Very Dental: Airway, Orthodontics and Omissions with Dr. Matt Standridge, part 1

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[00:00:56] Welcome to the Very Dental Podcast, where you'll find entertaining and relevant conversations with visionaries, clinicians and your friends in the dental space. Now here's your host, Dr. Alan Mead. Very Dental people, welcome to another episode of the Very Dental Podcast. I'm your host, Dr. Alan Mead. I have Dr. Matt Standridge on the next couple episodes, so I'm going to do something a little bit different.

[00:01:20] I'm actually going to release this episode like normal and then instead of Monday's Alan Mead Experience episode, I'm going to put part two of this interview up.

[00:01:30] So we're going to have two Very Dental's in a row here. Reason being, we have been talking for a while about covering the AAO's white paper on sleep disordered breathing and how the changes they've decided to make as far as a stance from the orthodontists organization. It was grinding Matt's gears pretty good, and there's been a lot of controversy about it, so we wanted to talk about it.

[00:01:59] So we dive pretty deep in these next couple episodes about what Matt, who's trained, he's done a lot of ortho training. He's also done a lot of airway training, a lot of sleep disordered breathing training. And he wanted to point out some of the, maybe the deficiencies that he's seeing in this white paper from the AAO. I think it's a great topic. I think a lot of people are talking about it, and it could affect a lot of people.

[00:02:24] So I'm just, I was very excited to have him on. We had enough of this, we had enough stuff to talk about that it's worth two episodes worth. So this is the first episode, and expect the next episode to be released next Monday. Thanks for listening to the show, and we'll catch you next episode. Very Dental people, welcome to another episode of the Very Dental Podcast. I'm your host, Dr. Alan Mead. Joining me again, and this guy has been on a lot of times.

[00:02:50] Lately, I've said quite a few different people are sort of the Tom Hanks of the Very Dental Podcast, where they've been on multiple times. I suspect Dr. Matt Standridge has got to be right up there. He's got to be fighting for the pole position there. Matt, how are you doing? Doing good. Yeah, I just heard your released episode with David Clark, and you mentioned that Tom Hanks thing, and I felt slightly insulted. To be honest, now I'm saying it to everyone, so I'm kind of... I've got to keep David on his toes.

[00:03:20] I'm kind of a whore this way, I'm sort of saying. I just say what everyone wants to hear, basically. Sorry, but it's true. But Matt, you may have been on the original Brain Trust, I want to say, or one of the original ones. Yeah, if not the very first one, probably the second one. It was early on.

[00:03:40] And I know that I met Matt at the same Cosminent course that Jason and I met for the first time in person. So there were a bunch of people there that were sort of in the bottom floor of the dental hacks and all this podcasting madness. So Matt has been there all this time. I feel like, I don't know, I feel like there's a song or something I should play. I don't know, I just feel like he's been here for a long time. Anyhow, Matt and I have been...

[00:04:08] Matt and I have a text chain that goes back years, and no, you can't see it. But that's best for both of us, to be perfectly honest. It's just for us and our FBI agent that's assigned to our chat. We welcome the FBI and CIA agents, exactly. So Matt and I have discussed a little bit. There's just in the last few weeks, the AAO, or American Association of Orthodontists,

[00:04:35] released a white paper, which personally is sort of racist, I think. But nonetheless, they released a white paper about airway, sleep disordered breathing, and how orthodontics is related to airway. I mean, I'm going to let Matt kind of take it away from me. But clearly, I turned to Matt for his expertise, because I heard a lot of people grumbling about

[00:05:03] it, and I didn't really know, even looking at it, I didn't really know where the grumbling was from. But I do know lots of people who are airway people, who treat airway. Shoot, we've had Jeff Raus on about a million times, and his entire shtick over at Spear is airway stuff, which does involve a lot of orthodontics. And it's a little bit dismissive from the AAO, it seems like. So before I say anymore, I guess, Matt, tell me everything you know. What do we need to know about this?

[00:05:30] And what kinds of rebuttals have there been to the orthodontists out there? Very curious. Yeah, it's been interesting. I just, I don't know what the goal of this paper was, honestly. I don't either. It's not obvious. Yeah, I agree. And I'll get into it, because there's a few things that I like. There's some stuff that I just don't understand why they didn't include it. And then there's a lot of stuff that just, quite frankly, pisses me off.

[00:06:00] And so we'll kind of work through that kind of structure. But this is kind of an updated version of their 2019 white paper, and that was called Obstructive Sleep Apnea and Orthodontics. Okay. And so here, they change it a bit. Now it's about sleep disorder breathing in orthodontics. Because OSA, as we know, is the end-stage disease, right? Right, you're right.

[00:06:27] SDB is a lot bigger net. Yep. Does that make sense? Yes. Earlier, catching it earlier, and the whole range of symptomology and that sort of thing. Right. And so, because like in that first 2019 version, OSA is mentioned 276 times. Oh, wow. Whereas sleep disorder breathing was only mentioned like 15 times. And so this new one, I do like it that it kind of broadens the net quite a bit.

[00:06:56] And that deals with orthodontists a lot, because we were talking pre-call. You know, this white paper is a little bit more geared, a little bit more focused on like pediatrics. Yeah. Basically. Growth and development, stuff like that. Well, okay. So before you get to that, growth and development is a big part of, okay, so there's a couple different ways you can intercede with sleep disorder breathing.

