to select a long list of "therapeutic" approaches/devices to achieve that end. Most if not all have precious little research supporting their premise. But these snake-oil salesmen/sales women, could easily invoke your argument suggesting the fallacies associated with the "western" research. They can simply respond that it works because I say it does. Another respondent in this thread cited his experience and publications. When I looked at his website, his "research" consists of 6 case reports. This is second from the bottom in the pyramid of evidence. Only lower is opinion and anecdote which describes the majority of the posts on this particular blog. The current research model may not be perfect, but it's preferable to the "it's so because I say it's so" approach being used by so many.

Roger Price link

7/4/2018 01:02:51 pm

James To,

I am so thrilled for you that you have such beautiful nieces and a model daughter. Nowhere in this blog has anyone ever suggested that traditional orthodontics does not produce pleasing results - and if that is all you focus on then that clearly explains your lack of understanding of anything else.

It is truly not necessary, and in fact offensive to refer to work done by esteemed colleagues as 'monkey the the zoo' and other disparaging remarks.

You make very clear your dislike and disdain of what the Mews do - even though you were a 'disciple' of theirs. I will most certainly be asking them - independent of this blog - what they think of you - and I'm sure that the other side of the coin will make for very interesting reading.

It is not the technique that is right or wrong, good or bad - it is the skill (or otherwise) of the clinician that will determine the outcome.

I worked on a daily basis with a very prominent orthodontist who does BioBloc, ALF, DNA, conventional braces, Invisalign and whatever else his 35 years of experience tells him is the appropriate treatment for a specific case.

He has a wall of his orthodontic successes - perfect upper and lower 6s, and these are all described as his hopeless profile failures.

James To

7/4/2018 01:21:13 pm

Hello Roger –

I’m sorry, but the MEW paper was a terrible! Hurts to even think I used to believe the stuff. Please ask them about me.

Why use something if the result is a horrible with no stability, bone loss and make patient hate you? You are correct about clinician skill, but is only good as theory based on science.

Mew theory unfortunately based on speculation and a fantasies. I respect him as my teacher, but I feel I got wrong trainings.

You are not a dentist or orthodontist so you don’t know how things are suppose to be. I am sure you are very good at what you do, but please don’t make silly claims – I have seen and done first hand what the Mew suggested and taught. It failed!

What is a perfect upper and lower 6s? Sorry…I not familiar with that terms. I have seen, done and known much more than you so I have a position to make statements. Thank you!

sandra kahn link

7/6/2018 01:04:13 pm

I feel for Drs. Like Dr. To who failed at the most difficult endeavor of changing patient's behavior and addressing cause and not symptoms.

However, beware that the fact that something is hard and most fail at it, does not make it impossible or wrong. How many fail in running 100mts in 10 seconds? Almost everyone, but Usain Bolt (and others) can, because he has trained properly and for many years. Forwardontics or Orthotropics is difficult, but with proper training and tools, growth guidance as described by John Mew, can be done successfully. Strict guidelines in timing and patient commitment are critical.

It is insane that the proof that treatment does not work is a bunch of poorly trained clinicians.

I have dedicated 4 years (sharpening the saw) to train in orthotropics, in the form of old fashioned mentorship from Dr. Simon Wong. If anyone does this, and still fails, then the technique may be faulted.

We have developed tools like GOPex/GOPex programs (with support app) as well as the BOW, to make technique more accessible and reliable. Anyone that does not recognize that postural re-education (not only myofunctional therapy) and strict adherence to age (less than 10 years old) adequate patient selection, will fail, betray their patients and hurt their practice.

I am happy to mentor anyone that is serious, but do not kid yourself, this is the Olympics, but it CAN be done.

Stay tuned, solid evidence-base clinical research is coming from the consecutively treated sample from Dr. Simon Wong. There are 2 major universities looking at the cases right now.

Roger Price link

7/6/2018 01:36:59 pm

Sandra,

Thank you for pointing out so succinctly that because something is difficult and that people are not adequately skilled that the process is wrong.

I am going to get rid of my Steinway Piano because I can't play Chopin's Etude in G# minor. Its the piano's fault because I took piano lessons for 6 months - but didn't practice all that much.

I cannot accept Dr To's exhortation to 'leave the orthodontists alone' as though they are being unfairly 'picked on'.

Orthodontists are highly trained in moving teeth - as that is what their professions are all about.

To my way of thinking that is only half the job - and an important half. The rest is to make sure that they understand why the teeth were misaligned in the first place and learn how to correct those underlying issues.

BUT MORE IMPORTANTLY - and I believe that this is where they feel so threatened - if we are able to detect and rectify the dysfunction early enough there will be no need to straighten the teeth in later years.

However - the orthodontists need not worry about their financial futures. There are millions of people out there who will pay to have their crooked teeth straightened - just look at Invisalign alone - and they don't represent the total market:

January 31, 2017 16:00 ET. $1.1 billion in 2016 - up 27.7%

Align Technology Announces Fourth Quarter and Year Ended 2016 Results
SAN JOSE, CA--(Marketwired - January 31, 2017) - Align Technology, Inc. (NASDAQ: ALGN)
Record 2016 revenues of $1.1 billion, up 27.7% year-over-year, and diluted EPS of $2.33
2016 Invisalign case shipments of 708.5 thousand cases, up 21.5% year-over-year
Q4 revenues up 27.3% year-over-year to $293.2 million

If they don't want to do that - that's fine - but they should not rubbish and denigrate the knowledge and skills of people who can do this because they know nothing about it.

I was taught many years ago - by a very wise professor - who had this sign on the wall behind his desk.

"EITHER LEAD, FOLLOW OR GET THE HELL OUT OF THE ROAD"

You guys have done a great job

Regards

Roger

Dustin B

7/6/2018 06:16:29 pm

Interesting discussion. Full disclosure - I have used alternative therapy in the past (for almost 11 years) before stopping due to some negative results. I still think it might be useful in some select cases, but I have reverted to extractions as required.

Just did not like the results I was seeing. Unhappy patients, parents and GP's are not practice builders!

While all this sounds good in theory, it does not seem to work in practice...as I found out. I would love to see examples of cases with FULL records showing positive outcomes...mine were quite the opposite.

On another note, one cannot take Mr. Price seriously...he is not a dentist so lacks a lot of essential knowledge about growth and development.

His suggestions seem to rambling, incoherent and ill-informed. We don’t need ignorance muddling the issue. This is a discussion among clinicians. Period.

@Dr. Kahn, Boyd and To – I would like to see some your examples of cases treated with these modalities. My results were quite similar to those described by Dr. To.

Cheers,
DB

Prof Dave Singh

7/6/2018 06:52:42 pm

Hello Sandra:
If you're an advocate of this approach, then I believe your leadership needs to include enhanced accountability. You use words like 'Forwardontics', which is simply a commercial trademark in my understanding. This needs to be clearly marked with either “TM” or (R), so those new to the topic are not misled into thinking that this is a clinically-accepted term, generally speaking. I had these discussions with John Mew many years ago. I pointed out that the term 'orthotropics' is a contradiction in its conjunction of ‘ortho’ meaning ‘straight’ and ‘tropic’, which means ‘bending’. You can’t have “straight bending”. You can have “unbending” but the term that has been used in the craniofacial literature for that is “orthocephalization”. You might also consider klinorhynchy as ‘evolutionary bending’ (for the cranial adaptations necessary for speech). I was educated in England, perhaps one generation after John. We were taught about plant phenomena such as ‘heliotropism’ where plants bend/deform/grow towards light, for example. I guess this is where John might have applied that idea (perhaps mistakenly) to craniofacial growth. Currently, “tropism” is used (correctly IMHO) in geometric morphometrics and mathematical modeling e.g. anisotropy (non-uniform shape change), etc. Clinically, the term “trophy” with a “p” is used to describe growth phenomena e.g. atrophy, hypertrophy, etc. I am not for or against your clinical approach, but I think that if we use words with agreed definitions, this will help in our collective understanding of the issues at hand.

sandra kahn link

7/6/2018 10:52:49 pm

“enhanced accountability. You use words like 'Forwardontics', which is simply a commercial trademark in my understanding.”

Do you know that the word “Parenting” did not exist 50 years ago? Just like this, humans have been making-up words to help understand concepts in an original way. This is what Forwardontics is.

I wear two hats, one as a clinician and the other as a mother. This is why I paired-up with a recognized, published, multiple science award-winning researcher evolutionary biologist and with Stanford University Press.

