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Untreated Sleep Apnea Results In A 20% Reduction In Life Expectancy

This article, published in the Spring 2007 Journal of the American Orthodontic Society, presents Dr. Hang’s unique vision for a preferred role of responsibility for the entire dental profession in the larger field of healthcare. Dr. Hang presents a strong argument against extraction of teeth and the use of mechanical devices that pull teeth back into the face such as headgears and many temporary anchorage devices (TAD’s) .

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Could we in dentistry actually move to the forefront of healthcare and longevity enhancement?  The most frequently featured articles in many dental journals might make one think our future is in esthetic dentistry.  Esthetic procedures have reinvigorated many dental practices, and a smile covers the dentist’s face when a middle aged Baby Boomer with severely worn teeth presents for treatment.   The conversation isn’t about whether the patient needs veneers or crowns, but focuses on the technical aspects or latest materials of delivering the obviously needed service.  
   I certainly do not argue with the value of esthetic dentistry having spent thousands of dollars on restoring my own mouth.  I do wonder why so few dentists don’t first ask the more important questions about snoring, blood pressure, and other possible signs of Obstructive Sleep Apnea (OSA).  For sure they are limiting the scope of their practices if they don’t recognize what is really happening.  More importantly they are treating with blinders on, may actually be putting makeup on a melanoma, and might miss the chance to save a life! 
   Given the fact that one of the most common signs of OSA is bruxism and Blevins1 indicates OSA patients are 6 times more likely to brux than normal patients it seems asking some simple questions before firing up the handpiece would be more appropriate.  John Remmers, M.D. 2, the Harvard trained physician who coined the term Obstructive Sleep Apnea, states  that OSA will become the most common chronic disease in industrialized countries and notes that 65-80% of stroke patients have OSA.
   My experience suggests few cardiologists (those who obviously should know), and pitifully few dentists actually understand this.  Given that OSA greatly increases a person’s chance of heart attack,

stroke, cancer, and early death it seems that we might be in a critical position to screen patients, refer patients, treat patients, and actually assume a primary role in saving lives.  No dentist needs expensive laboratory tests to ask a few obvious questions.   The alarm should sound as soon as we see worn teeth.  Questions about snoring, sleeping patterns, how patients feel on awakening, blood pressure, etc. start the fact finding process. 
   Remmers3 notes that OSA is essentially a structural problem relating to the fact that the maxilla and mandible are too far back in those suffering from OSA.  He agrees that the problem would not exist if the maxilla and mandible were ideally positioned in the face. Price4 and Corrucini5 have shown clearly that malocclusion (and poor facial development) are not genetically determined, but environmentally caused.    Harvold’s6 monkey studies have shown how alteration of the nasal airway alters facial growth.  Mew7 describes mechanisms by which the maxilla and mandible fall short of their genetically determined positions with the first sign of any malocclusion being that the maxillary incisors drop back from their ideal position in the face in all malocclusions. He states that none of this would occur if patients had proper oral posture with their teeth lightly together, their tongue to the palate, and their lips sealed without strain. 
   Few children in industrialized societies eating the Western diet and breathing  pollutants have adequate immune systems allowing them to combat the allergens well enough to maintain nasal breathing, maintain proper oral posture and, therefore, ideal facial growth.  The orthodontic profession is the beneficiary of this as the jaws fail to assume their proper positions, teeth crowd, and the different malocclusions develop in response to various specific alterations in oral posture.

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  As the patient enters the typical orthodontic practice the malocclusion is noted,  a therapy to straighten the teeth prescribed, and treatment begun (all hopefully on the first visit!).  Without realizing that the maxilla is too far back in virtually all malocclusions, treatment is frequently aimed at further retracting the allegedly protruding teeth.  Bicuspid extraction, headgear, and now temporary anchorage devices (TAD’s) are weapons in the war on malocclusion and may be used to retract the anterior teeth.   The grand majority of all orthodontic care is retractive in nature and the result is a patient with a maxilla and mandible in more retruded positions in most cases following the treatment than at the beginning.
  Given the fact that the spine refuses to move out of the way during treatment and forms the rear boundary of the airway, conditions for a train wreck are set up as mechanotherapy results in the tongue being displaced distally as the maxilla and mandible move back.  Mew has noted how these changes to the face continue throughout life as long as the oral posture is not corrected.  There is little hope for a better outcome as long as those doing orthodontics have not embraced means of reversing the direction of growth of the face to a more forward direction. 
   Those using Herbst appliances (as reported by Van Laecken8), Twin Blocks, and other tooth borne appliances which allegedly develop the mandible forward need a strong dose of reality since these appliances have a huge headgear effect and, while making the teeth fit in  a Class I occlusion, retract the teeth within the face.   To my knowledge, to date there is no study in the literature documenting nonsurgical reversal of essentially unfavorable vertical growth to more favorable horizontal growth other than using Mew’s Biobloc technique (Singh9).    Johnston10 has noted that the result of both traditional orthodontics and so-called functional orthodontics is still a face with a “moderate midfacial dentoalveolar retrusion”. 
None of this is good news to the