You want to scold me on the use of my made-up term, that I created to explain to patients and parents the goals of our chosen therapy protocol clearly? What we do requires compliance and understanding because our patients have to do most of the work (this is the reason most clinicians fail). Actually the term was strongly encouraged by the Stanford team to help clarify confusing terms like orthotropics.

I wonder if the people commenting here have actually read our book? The review lumped orthotropics and orthopedics (“Dr. Kahn distinguishes orthodontists who (in her view) only straighten teeth from dental orthopedists (also called orthotropists).”; even though I wrote a whole section explaining why orthotropics and orthopedics is totally different.

The book is written in simple language, for parents and everyone who has jaws. Hence the need for a more descriptive word, not a trademark for selling purposes.

Now for those who want to see our cases, with full records. You will have to wait until they are published in a peer reviewed journal. I want this more than you do. We have to do this right, including the careful comparison with control groups. Unfortunately, this takes time, but we are getting close.

If you want to continue this conversation email me privately.

Kevin Boyd

7/7/2018 03:22:28 pm

Dear Dustin B

I have shown some of our results at meetings over the past 6-12 months, and will be showing cases over the next 6-12 months at various European and US venues; please contact me directly if you might care to attend future or view past presentations.

Kevin Boyd

kbo569@gmail.com

David McIntosh

7/2/2018 06:10:19 am

I’m confused. Is the suggestion here being made in general terms that the environment has no effect on form. Furthermore is it being suggested that skeletal deficiency has no impact on airway resistance?

Roger Price link

7/4/2018 02:02:09 pm

James - yes I am good at what I do, and with 6 decades of experience behind me, even though I am not a dentist or an orthodontist, I will tell you the following without hesitation.

Moving any bony structure which has muscles, tendons and fascia attached - irrespective of the technique used - will result in relapse of one form or another unless the cause of the skeletal dysfunction is identified and addressed.

My involvement in the dental-orthodontic profession is tangential. I look after The Person Attached to the Symptoms while you look after The Symptoms Attached to the Person.

Neither is stable without addressing the other. I cannot correct dysfunctional breathing behavior if the upper arch is so narrow and high that there is no room for the tongue and the vault encroaches into the nasal passages. I HAVE to have a dental colleague expand that arch so that I can achieve my goals.

The opposite holds true as well. What long term stability can you expect by expanding the maxilla and having the tongue resting on the floor of the mouth? NONE - unless you use a permanently bonded wire to prevent relapse.

The orthodontist I worked with had the same relapse as anyone else until he started to address the physiological and behavioral aspects that were a large part of the original problem.

There is all but no relapse provided that the posture, fascia, breathing and muscle function is balanced.

I accept that this might seem a nonsensical notion to you because you were trained as a dentist and never had any of this in your education or experience.

Just because you don't know about it is no reason to claim that it is not applicable.

When you open your eyes and mind and realize that there is a person attached to those teeth - you will appreciate that the teeth are not the problem. They are the consequence of other issues and dysfunctional patterns elsewhere in the body - and those could be ANYWHERE in the eleven functioning systems.

Upper and lower sixes refer to 6 - 11 and 22 - 27 depending on which system you use - or upper and lower canine to canine - basically the visible teeth in a smile.

The renowned American Philosopher Wayne Dyer stated:

"The highest form of ignorance is when you reject something that you know nothing about"

The more I learn the more I understand how little I really know. It is a humbling thought but gives me much joy every time another nugget of information finds its way into my life.

James To

7/4/2018 03:16:15 pm

Roger – You make too many assumptions about what I do! You do not know. I look after Person too! Very much.

Where’s proof that expanding maxilla and moving tongue is stable without retainers? That is right! There is none.

You were trained to ask questions and you accept theories without any evidence of their efficacy because of bias. You have very much bias…but no experience.

I have experience with this and it no work! Leave the orthodontists alone – They are right and you must listen to them. If you disagree, you must prove to us with high quality evidence. Otherwise, why should we ever believe you?

We are not trained to accept just at face value! I did with MEW and see what happened!
I will leave you with saying from German met physicist Charles Schuldiner who said “So easy it is deny someone else’s knowledge”

Kevin Boyd link

7/5/2018 01:21:58 pm

Dear Dr. James To

Given your frequent descriptions of treatment failures after having attempted to help these children with utilization of so-called orthotropic techniques, have you ever considered that maybe at least some of your disappointing results might actually emanate from operator error? Orthotropic concepts are difficult to assimilate, for clinicians and their patients/patients' parents, especially when they are not viewed and understood from an evolutionary perspective, and even then so, also more difficult to execute when a clinician does not have adequate training and experience in managing the normal/age-appropriate expectations, fears and anxieties of children (and their adult caregivers) within the context of a clinical setting. The fact that you had decided to cease providing orthodontic services to children altogether seems to have been a prudent one and will likely prevent future problems for you......but to attribute your perceived Tx failures to a technique per se, while simultaneously assuming absolutely no personal responsibility, is not only unfair to Dr. Mew, but also Dr. To, maybe preventing a huge learning opportunity for yourself .....to understand and learn from where you might have made some wiser clinical decisions for some of those kids.

James To

7/5/2018 01:39:47 pm

Hello Dr. Boyd – Thank you for responding. That was the first thing I thought...that I do something wrong!!

So, I contacted 3 other colleagues all who were senior to me with OT, Myotherapy and EpiG. One was even orthodontist in different state! All heavy users of removable biobloc and other appliances and two had myotherapist in office. These were the clinicians who got me interested and involved in 1st place.

Imagine my disappointment when two of them shared similar results and the third one did not want to talk about it at all! Two patients were suing him because of these concept treatments. Tell me what I should think???

So, when I saw Dr. O’Brine’s lectures and teaching, I slowly began to understand how wrong MEW was. I was soooo sad .

I know now, orthodontics look easy, but actually not. There is a reason orthodontist recommend extraction, surgery, expander, facemask etc. They know much more than us about evidence and proof of what to do. I feel like fool now. SorrY!

Chintu Kale

7/5/2018 08:09:52 pm

Rather late to this discussion, but I would have to agree with Dr. To. I experienced quite a similar trajectory of initial euphoria, positive feedback followed by very bad relapse and a lack of stability.

I don't offer myotherapy anymore, although deep inside, I still think it has some value. As a heretic of orthodontic theory as it was taught, I was forced to capitulate and "eat" humble pie. Not a good feeling.

I have since reverted to what I was taught during residency, but still don't like to extract teeth even if it needs to be done.
I only treat non-extraction cases now...anything with crowding/protrusion, class II or open bite I refer to a very competent orthodontist down the street.

Dr. Hang is great, but the results are not what he claims. My practice took a hit too.

Kevin Boyd

7/6/2018 04:06:15 am

Did you dissect and analyze your perceived Tx failures Dr. To? At what ages were you initiating treatment on these children? Did you cause harm to any of these children. If so, how did you rectify? Would you be willing to post pre-Tx and Tx-progress records of a case that went poorly for you as evidence of your claim that John Mew somehow led you astray?

Thank you for considering

James To

7/6/2018 05:26:05 am

Hello Dr. Boyd! I used help of two colleagues to analyse the treatments and the results. I would initiate treatment as young as 5 years and up to 15 years of age.

But, the biggest problems was relapse of expansion, crowding, too much protrusion/teeth flare and open bites. Patients could not get lip together easily.

I would love to show case, but fear that it is a open forum

Kevin Boyd

7/6/2018 01:05:59 pm

Thank you Dr. To. Please consider sharing your Tx failure records with me off of this forum as I would really like to understand what went wrong for you and your young patients.....especially with the very young patients as I am involved in ongoing trials as a pediatric dental Sleep Medicine consultant at two tertiary care childrens' hospitals. Many of our very young patients have benefitted from our intervention protocol and I would like to share with you some of the results, both good and not-as-good. My email address is kbo569@gmail.com.

Kind Regards

Kev

Roger Price link

7/6/2018 09:20:08 pm

So Dustin B

Only dentists know about growth and development.

That is going to come as shock to many other professions.

And no other professionals should be taken seriously because they are not dentists. That's another shock........

If my 'suggestions seem rambling, incoherent and uninformed' and I am 'ignorant and muddling the issue' then I am afraid that there are hundreds of thousands of colleagues of mine, around the world, who fall into this grab-bag of sheer ignorance that characterizes your comments.

I will grant you that many of these world figures are not dentists - they are only Professors, PhDs, DDSc etc. and regarded worldwide as being at the top of their professions in the fields of Behavioral Physiology, Behavioral Psychology, Early Growth and Development - areas dealing with the whole child - not only the teeth.

And - if something doesn't make sense to you - do you think that the ignorance could possibly be at your end?

Your claim that 'this is a discussion among clinicians. Period. - is equally uninformed. Are dentists the only clinicians on the planet?

And - again - many of the criticisms leveled by Drs. Profitt and Ackerman were not of a clinical nature at all - they referred to what they felt was a misguided understanding of the growth and development of 'man' through the ages.

I'm not quite sure who it is who shouldn't be taken seriously.

You might wish to read Lawrence J Peter's book in which he propounds The Peter Principle.

And Cheers to you to.

Roger Price

Dustin B

7/6/2018 10:04:20 pm

Sorry Rogey old chap...you just don't know what you don't know bub. What have you done to deserve our attention? Take a chill pill and the let those who know teach you a thing or two. Listen carefully... knowledge enters as a whisper.

G'night!

Prof Dave Singh

7/7/2018 12:02:37 pm

Hi Sandra:
Forgive me if my comments sounded like ‘scolding’. Far from it. But again, words like “parenting” are generic and broadly-accepted without much controversy, unlike ‘forwardontics’. Mew’s idea of ‘forward growth of the jaws’ is central to this discussion. The orthodontic literature does not support that notion. Human jaws don’t grow forwards, unlike pigs or wolves that develop snouts or muzzles, for example. Please review the brachyrrhine gene mutation. But, part of this difference lies in cranial base alterations, which I mentioned previously. So, how can one think about forward jaw growth in humans? Perhaps it emanated from Down’s paper (1938) on mesial drift in association with the anterior component of (masticatory) force? About this time, cephalometrics was a new science, which has since been discredited (Moyers and Bookstein, 1982, 1979) in that compressing a 3D object into an imagined 2D space doesn’t correctly depict clinical changes that we wish to determine. With 3D imaging techniques, geometric morphometric and mathematical modeling, however, we can take your clinical data, throw them into 3D statistical shape-space and see where they land. Then we can use various algorithms to see what happened, where it happened, by how much and if the changes were, in fact, statistically significant. When I did this with 2D data for ‘orthotropic’ cases, the findings did not support Mew’s assertions. I would be very interested to see what your 3D data will show. What do you have as a control group? I will venture a prediction; the facial components will grow upwards and outwards, giving the impression of some forward growth when viewed from the lateral aspect, mimicking the mechanism of mesial drift perhaps in association with anterior cranial base allometry. Again, I have nothing against your clinical approach, but I’m interested in unraveling developmental mechanisms that might be useful to craniofacial clinicians.
p.s. Not sure if your last sentence was directed to me or a general invitation

sandra kahn link

7/7/2018 12:42:28 pm

Dave,
I have been a fan of yours for a long time, reading many of your papers. Again, the term Forwardontics was coined to explain the goals of therapy to the lay public. Not for profit, but for our treatment ideals. My daughter just had orthognathic surgery and was moved forward 1.5cm, to be where she looks ideal and balanced. I can show you the superimposition, her face definitely came "FORWARD".

I am a clinician and I am collaborating with brilliant minds (like Paul) for the research part. The normal control is going to be provided by seasoned scholars, possibly Dr. Buschang or Dr. Aizenbud.

The email comment goes for you or for anyone that wants to continue positive discussion. It is difficult for me to follow conversations in this forum.

Helen Jones link

7/2/2018 06:43:09 am

Please correct me if I am wrong but my understanding is that the scientific proof for treatment outcome using a conventional method is that it is unstable and requires life long retention. Time then, perhaps, to look for a better way and this book gives much food for thought.

Prof Dave Singh

7/7/2018 05:12:30 pm

Sandra:
It seems to me that I was correct in assuming that 'Forwardontics' is a not a scientific or clinical term. In the UPR Craniofacial Center, our team undertook distraction osteogenesis on teenagers with craniofacial syndromes (similar to that which you describe for your non-syndromic daughter, I assume). If that is the case, then when addressing clinical/scientific/professional audiences, consider using the word "prognathism" instead of 'forwardontics'. I am not scolding 😊 because this term has existed in the evolutionary/anthropologic/clinical disciplines for centuries, and as you suggest, it is forward placement of the jaws – but relative to what, one may ask? The answer is, of course, the bent cranial base of the modern hominids, with their large teeth (Dryopithecus cusp pattern), primary palate and mental process that excludes them from the Pan genus but predisposes them to SDB. Therefore, there is no need IMHO to invent a new word for the prognathic phenomenon, at least for these types of discussions.
p.s. Looking forward to England vs. Croatia next Wednesday in the FIFA 2018 World cup now that we’ve finished watching England vs. Sweden and Russia vs. Croatia – thrilling matches today 😊

Lysle Johnston

7/2/2018 06:52:52 am

The problem stems from the convenient fact that nobody dies from treatment, no matter how crazy and ineffective. Everything "works," so nothing matters. Angle's learned medical calling is rapidly becoming low-grade cosmetology. Critiques, no matter how thoughtful and scholarly, have little impact on self-serving, profitable fantasy.

Kevin Boyd link

7/2/2018 11:33:16 am

Dear Dr. Johnston-as you alluded, EH Angle understood Class II 'disto-occlusion' as first being evident in the primary dentition, and almost alwaypersistent/worsening beyond .... and often associated with nasal disuse/mouth-breathing. When why was he first ignored on a large scale....and why is he still being ignored do you think? I think I know. why....and determined to change this. I wish you would help me do this.

Kevin Boyd
CMU 1977

Fire Up CHIPS!

Roger Price link

7/2/2018 07:00:51 am

I am intrigued at the closed-mindedness of some of those who have responded to this post.

I have been around in the medical and dental professions for a long time - 61 years to be exact, and have had 5 out of 6 children go through the hands of 'real orthodontists' back in the dark days of the '80s when I had zero understanding of the concept of etiology vs symptomatology.

The children come from 3 different mothers and 3 different fathers so please spare me the 'genetics' as a reason.
All 6 children are now in their 40s.
3 of those 5 were C-Section births and are midface deficient.
4 were tongue or lip tied (or both) and were bottle fed from 3 months.
1 struggled to breastfeed and was finally given a bottle.
All 5 used pacifiers for various lengths of time
All 5 have relapsed to one degree or another.
2 have serious TMJ issues
3 have disordered sleep - which 'magically' disappeared when the tethers were released - well into adulthood - and their tongues were trained to sit up and forward.

Of course none of this was double blinded, randomized placebo controlled, Cochrane reviewed, meta-analyzed or studied longitudinally - but trust me - for this parent - the reality is blindingly evident.

I have, during these 6 decades, seen some eye-watering about flips where 'incontrovertibly researched procedures and drugs' were reversed, eliminated, castigated and denounced due to the 'discovery' that they either caused major harm - even death - and that there was a better way.

Sisyphus had it easy. All he had to contend with was a rock. Those of us who are open-minded to all possibilities have a much more difficult task. We are faced with ego -

And - Rob Wakefield, battering has two ts and people's needs an apostrophe. Also an idea to proof your comments before posting so you don't let the typos through.

Alvin Fogherty

7/2/2018 07:21:57 am

I'm intrigued at the lack of critical-thinking ability among some who have responded to this post. Perhaps we should all just concoct and stitch together unscientific anecdotes and ludicrous theories since that seems to be more popular than evidence-based science. Of course, the proponents of such malarkey talk about "open-mindedness" and other such drivel to push their sophistry. They are fooling nobody.

Peter Doyle

7/2/2018 09:47:26 am

The idea that orthodontic research is up to any standard that either side of this argument can claim superiority’ is nonsense. As for “all my treatments are based on sound scientific evidence based research “ are kidding no one but themselves. Do no harm seems to be a good maxim to start from . Craniomqndibular disorder is a real thing that the established profession have blissfully ignored. More research please .

G. Yadav

7/2/2018 10:37:41 am

Another convenient nonsensical excuse used by the anti-science lobby. There can be no debate when one side actually has the evidence whereas the other side only has anecdote and emotion. All these so-called disorders seem to be based on nothing more than unfounded and simplistic theories attempting explain complex phenomena.