airway which depends on proper positioning of the maxilla and mandible for its patency.      Essentially we are living in world where children grow up with poor oral posture, have their faces start to drop back as a result, develop malocclusions, and have orthodontic care to straighten their teeth which only sprays gasoline (retractive mechanics) on the raging fire.  When their tongue space becomes severely violated they ultimately may suffer from OSA related problems.  The profession needs to connect the dots between retractive orthodontics in adolescence and OSA usually in later decades of life.
   In reality children would be better off with no orthodontic care than treatment which in any way reduces the airway.  The orthodontic profession pays lip service to teeth being in a “balance between forces acting on them” and essentially ignores the balance by violating the tongue space with retraction of teeth and is deathly afraid of advancing the teeth for fear of causing recession.   Melsen11 has shown that recession is not a worry in significant advancement of the teeth with orthodontics, but few have heeded.  Witness the frequent discussion of interproximal enamel reduction in the literature as recently described by Zachrisson12 (almost two years after the appearance of the Melsen article).
   I am unaware of even one case of gum recession causing death, but people die daily from OSA related disease processes.  Perhaps a change of direction of the profession is needed.
      The extraction of bicuspid teeth is alive and well (despite rhetoric to the contrary) as noted by Chaushu et. al.13, and now we have TAD’s to enhance our ability to retract teeth without extractions.
It isn’t surprising to anyone doing TMD or OSA therapy that a size 32 tongue (meant to be surrounded by 32 teeth) doesn’t like living in a size 24 space (minus four bicuspids and four third molars). 
  To my knowledge, in spite of emotional arguments regarding facial esthetics being negatively affected by bicuspid extraction,


no serious discussions have occurredregarding tongue space and airway space reduction associated with bicuspid extraction.  Who among us would like to wear a shoe that is two sizes smaller than our feet?   Can our tongues fare any better in a reduced space? TAD’s can actually prevent extractions but are not immune from dangerously decreasing the tongue space

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as they retract the teeth. The nonextraction vs. extraction argument is irrelevant since the literature confirms the posterior airway space can be violated by extraction treatment (Giancotti14) and nonextraction treatment with TAD’s (Jeon, et al15). What really matters is whether treatment increases, or at least does not reduce, the tongue space. Is it not time to completely cease bicuspid extraction, headgear, TAD’s used for retraction, and all retractive mechanics until their effect on decreasing tongue space and possibly producing OSA has been completely resolved with research done by parties with no self interest to protect? There have been a number of similar concerns in medicine which have resulted in termination of certain treatments until safety and efficacy is established. Why should the dental profession somehow be exempt from such concerns? Is there hope for a different way of treatment? I believe there is a solution for this problem in all age groups, and I offer the following examples of ways to address the problem in varying situations. A classic example is of the following 57 year old individual in Figure 1 whose only reason to seek treatment was to restore his severely worn teeth.

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Six months prior to my examination his cardiologist placed a stent to prevent a heart attack, but did not ask if he snored, nor did he suggest a sleep study.  A sleep study I suggested reported 454 apneas or hypopneas, arterial oxygen desaturation to as low as 70%, and 54% of the night spent with an oxygen saturation below 90%.  This is a recipe for early death due to heart attack or stroke, and could be repeated

millions of times in any industrialized country with patients who have similarly worn teeth.
  The patient featured in Figure 2 (after removable appliance therapy to open spaces but prior to placement of fixed appliances) is a 52 year old female who presented for treatment for her OSA complaining of waking up “gasping for breath” and thinking she would “drown or choke to death”.  She also presented

with a severe headache pattern and bought her pain reliever of choice “by the jug”.   She could not tolerate an oral appliance, nor a CPAP machine to treat her OSA and was referred to our office for treatment.   She had received orthodontic treatment with four bicuspids having been removed approximately 20 years earlier and never felt she had “room for my tongue” (her description). 