Prof Dave Singh

7/2/2018 11:48:55 am

In the introduction, the Reviewers do not provide their definition of ‘malocclusion’ making the assumption that there is an universally-agreed definition, of which I am not aware [1]
Paragraph 1 of the critique starts with an error. It should read "Labeling malocclusion as a disease of civilization" not ‘orthodontics’?
The citation of Corruccini's research of rural and urban Punjabis is misquoted and misleading in my understanding of their paper. Where is the Reference for this?
Jaw size
Para 1: Phenotypic variation can occur rapidly (perhaps in one generation). Please note Dr Crick’s idea (who worked with Dr Watson on DNA structure) of the Big bang theory of human brain evolution. He claimed that the human brain evolved very fast in evolutionary history (like a hurricane building a Chevvy by passing thru a junk yard, or words to that effect).
Para 2: Yes there is evidence of genetic influence on both jaw size and jaw relationships. However, the ‘jaws’ are not homogeneous. The maxilla is devoid of cartilage unlike the mandible, and genetic mutations of cartilage can produce phenotypic variation, for example, the Hapsburg jaw. Moreover, genetic mutations of the cartilage of the cranial base can have epigenetic effects on the face and, therefore, the jaws and teeth [2]. These epigenetic phenomena might explain clinical facies, such as those seen in Down syndrome, for example.

Orthodontic treatment
The Reviewers obfuscate the reader by incorrectly ascribing the myofunctional concept to Mew’s idea. This is incorrect [3, 4]. Put simply, the myofunctional concept is ostensibly based on soft tissue effects (muscle stretch) to achieve correction, while Mew’s idea is 'forward growth' of the jaws. But the Reviewers are correct that ‘forward’ growth of the jaws is not supported by the orthodontic literature [3-4, 5-6].

Moss’ functional matrix was a good start in understanding the developmental mechanisms involved in the precipitation of malocclusions, but it was incomplete since the technology was lacking, and teeth were omitted from his ideas. Moss talked about the ‘genomic thesis’ that Drs Proffit and Ackerman subscribe to. He talked about the ‘epigenetic antithesis’, which Drs Kahn and Ehrlich subscribe to. He talked about the ‘resolving synthesis’ that I used to formulate the Spatial Matrix hypothesis [7], which predicted issues such as obstructive sleep apnea that are currently being discussed.

References
1. Singh GD. Outdated definition. Brit. Dent. J. 203(4), 174, 2007.
2. Parsons TE, Downey CM, Jirik FR, Hallgrimsson B, Jamniczky HA. Mind the gap: genetic manipulation of basicranial growth within synchondroses modulates calvarial and facial shape in mice through epigenetic interactions. PLoS One. 2015;10(2).
3. Singh GD, Medina L, Hang WM. Soft tissue changes using Biobloc appliances: Geometric morphometrics. Int J Orthod. 20:29-34, 2009.
4. Singh GD, García AV, Hang WM. Evaluation of the posterior airway space following Biobloc therapy: Geometric morphometrics. Cranio 25(2): 84-89, 2007.
5. Singh GD and Clark WJ. Localization of mandibular changes in patients with Class II division 1 malocclusions treated using Twin Block appliances: finite-ele
6. Singh GD and Hodge MR. Bimaxillary morphometry in patients with Class II division 1 malocclusion treated with Twin Block appliances. Angle Orthod. 72(5), 402–409, 2002.ment modeling. Am J Orthod Dentofacial Orthop. 119(4), 419-425, 2001.
7. Singh GD. On Growth and Treatment: the Spatial Matrix hypothesis. In: Growth and treatment: A meeting of the minds. McNamara JA Jr (ed.) Vol 41, Craniofacial Growth Series, Ann Arbor, USA, 2004, 197-239.

Dr. Martin Denbar link

7/2/2018 11:52:26 am

It has always fascinated me how most all the accepted research is performed through the dental schools. Most all the dental schools orthodontic programs will not even discuss anything but conventional orthodontics. I have tried to discuss airway topics with all three orthodontic dept. at the dental schools here in Texas. Not one will return a call or answer an email. Then they castigate any group that looks outside the “box” of their normalcy with impunity and stating they don’t like the studies, articles or thinking since it does not meet their standards.
Reminds me of the old days in the late 1990’s when I was treating with oral appliances and I contacted the dental school in San Antonio to discuss cases and my results. I was told to quite what I was doing, I shouldn’t be doing OAT on patients, no “real” research available on it and their final comment of we will call you when we feel it is appropriate, but don’t call again.
It will be interesting to see how long the old guard that is protecting their turf at all costs will take to start looking outside their box.

Peter Schatz

7/2/2018 12:02:41 pm

Is it the job of academics to play whack a mole every time someone fabricates a theory? Why don't those who complain and moan about research actually learn how to do it and then impress the rest of us with their data? The answer seems quite obvious - anything that would discredit their fondly-embraced theory is verboten. I don't blame the school for not wanting to waste time on a wild-goose chase. It will be interesting to see when these fringe practitioners will eschew denial and accept reality.

Roger Price link

7/3/2018 11:23:34 am

Paul.

Maybe you've lost sight of the fact that those 'academics' to whom you refer, are the product of what often started out as 'fabricated theories' - which were violently opposed at the time and then became accepted as valid.

I have been around long enough to see eye-watering reversals, back-flips and about turns where Gold Standards have been shown to be 'lead based Fools Gold'.

So you truly believe that anyone who does not accept the very questionable 'reductionist scientific model of research' is in denial and eschews reality.

Dr Tim Horton, recent editor-in-chief of The Lancet - the so-called bible of research - published an article in 2015 in which he stated that 50%, or even more of the research published in his magazine was false. Yet you and your colleagues seem to hang your hats on 'research' even if it is skewed, bogus, plainly fraudulent and blatantly wrong. The mere fact that it was published seems to be good enough for you.

It is not possible to double-blind and randomize everything - no matter how much you might wish for this to be true. Current IRB restrictions make much of the 'research' of the past impossible to replicate because disadvantaging people acting as controls is not permitted.

A Gold Standard does not mean it is correct or the right or best way of doing something. All it means is that someone (usually a commercial interest with a LOT of money) has convinced a lot of people that what they have to offer is the best and this becomes embraced by the majority of people who accept what the 'experts' tell them.

Is it not a sobering thought that less than 16% of the world's population uses Western medicine? That 16%, which is almost exclusively restricted to the so-called developed economies, represents in the US alone, over $1.3 trillion every year.

Out of all the OECD countries the US spends the most per head ($10,000 per man woman and child) and has the worst outcomes. Anyone who believes that Western Medicine provides 'Health Systems" is deluded. Western medicine is a Disease Management Business - and Orthodontics is an extremely profitable segment of this system.

I have been working daily, for the past 20 years, with dentists and orthodontists and I am extremely fortunate to fall outside of the brilliant Einstein comment "The thing that gets in the way of my Learning is my Education".

I have no formal education in dentistry or orthodontics so I don't have to feel threatened by something which challenges the dogma I was taught. I do however have plenty of education in the Human Body, Behavior, Physiology, Nutrition, Manual Therapy, Pharmacology, Pharmacokinetics, and I will not bore you with anything else - but it is a long list.

I cannot see - no matter how hard I try - the sense in taking perfectly stable teeth - albeit in the wrong place - and making them unstable in the 'right place'. So unstable in fact that they require permanent retention otherwise they will want to return to the place where they were comfortable.

Ortho-dontics is all about straight teeth, with scant concern as to why they were in the wrong place to start with. The hoary old concepts about having Mom's Jaw and Dad's Teeth have been debunked by thinking people who see that the genetics largely control tooth size, missing or supernumerary teeth, and it is the forces of the muscles of the tongue, cheeks and face that will determine the ultimate position of the teeth.

Would you deny that muscle trumps bone in any challenge? If you deny this then there is simply no point in wasting any more time discussing this. Just look at scoliosis, lordosis, kyphosis, forward head posture and Blind Freddy can see that the skeleton was 'bent into this shape' by the process of the muscles, tendons and fascia.

Just because something is being done doesn't mean it is the right or best way.

P. Schatz

7/3/2018 12:00:08 pm

Did you mean Peter?

So we are supposed to discard all science and believe you? Why? Because of “some claims” you make? What proof can you offer?

What research do we and our colleagues hang our hats on? Show us. Just sayin’ don’t make it so.

It seems like you have no formal education in dentistry and orthodontics. So, that explains a lot! How can we take you seriously when you speak in riddles, offer zero proof and reach outlandish conclusions not supported by fact?

There is literally nothing that can be gathered from your points except that you vehemently oppose dentistry/orthodontics as it is practiced. So, what’s your big plan?
Perhaps you are not aware of who it is you decided to impugn on this blog. These two are researchers of the ilk you are probably not familiar with.

You cannot see, because there is so much you simply do not know. My suggestion is to don some humility, acknowledge your inchoate state and learn a thing or two about dentistry before spouting off these incoherent ideas.

I don’t know the point of the rest of your diatribes and do not know anyone named Freddy – Blind or Sighted. Have a nice day.

Miguel Gonzales

7/2/2018 12:23:26 pm

Brilliant analysis and critique! Very revealing to see the cyclical pattern of these quasi-intellectual ideas. Dr. Rogers would no doubt be mortified to see how some of his ideas have been co-opted and manipulated for commercial gain. Thank you for being a voice of reason. But, reading the comments, I fear you may have provoked many financially or otherwise conflicted individuals who would rather continue to obfuscate patients and dentists.

Martin Denbar link

7/2/2018 04:54:35 pm

Got to hand it to you, by your estimation OAT should never have happened. Why those upstarts that dared to defy the all knowledgeable, almighty in the dental school establishment. As one of the initial clinicians that used and published on Combination Therapy using an Interface, I guess I should have been graced by the likes of you before I dared treat and manage the untreatable.

Shall I contact the hundreds of untreatable patients that I have controlled using Combination Therapy and tell them to discontinue treatment because you feel the results are anecdotal and therefore invalid. There was no research to support what I did back in 2002, only common sense, clinical experience, knowledge of the field and an open mind using a noninvasive therapy for a patient with no hope.

As a Quasi-intellectual doctor, your words, it will be interesting to watch a few conventionally trained orthodontists and GPs that are inquisitive, open-minded to new ideas that are backed by studies (guess the ones you don’t like) and able to mix the conventional with new ideas that don’t fit the conventional narrative overtake your field.

Peter Schatz

7/2/2018 05:12:44 pm

Managed to treat the untreatable? Oh my! What a mighty claim! What, pray, have you treated? And, where might one find the data for this rather lofty and unsubstantiated statement?

I assume there were adequate control groups, of course? No? There were no control groups? Is it any wonder that the dental school ignored your fatuous assertions?

Please contact all your patients (real and imaginary) and tell them whatever you please. Nobody knows or can verify any of the things you say, and yet you take umbrage?

The concept of the scientific method seems to be alien to you. Your pronouncements lack logic, lucidity or veracity.
It is simply quite impossible to treat any of your statements with anything but mirth and hilarity. Your daring is commendable…you have certainly dared and succeeded in deluding yourself, and a few other uncritical souls. Kudos Sir!

Roger Price link

7/3/2018 12:24:27 pm

Peter - I did mean Paul as my remarks were addressed to Dr Paul Thomas.

I fail to see where I discard all science. All I am pointing out is that blind adherence to dogma is not a smart way to go, and that there is more than one way to address most issues.

Please remember the sage comment that "The Spectator sees more of the game than the Players do"

I do not 'vehemently oppose dentistry and orthodontics as it is currently practiced' because, thankfully and happily there is an ever growing cadre of dentists and orthodontists who are prepared to discard their biases and look at things from a different point of view.

I certainly do not need to 'don some humility' - and do not live in an inchoate state, and my ideas only seem incoherent to those who fail to take a step back and do a reality check.

The world of Behavioral Psychology and Behavioral Physiology is vastly bigger than that of dentistry and orthodontics combined - and there are multiples of Professors and Researchers of 'equal ilk' than exist in your field.

In today's enlightened world there is no longer place for silo thinking - that has proved to be detrimental to the human body as a whole.

I am having a nice day, thank you, and I wish you the same

P. Schatz

7/3/2018 12:54:17 pm

My apologies since I saw your post below mine. You seem very well-versed in Behavioral Psychology and Behavioral Physiology…what is your implication of it’s influence on Orthodontics. And what is your proof?

Thus far, I fail to see anything but random, unconnected events. Correlation does not imply causation.

You seem to not understand the concept of extractions....I'd refer you to some orthodontic textbooks to learn about that. It's a very valid procedure, so please refrain from making fallacious statements.

You lose credibility when you attack established science with no evidence to prove your perspective.

Other points of view are always welcome, but need to be supported by a basis and with data.

Martin Denbar link

7/2/2018 08:35:45 pm

Sorry, won't lower myself to your level. Enjoy your day.

Paul M Thomas

7/3/2018 07:25:27 am

No need to lower yourself to any level. Surely you wouldn't embark on treatment of OSA without concrete evidence that it actually exists in the patient of interest!
Therefore, just show us the data using what is considered the gold standard in contemporary research. Randomized controlled clinical trial using polysomnography as the measure of disease and successful treatment. You could even employ the double blinded bit if you wanted to test your ability to identify those suffering OSA by clinical exam only. Assuming you could identify a sample of affected, impose your treatment methods and show they are effective by performing another sleep study at the conclusion of therapy.

Roger Price link

7/3/2018 11:47:47 am

Paul,

In all the years that I have been involved with the dental and orthodontic profession I have been stunned by the lack of knowledge and understanding about the function of the human body - outside of the teeth and jaws.

Nowhere is this more obvious than in the realm of 'sleep disorders'.

If you would care to invest 2 minutes of your time and listen to the following interview you might rethink your position on OSA, polysomnography and your reference to disrupted sleep as being a 'disease'.

https://www.youtube.com/watch?v=6bSOrNaZ_-o

Dr Barbara Phillips, a Pulmonologist, Head of Sleep Medicine at Kansas University and Editor in Chief of Chest Magazine - one of the bastions of Pulmonology - who was interviewed on the MD Channel makes no bones about the disarray of the medical profession when it comes to 'sleep'. She states that 'this has to change' and she is right. 45 years of blind adherence to night time intervention has brought very little benefit to the tens of millions of people who suffer fractionated sleep.

Is it not beyond bizarre that the two Gold Standards in so-called Sleep Medicine and Sleep Dentistry are in fact Breathing Devices? -

Neither CPAP nor OAT have anything to do with 'SLEEP' They both address Breathing - yet doctors and dentists, at large, know precious little about Breathing, its mechanics, dynamics, habits, compensations and payoffs.

MMA surgery addresses repositioning the jaws so that the patient can breathe better. This has nothing to do with 'sleep disorders'

The unthinking masses, both medical and dental, keep on referring to Sleep Disordered Breathing as though it is the process of Sleep that disorders Breathing - which is total nonsense - for were that the case nobody would ever sleep.

The 'sheeple' follow the dictates that currently exist and which simply do not work - save for the small number of people for whom the CPAP air splint is appropriate.

The 'Inconvenient Truth' is that the vast majority of 'sleep disorders' are in fact Breathing Disorders which interrupt sleep. These Breathing Disorders are created largely during the day, as a result of poor postural and nutritional habits, inappropriate stress responses, compensation for aberrant behavior patterns, and these compensations take place unnoticed when the person is awake. They compensate without realizing it.

However at night it is a different story. There are two solutions to not being able to breathe at night.
Wake up - partially or fully
Die.

If you are going to reference OSA and PSG as a means of supporting your orthodontic position then it might be an idea to become familiar with current, modern and alternative approaches to sleep disorders - much along the same lines as current, modern and alternative approaches to physically dragging teeth to an unstable position and forcing them to stay there - with no thought as to what the consequences of this action might be.

The body seeks balance and will compensate for any imbalance - be it forced or intuitive.

Roger Price link

7/3/2018 01:42:26 pm

Peter.

Are you perhaps confusing me with someone else?

I have never mentioned extractions in any way shape or form and I am a proponent of all forms of intervention, provided that they are necessary, appropriate and do not cause collateral damage.

The fact that science is 'established' only means that it concurs with our current thinking. How much 'established science' has been debunked over the years and proved to be invalid?

I am a scientist - and have been one for 6 decades - and one of the things that I most love about it is that it can be challenged and changed - but this takes time and there are people who resist change with every fibre of their being.

There is nothing personal in my challenges - just the ardent hope that blinkers will be moved to the side and that other points of view will be considered. ALL science was conjecture at some point until it became accepted and valid for its time.

Much of what I studied in the fifties, in well respected Universities and scientific organizations around the world has been proven to be inaccurate - even though it was deemed to be valid at the time. As technology and experience progress we are able to see things that we missed previously.

One cannot dispute that the sole and total function of the human organism is 'to take the next breath'.

To deny this would be plain stupid. How the body ensures that this process continues to happen is different for everyone. Subtly in some cases, glaringly obvious in others.

It is these subtle changes in the physiological and psychological behavior patterns that control how the organism grows and develops, and orthodontic issues do not develop solely when the teeth erupt or when primary dentition gives way to permanent dentition.

To look at teeth in isolation flies in the face of what constitutes the growth and development of the total human being - they are just a small part of the overall process BUT are so visible that they become very important.