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We recommended treatment to reopen her four extraction spaces but made no promises of the outcome. 
   In the midst of her treatment she began to feel better and was elated when her husband informed her that she wasn’t even snoring any more.  In addition to completely eliminating the OSA her 20 year headache pattern is now a thing of the past.  Her case is hardly isolated with hundreds of thousands more in North America who might similarly benefit from such treatment.   Is it not time for orthodontic training programs to include instruction on the intricacies of reopening bicuspid extraction spaces rather than producing the spaces and closing them?
  The patient featured in Figure 3 is a 60 year old male suffering from OSA who could not tolerate an oral appliance nor a CPAP machine.  He underwent surgery to advance the maxilla and mandible with a counterclockwise rotation (to maximize chin advancement and forward tongue movement).  His airway opened dramatically as shown by the Posterior Airway Space (PAS) pre and post-surgery.   His OSA is now a thing of the past.
   The patient featured in Figure 4 is an 8 year old female with no OSA problem, but with a severe Class II Division 1 malocclusion with deep overbite and large overjet.  Such Class II patients usually have severely recessed maxillas, in addition to recessed mandibles. After undergoing Biobloc Orthotropics as taught by Dr. John Mew both jaws were developed forward and her Posterior Airway Space (PAS) opened dramatically.  Interestingly another orthodontist had recommended removal of four bicuspid teeth and headgear.    If Remmers is correct in his statement that OSA would not exist if jaws were properly related to the face I have to believe that she will not ever be burdened with OSA.
   These cases illustrate different treatments to address OSA in different situations.  This article is not meant to be an exhaustive review of all forms of OSA treatment but to make the reader aware that these patients are in all dental practices and could be helped if the dentist knew how. 

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Not all patients who present with worn teeth suffer from OSA, but we can no longer ignore the frequent connection and restore people with worn dentitions without screening for OSA.  How can we ethically continue to straighten teeth with techniques we know retract the teeth in the face and may ultimately result in more unfavorable facial balance and compromised airways?  Are we prepared to make hard decisions in this profession before they are made for us by outside forces?  I believe the time has come for dentists to assume what seems an obvious role working with our medical colleagues and move our profession in a new direction with recognition, prevention, and actual treatment of OSA being primary goals of treatment.   Time will tell if others agree.  

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  1. Blevins, Bryan D.D.S. speaking at the American Academy of Craniofacial Pain, Phoenix, AZ. January 2006.
  2. Remmers, John M.D. speaking at the American Academy of Craniofacial Pain, Phoenix, AZ, January 2006.
  3. Remmers, John M.D. personal communication at the American Academy of Craniofacial Pain, Phoenix, AZ, January 2006.
  4. Price, Weston A. D.D.S., Nutrition and Physical Degeneration, Price-Pottenger Foundation, 1939.
  5. Corrucini, Robert PhD., How Anthropology Informs the Orthodontic Diagnosis of malocclusion’s cause, Edwin Mellen Press, 1999.
  6. Harvold, E.P. “Neuromuscular and morphological adaptations in experimentally induced oral respiration.” In: Nasorespiration, Function, and Craniofacial Growth. J.A. McNamara, Jr. (Ed) Monograph 9, Center for Human Growth and Development, University of Michigan, 1979.
  7. Mew, J. The postural basis of malocclusion   Angle Orthod. 1988.
  8. Van Laecken, R. et al  Treatment effects of the edgewise Herbst appliance: A cephalometric and tomographic investigation AJO/DO Vol. 130, Number 5, Nov. 2006.
  1. Singh D., Hang W., et. al unpublished manuscript
  2. Johnston, L.E.:  Growing jaws for fun and profit. What doesn’t and why. McNamara,ed. Craniofacial growth series 35. Center for Human Growth and Development, University of Michigan: Ann Arbor, 1999.
  3. Melsen, B. Factors of importance for the development of dehiscences during labial movement of mandibular incisors:  A retrospective study of adult orthodontic patients. AJO/DO Vol 127, Number 5. May 2005.
  4. Zachrisson, B. et al Dental health assessed more than 10 years after interpromixal enamel reduction of mandibular anterior teeth AJO/DO Vol. 131, Number 2, Feb. 2007
  5. Chaushu, G. Patients’ perception of recovery after routine extraction of healthy Premolars AJO/DO Vol. 131 Number 2, Feb. 2007
  6. Giancotti, A and Gianelly, A Three-dimensional control in extraction cases using a bidemensional approach WJO Summer 2001, Volume  2
  7. Jeon, Jai-Min et. al. En-masse distalization with miniscrew anchorage in Class II nonextraction treatment, JCO August 2006.
dr. hang photo
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