A close friend who is the Chair of Orthodontics at a leading University told me that his definition of orthodontics was as follows:-

"ORTHODONTICS IS AN ART, DESPERATELY TRYING TO BE A SCIENCE"

"nihil proficere sine mutatio" There is no progress without challenge

Paul M Thomas

7/4/2018 05:45:28 am

I should have clarified that my comments are related to OBSTRUCTIVE sleep disorders, not all sleep disorders. I do not ascribe to the mindless expansion of dental arches into a position of instability. I suggest that orthodontic therapy is largely cosmetic, but not without value. (That's 'going to prompt a cascade of responses, I suspect) I agree with Prof Singh's comments below about the multiple etiologies of sleep disorders. I agree that much of the discussion is regarding breathing disorder which may disturb sleep. My concern is regarding the clinicians (not all orthodontists) who embrace some form of treatment without clear knowledge that there is a sleep/breathing disorder and without knowledge that breathing has been improved as a result of their intervention. This is especially disturbing when the recipients are growing children recruited into a practice with promises to parents of curing disordered breathing. Orthodontics as practiced in the USA largely remains a cottage industry. There is precious little oversight regarding proposed treatments and the therapeutic value of results. Taking the extreme of MMA for OSA, there is still a paucity of data to document improvement. Does an expanded airway = cure of the breathing disorder? For that matter, there is precious little data to suggest that orthodontics/orthognathic surgery for treatment of the extreme malocclusions has functional benefit. (and this is pressing the limits of the soft tissues you rightly mention) As I'm sure you know, if one looks historically at expansion vs non-expansion in the context of orthodontic therapy, the pendulum has swung from one extreme to the other. It would appear, the current thinking by a segment of clinicians justify the approach by believing (or espousing), expansion = treatment for sleep/breathing disorders. This should be a concern for anyone (the lonely 17% ;you mention) believing in the value of evidence based therapy.

Prof Dave Singh

7/3/2018 01:59:13 pm

Roger:

You may have inadvertently oversimplified a rather complex area of discussion?
Sleep Medicine is a medical specialty, treating over 74 known sleep disorders (ICSD, 2014). These sleep disorders are classically divided into three etiologic/overlapping sectors; Neurologic, Metabolic and Craniofacial. Obstructive Sleep Apnea (OSA) is only one of those 74 recognized disorders. Current practice parameters legally-permit general dentists/orthodontists with additional training to treat only mild to moderate cases of OSA. Similarly, your assertions on daytime breathing have limited applications in conditions such as narcolepsy, familial insomnia, etc. But the vast majority of OSA cases seen in dental practice appear to be craniofacial in origin. The dental profession has a history of identifying specific conditions and almost eradicating them (e.g. dental caries, periodontal disease, etc). In that context, I wonder if the dental profession turns its attention to mild to moderate OSA, as suggested by the recent ADA initiatives, then perhaps a new specialty of Dental Sleep Medicine might emerge, similar to other dental specialties, such as Orthodontics and Oral Maxillofacial Surgery.

Roger Price link

7/4/2018 08:59:21 am

Paul and Dave,

Stepping back from the detail for the moment and looking at the broader picture, the statistics cannot be ignored. Neither can the limitations of reductionist research principles be ignored.

I am not saying that research is unnecessary – I have been part of a number of research projects in my career, and am currently involved in a project with NYU Rusk Rehab evaluating the benefits of using capnometry in the management of COPD - but there are limitations – especially in children – because of the multiplicity of individual underlying issues – for this research to be valid.

Without putting too fine a point on it – how much ‘correction’ was applied to the much vaunted orthodontic ‘research’ that seems to form the basis for the denigration of anything that is not mechanical ‘level and align to lower incisors’ based?

It is an accepted fact, supported by statistics and data from numerous sources in ‘sleep medicine’ that CPAP compliance is very low and that a significant percentage of people simply give up. You will also recall, if you watched the video I posted, that Prof. Barbara Phillips stated that tens of thousands of people simply refuse treatment after OSA diagnosis because it is “too expensive, too complicated, too patient unfriendly and too test orientated”

It is also an accepted fact – born out of the reality that ALL ORTHODONTIC TREATMENT requires retention – that >90% of forced tooth relocation will relapse over time. This is not a stellar outcome in any terms.

What would the reaction be to the orthopedic surgeon who straightens a deformed limb and then tells the patient that they need to wear a cast forever otherwise the limb will again deform? The two situations are not that dissimilar.

I have noticed an almost hysterical emphasis on ‘research’ – or the lack of it – when it comes to any discussion on myofunctional orthodontics – which Kevin O’Brien so snidely refers to as ‘myofictional’ orthodontics. If that doesn’t reflect total bias – what does?

Can someone please explain to this non-dental and non-orthodontic scientist how it is possible to control or double-blind any form of research without applying exclusions, conditions, exemptions or corrections?

What sense does it make to eliminate people because of a ‘pre-existing condition’ where that condition could very well be the key factor or linchpin in what you are trying to research?

How can you validly compare two human beings, or two groups of human beings if you eliminate crucial facts and developmental traits, which are unique to each individual, and ‘make them the same’ for the purpose of this specific research?

How can you ignore such basic, vitally important factors as:
• Nature of gestation – complicated or ‘normal’
• Birth process – ‘normal’, assisted or mechanically or surgically mediated
• Nursing process – breastfed or bottle fed
• Nursing duration – optimal 2 years before weaning, or bottle and pacifier for an indeterminate time
• Weaning or transitioning to solids – when and what type of solids
• Release or retention of neonatal reflexes

ALL OF THESE will have a bearing on the outcome of the ‘trial’ so it is nigh impossible to find adequate numbers of same gender children where the above conditions – and there are more – will be accounted for so that the outcome is valid.

Just ‘correct for them’ and come up with an outcome that does not truly reflect the situation but is deemed to be ‘valid’ because it was published. Remember what Tim Horton of The Lancet said about the accuracy of published research………

So let’s ignore all of the underlying etiology and correct the sample so that we have x number of boys and y number of girls between the ages of 7 – 12, and publish a paper which says there is no statistically relevant difference between process A or B.

How about we look at the thousands of N=1 families where their children (and very often the parents themselves) have experienced life-changing results as a result of individually assessed and planned treatments? For these people the outcome of the ‘trial’ was 100%.

Nothing is ever completely right or completely wrong and failure to look at things with an open mind will just preserve the status quo.

Don’t forget the following facts.

Using double-blinded, randomized controlled, placebo mediated trials, which were regarded as being evidence based and best practice – and were FDA and other government agency approved:

1. THALIDOMIDE Recent investigations indicate that Thalidomide resulted in the birth of 100,000 or more babies with phocomelia - About Thalidomide - Thalidomide Tru

Roger Price link

7/4/2018 10:34:53 am

Apologies - the last portion must have exceeded the maximum post length.

Don’t forget the following facts.
Using double-blinded, randomized controlled, placebo mediated trials, which were regarded as being evidence based and best practice – and were FDA and other government agency approved:

1. THALIDOMIDE Recent investigations indicate that Thalidomide resulted in the birth of 100,000 or more babies with phocomelia - About Thalidomide - Thalidomide Trust
https://www.thalidomidetrust.org ›

2. VIOXX - When half a million Americans died and nobody noticed | News | The ...
www.theweek.co.uk/us/46535/when-half-million-americans-died-and-nobody-noticed

3. CHLORAMPHENICOL AND APLASTIC ANEMIA
Jack J. Rheingold, M.D.; Carroll L. Spurling, M.D.
JAMA. 1952;149(14):1301-1304. doi:10.1001/jama.1952.02930310037008
https://www.motherjones.com/politics/1979/11/dump-killed-twenty-thousand/

I could cite dozens more cases – including implants, surgeries, prostheses and more drugs which account for this staggering statistic – and remember that ALL OF THESE PROCEDURES WERE RESEARCHED AND PUBLISHED IN HIGHLY RESPECTED JOURNALS.
Medical errors third-leading cause of death in America - CNBC.com
https://www.cnbc.com/.../medical-errors-third-leading-cause-of-death-in-america.html
Feb 22, 2018 - A recent Johns Hopkins study claims more than 250,000 people in the U.S. die every year from medical errors. Other reports claim the numbers to be as high as 440,000. Medical errors are the third-leading cause of death after heart disease and cancer.

Kevin Boyd

7/3/2018 10:02:36 pm

Hi Dave

Per your recent mentioning, ‘The dental profession has a history of identifying specific conditions and almost eradicating them (e.g. dental caries, periodontal disease, etc)’, as it is obviously not a recent phenomenon, will you please elaborate regarding precisely when the dental profession had ‘almost eradicated dental caries and periodontal disease’?

Prof Dave Singh

7/5/2018 10:09:57 am

Hi Kevin:
That was hardly the main point of my comment :) The gist of this discussion, IMHO, is how to reconcile the opposing view of Drs Proffit and Ackerman and Drs Kahn and Ehrlich. The two points of view are supported by various folks such as Dr O'Brien, Dr Murray, Dr To and Mr Price. My idea (the Spatial matrix hypothesis) is based on work such as:
The ontogenetic complexity of developmental constraints. J. Evol. Biol. 6: 621 -641 (1993) by Zelditch et al. It references the late Dr ML Moss. So, as a clinician, I attempt to use developmental and evolutionary biology to understand clinical behavior beyond the 'form and function' paradigm that we have been in mired in for quite a while now. I think the concept of complexity helps us to understand various clinical outcomes (good or bad) and I have used Waddington's epigenetic landscape as way to explain phenotypic variation (e.g. Class II malocclusion) and concomitant developmental compensation to permit compromised function (e.g. sleep disorder breathing) based on the behavior of various craniofacial components. Every orthodontist knows that orthodontic decompensation is required prior to orthognathic surgery in severe cases. By working with children with craniosynostoses, I ventured that regular patients with developmental compensation could be orthopedically decompensated non-surgically, deploying the epigenetic antithesis. My fear is that traditionalist thinking might stifle innovation - so despite a healthy degree of scientific skepticism, we need to undertake further research on these 'heretical' ideas.

Helen Jones link

7/6/2018 05:10:23 am

Dave
You stated "The dental profession has a history of identifying specific conditions and almost eradicating them (e.g. dental caries, periodontal disease, etc)." So how about making the eradication of malocclusion the next challenge?

Prevention requires early intervention so waiting until the teenage years is not going to work. It seems that the views of Edward Angles have been carefully selected - accept Angles classification but not his views on nasal airway and earlier treatment.
If malocclusion is genetic why would anyone be concerned about thumb-sucking?

P Schatz

7/6/2018 06:18:04 am

How does one claim to prevent something that might never occur? Can I claim to prevent kidney stones by gently caressing the ear lobe for 3 minutes 2 times a day? If death is inevitable, why exercise?

Kevin Boyd

7/6/2018 08:32:36 am

Dear Dr Paul Schatz

I completely agree with you that it’d be foolish to propose a preventive Tx intervention strategy for a disease of which there are no obvious validated risk traits manifesting. But that said, on the continuum of pediatric Sleep Disordered Breathing(SDB) ‘behavioral’ traits/symptoms, from innocent mild/quiet snoring on the low end, to witnessed obstructive sleep apnic events at the high end, if indeed there were also scientifically-validated ‘physical’ (craniofacial) risk phenotypes present, such as high/ narrow palatal vaults, anterior open-bites, grade 3+ ankyloglossia, moderate to severe Cl II retrognathia, etc., say in your own 4 year-old child, would you maybe at least consider appropriate intervention strategies such as RPE, frenectomy, etc. in the primary dentition if it might help mitigate not only the malocclusion traits, but also maybe some/all of the SDB/OSA traits?

I am diametrically opposed to any dentist who offers orthodontics/dentofacial orthopedics as a primary intervention for SDB/OSA ....it’s false advertising, grounds for malpractice liability and also practicing medicine without license to do so. To not make false promises, but rather to inform a parent that coincidental to maxillary expansion, lingual frenectomy, etc., it is quite possible for their child to experience improvements in some/all of their sleep-associated behavioral problems, such as bedwetting, snoring, bruxism, night terrors and various other parasomnias, is a prudent and medically defensible approac that at the very least, will take some forms of malocclusion off the table as possibly being contributory to the multidue of etiological components of pediatric SDB/OSA.

Note: references available upon request for validating all of these (and other) malocclusion phenotypes as being comorbidities of existing SDB/OSA disease, or predictive of increased risk in a children without obvious disease

P. Schatz

7/6/2018 08:47:37 am

Dr. Boyd - I think your approach is quite nuanced and much more practicable. I would certainly refer for T&A evaluation, however, RPE in a 4 y.o.? What about creating a buccal cross-bite?

Any data with a control group that shows the efficacy or benefit of such an intervention?

Thanks!
PS

Prof Dave Singh

7/6/2018 08:58:44 am

I agree with you, Helen. Prevention is better than cure. Note that Angle's classification is outdated IMHO. For example, anterior/posterior open bite and 'gummy smile'/vertical maxillary excess, low clinical crown height, etc. were omitted from his classification, but predicted by the work of Corrucini. if we extrapolate the preventive notion in the context of this discussion, might we as a profession look to prevent certain cases of SDB also? I regard (craniofacial) complexity as a finite number of clinical outcomes (malocclusions, TMD, tori, SDB, sleep bruxism etc) but you can't predict which one(s) a particular patient will present with, according to Waddington's epigenetic landscape.

P. Schatz

7/6/2018 09:45:25 am

Claims of prevention of a condition that might never occur + the absence of a control group = junk science. Anyone can make up any # of "scenarios" where their intervention would "prevent" something from occurring. See the ear lobe analogy.

Kevin Boyd link

7/7/2018 03:06:21 pm

Dear Dr. Schatz

A collaborative ENT (et al, p.r.n.) consultation is indeed part of our protocol.

As for creating a buccal cross-bites, at/or before the age of four.....certainly would be unusual, and never an irreversible problem in that simultaneousl, or at some point after initiating RPE, we begin mandibular arch development as well. Keep in mind sir, I am a US-trained and American Board certified pedodontist, so I have formal training not only in G&D and orthodontics/dentofacial orthopedics, but also with over 30 years experience in managing toddlers' (and their parents'), age-approiate anxiety and their expectations regarding all kinds of indicated dental and orthodontic treatments; whilst I had to spend hundreds of hours in the Dept. Orthodontics during my pedo residency, the ortho residents were not at all required to spend a single minute in the pedo dept. learning about how to develop and utilize pediatric behavior guidance skills.....go figure.....maybe this has something to do with why you and others are so resistant to assessing and treating the very young?

RPE is a medically defensible and scientifically-supported procedure known to often coincide with mitigation of pediatric SDB/OSA symptoms...... over the next 6 months I will be lecturing in the UK, Rome, Paris and various places in the US about this protocol if you care to see case studies that clearly show how appropriately timed and applied orthodontic/dentofacial orthopedic intervention can impact airway health in young/very young children who are either at-risk for airway disease, or are already diagnosed (based upon in-house overnight polysomnography (sleep study) SDB/OSA and co-morbid specific validated malocclusion phenotypes. Please email me (kbo569@gmail.com) if you'd like my lecture schedule for future or from past presentations.

Kevin Boyd link

7/5/2018 12:37:12 pm

Thanks Dave

Yes, of course I know that your statement, "The dental profession has a history of identifying specific conditions and almost eradicating them (e.g. dental caries, periodontal disease, etc)" was absolutely not the 'main point' of your commentary, however, you did indeed utilize it as being supportive to your main point, which was, "....In that context, I wonder if the dental profession turns its attention to mild to moderate OSA,.....").

And with all due respect Dave, you did seem to imply, albeit maybe unintentionally(?), that our profession has established an amazing precedent by 'almost eradicating caries and periodontal disease', and provided us without a single supportive reference for this, which seems uncharacteristic of your usual scientific rigor and elegant style.

Beata Holowko link

7/14/2018 04:24:20 am

https://www.researchgate.net/publication/325347225_Why_Human_Jawbones_Shrink_so_Rapidly_in_Evolution_Scale

Alireza Hourfar

7/14/2018 05:09:16 pm

So I hear DNA appliance is great! I go to check it up with an open mind. So you make a removable appliance with a jack screw, clasps for retention, some modified labializing springs, a labial bow and bite block: DNA appliance! Seriously?? Sir, you have revolutionized orthodontics!! Is it great news to general dentists, pediatric dentists and pharmachologists?! Crozat, europian-style remeovable appliances , and functional appliances have all been in the mainstream of orthodontics. Now, if we take them and rename them as ALF, DNA and Orthotropics we will become visionaries!!

Sandra link

7/15/2018 09:45:10 am

This comment is complete nonsense. It’s like saying that a different surgical technique is not valid because the scalpel has been around for a long time.

We wrote about a different way of thinking and addressing a problem, not about any specific “magical” appliance or technique.

These contributors are pen-happy to write their thoughts with out having bothered to even browse our text.

If they did, they would argue about the hurdles of transferring patient responsibility to address the environment early in life, rather than attack specific techniques.

I even question if Dr. Proffit actually read our book. There is a lack of consistency with the voice that I know from his articles (After all, his original work on the importance of oral posture is fundamental for our GOPex program).

Additionally, the review states that orthotropics and orthopedics are the same, even though we have a whole section of the book explaining why these are totally different.

This review and the spark of unrelated criticisms makes me think that Jaws has struck a fiber in the leaders of our profession, a profession in crisis.

It feels like they felt threatened by a book with solid evidence, that what we are observing in our children is not Genetic as we have been lead to believe. Paul Ehrlich is among the most brilliant evolutionist of our era. I would like all these doctors with their “big words” debate him on the premise of our book and not on the absurd personal quests of clinicians with specific agendas, that are unrelated to the facts introduced in Jaws.

Of course there is a need to research what we should do as a profession, but the environmental and postural influences in malocclusion and jaw size, are unequivocally solid.

I look forward to reading and addressing real comments about the book. Yes, a sensationalist book, much needed for a profession in absolute crisis!

Raza Barbour

7/17/2018 06:17:18 am

I have actually read the book and feel that Drs. Proffit and Ackerman were much too kind in their evaluation. The book is completely devoid of critical thought. Orthotropics is a made up word...a synthesis of Ortho (Straight) and Tropic (Nonsense). Jaws has struck a fiber...one of unmitigated bewilderment. It belongs in the Fantasy section of the library. The reason our profession is in crisis is directly attributable to such pseudo-science.

sandra kahn link

7/17/2018 03:17:04 pm

Raza,

"The reason our profession is in crisis is directly attributable to such pseudo-science."

I'm not sure if your just don't recognize that our profession, orthodontics, is in crisis, or if you just do not consider a total lack of retention and Invisalign over-the-counter shops, the reasons for the crisis.

In either case I think you live in a bubble if you think "pseudoscience" is why patients are not willing to pay proportionately for our services, are increasingly unhappy with long-term results and complain of post treatment pain, airway and other health symptoms.

R. Barbour

7/17/2018 04:11:08 pm

Sandra –

So we should believe you then? Based on what evidence?

Total lack of retention is a crisis how? And your solution obviates retention? How convenient! Does it also prevent cardiac arrest?

My dear, I’m afraid you simply don’t understand the concept of a cause-effect relationship. You are chock full of conflation, cognitive bias, and false attribution just like the book.

All these so-called conditions have nothing to do with orthodontic treatment. If you disagree, prove it. Don’t expect us to take you at your word.

If you have been in the profession as long as I have (yes, I have seen Mew many times) you can spot snake oil a mile away.

Prof Dave Singh

7/15/2018 01:39:38 am

Hello Alireza:
Not sure if this the right forum for the specific criticisms that you are making. This discussion is centered on the notion whether craniofacial growth can be attenuated clinically. If you read my prior comments on this discussion board and then finish with the penultimate response, I think you might have a better idea of what we're talking about.
Meantime, please feel to contact me offline if you require information about the 40 or so publications on the specific criticisms that you are making. I am speaking at a Sleep Disorders conference next week on this topic, which is not, orthodontics, of course. My email is: drsingh@drdavesingh.com
Prof Dave Singh DMD PhD DDSc

Roger Price link

7/17/2018 07:02:38 am

Raza Barbour.

Please help me out here because I'm confused.

On the one hand, you and your orthodontic colleagues continue to affirm that you are the only people who know anything about crooked teeth, you have been following your 'research-based procedures' for decades, with great success, and everyone that doesn't agree with your dictates should just be dismissed as dangerous idiots and go away - leaving orthodontics to you.

If this is true - why is your profession in crisis?

Do you seriously expect people to believe that the release of Jaws, only a couple of months ago, has already had such an impact that you were prompted to write the following?

"Jaws has struck a fiber...one of unmitigated bewilderment. It belongs in the Fantasy section of the library. The reason our profession is in crisis is directly attributable to such pseudo-science.

Please tell me who is 'bewildered' by what is in the book? I have been intimately involved in dentistry and orthodontics, on a daily basis, for the past 20 years - and still am.

The people with whom I interact are not 'bewildered' at all - in fact they are open-minded and smart enough to understand that just because something has been done one way for a long time, doesn't mean that it is the correct or best way of doing it.

Do you seriously believe that you and your colleagues are the only people on this planet who know anything - or perhaps I should say 'everything' about crooked teeth?

AND - furthermore - if such concepts which are gaining more and more acceptance daily - belong in the Fantasy section of the library why is there an ever increasing number of people moving away from the idea of simply 'moving teeth to a new position and having to permanently retain them there to prevent them from going back to where they were 'happy and stable'?

I have been accused of being 'unfit to be on this blog' because I am not a dentist or orthodontist, or someone to be disregarded and dismissed because I am misguided and ignorant. The degree of patronization and condescension from some of your colleagues is eye-watering, and speaks volumes. Unbridled criticism says more about the person doing the criticizing than the one being criticized.

It might be wise to remember that when you point a finger, there are always three pointing back at yourself.

Insults, sarcasm, dismissive remarks about others and what they know is why 'orthodontics' is in crisis – not a book that has been out for a couple of months.

To quote the sage American philosopher Wayne Dyer.

“The highest form of ignorance is when you reject something you don't know anything about.”

Have you ever considered that perhaps embracing modern ideas and concepts - not just 'modern brackets' - might help you get 'out of crisis'.

Maybe you missed an earlier post which came directly from the Professor and Chair of Orthodontics of an extremely well established and respected University – in which he stated.

“ORTHODONTICS IS AN ART – DESPERATELY TRYING TO BE A SCIENCE”

R. Barbour

7/17/2018 07:55:05 am

Mr. Rogers

Exactly right. Who are you and why should we care? Who says our profession is in “crisis”? You? I have been in this field for 60 years now and have seen plenty come and go so I’m yet to understand why anyone would listen to anything you say other than for comic relief.
These “people” you claim to be involved with…are they real or like your other obfuscations?
Please spare us the indignation….I for one do not believe you. You talk the talk but can't walk the walk. Provide proof or stop blathering like one who has lost his mind.
And enough with the nonsensical quotes. I’ll leave you with one - “The art of knowing is knowing what to ignore”. You.

Roger Price link

7/17/2018 08:01:30 am

R. Barbour.

YOU ARE THE ONE who said your profession is in crisis. Just read your earlier post.

"The reason our profession is in crisis is directly attributable to such pseudo-science."

R. Barbour

7/17/2018 08:17:22 am

Roger - Pretty self-explanatory, no? Read it again.
It will make sense (hopefully)

Beata Holowko

7/18/2018 09:04:21 am

I think that many dentists and orthodontists expect easy and simple methods of treatment of malocclusion and expect a pretty face in all patients. The process is more complex, dependent on neurocranium, base of the skull. The evolutionary processes in the brain and head of H.Sapiens have accelerated considerably compared with Apes, the increase in neocortex relegates the jaws to the front basicium. Orthodontic and orthopedic surgery have a weak influence on basicranium flexion, which is influenced by other epigenetic factors.

Prof Dave Singh

7/18/2018 02:02:06 pm

You are correct, Dr Beata - we did a study a while ago looking at the influence of cranial base morphology on the upper airway - and its variation in other ethnic groups. I believe the airway study was published in the Australian Orthodontic journal about 10yrs ago - if I'm not mistaken

Darick Nordstrom

7/30/2019 07:27:56 am

This does remind me of the blind men and the elephant. There certainly are some truths in each observation, but definitely limited by perspective. Practicing with the humility that comes from that realization is far safer than assuming that our ability to 'sell' many on our trendy opinion constitutes fact. The problem is that, in the eternities, we are far more accountable to the patients we mis-treat (or dissuade in their quest for health, based on our fabricated celebrity), than we are to our peers who follow us.

A T Still, MD, DO taught: "Before you can go out in the world and fight the fight, you must master human anatomy and physical laws. " Obviously, if there is so much disagreement, we, as a profession, have not mastered our understanding.

One of my younger grandsons just figured out bike-riding. His world revolves around that right now. It is tempting, when we discover (for ourselves) a new principle, to assume we are the first, and that the world revolves around that principle. Not only are we adults, but doctors. We can't ethically entertain such fantasies for more than a moment, but must then, in humility, keep exploring.

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JAWS – Dr. Proffit and Dr. Ackerman Review a Sensationalist Book

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