[00:07:22] There's the guy like me whose wife has complained about snoring. Actually, that's not actually true, but I mean like a 50-some year old fat guy who snores a lot and, or actually, I just saw a kid who was 25. I just had an exam and I asked him if he'd been like, he had all the clastic symptoms and stuff. Have you talked to someone about, oh yeah, he's 25 years old, already has a CPAP, everything like that. So like there's adults.

[00:07:49] And then the whole other aspect is like, what if we could see things early on in a kid and help, help, you know, help influence the way that they grow. And this is where the controversy comes in because I mean, this, this is, I'm gonna let you pick it up from there. But like the reality is like, there's two different populations that you're sort of treating. And in some ways you're trying to prevent the stuff that'll happen to the older people in a younger person with their development. Right. Yeah, exactly.

[00:08:17] And it's just like anything, if we can get to these kids earlier and get them on the right growth path and, you know, get them the right oral habits, get them the nasal breathing, do all this stuff and fix their, fix their anatomical issues. How, how does that set somebody up for better future and for better results into adulthood? You know, and, and we'll get into that because I've got some studies to go over with you.

[00:08:43] So, so this, this paper is more geared towards, um, pediatrics. Um, they don't really cover a whole lot of like the, uh, the Marpies and MSEs and all that stuff where it's kind of all the rage right now with adults. Yep. Um, but, um, so moving into sleep disorder, breathing, I like that.

[00:09:06] Um, secondly, they do call for orthodontists to screen every pediatric patient with an emphasis on early detection. That's kind of face value good, but I'm going to nitpick that here in a little bit too. Okay. Um, and then also they acknowledge that, um, SDB is multifactorial. You need an interdisciplinary approach, all that stuff. So that's, that's really important. We need to talk to our physicians. We need to talk with, uh, ENTs, stuff like that.

[00:09:36] So that's the short list of the good, but I want to give credit where credit's due. Sure. That's fair. Um, next I want to talk about omissions because, um, I'm not actually, I'm going to start with the authorship quite honestly. Okay. Okay. Um, because so in 2019 they had 14 authors. One of them was a sleep physician, right? Okay.

[00:10:02] And so if they go from 2019 to 2026, you feel like they would be expounding on their research. They would be broadening their horizons. Right. Yeah. Well, here they actually shrunk it down. They regressed. Last, this one is only nine authors, which is eight orthodontists and one staff librarian. Um, they, and they have zero, uh, they got rid of their one sleep physician. They have zero physicians.

[00:10:29] They don't have any myofunctional folks on there or anything. So it's like, how are we updating and expanding on the newer research while shrinking our board? Yeah. To be a fly on the wall when that meeting took place, like, ah, let's have less authors and let's get that, that sleep physician out of there. Cause geez, that only complicated. I mean, I'm just, I'm not even kidding. How could they have made that decision? That seems wild to me. I have no idea. And that's why I don't understand it.

[00:10:58] Um, and so that, that right there to me is kind of a big problem that we can't really just, you know, shoe under the rug. Right. Um, and then there's another thing. So they brought in the scope of two S S E B, right? Yeah. It changed the title to S D B. Great. But then the very first paragraph or the little summary right under the, where they state the

[00:11:24] authors, it says that the goal of this paper is to quote, to guide practicing orthodontists on the role of orthodontics and managing obstructive sleep apnea. Okay. Okay. So we're, we're, we're running right back to OSA. Yeah. They, they narrowed it again. Okay. So they started, they started in the right, in the right spot, maybe by widening it and then they narrowed it back. Now they do talk about S D B a bit and, and more of the fleshed out intro, but like that

[00:11:53] little summary, it's just like, why, why was that a simple copy and paste from the 2019? Maybe. Maybe. Maybe. Maybe. Maybe. But, but, you know, earlier I said that they, they recommended screening all pediatric patients and that's great. But then the issue with that is they give almost no guidance on how to do it.

[00:12:16] The only things they mention are tonsils, tongue size and position, growth and development, obesity, snoring, and mouth breathing. And they do talk about a pediatric questionnaire, but that's it. And, you know, there are more than 30 clinical observable signs and symptoms of PSDB. You know, you have your allergic shiners and venous pooling, right?

[00:12:42] You have, uh, for mouth breathing, you have that thick hyperplastic gums, chapped lips. You have bruxism. There's the, there's arch shapes, narrow V-shaped arches, high vaulted palates. Um, if you have CBCT, deviated septums, turbinate hypertrophy, you know, all this stuff that we can see, but they don't mention or guide us in any of that. It's actually worse.

[00:13:06] They basically, they basically say x-rays and scans are not to be used to screen any of this stuff. That's. Yeah. We'll get into that. You're getting there, but that's like wild. Yeah. That's my first big year to grind right there. But, but they don't give you like for all the different. Yeah. It's weird to me. That's weird to me. Yeah. And, and they don't really talk about comorbidities. Now here's the wild thing. Cause in 2019, their version, they, they actually talked about comorbidities, um, a lot more

[00:13:36] than this updated version. So in the original, at least they mentioned, like they mentioned restless sleep, um, hyper extended neck sleep position, the paradoxical breathing, but they've completely taken that out for this one. Interesting. Um, and also they never talk about nasal breathing. Um, they, they never talk about the promotion of nasal breathing, which, and that surprises me because we know that that is, that that's crucial, right?

[00:14:03] It filters, humidifies pressure as an air, paranasal sinuses produce nitrous oxide, you know, all this stuff. Right. And so basically at the end of the day, this article doesn't give a whole lot of guidance. It just gives a whole lot of list of things not to do or say, or makes claims that makes claims that, um, there's no good evidence showing that it would be beneficial. Um, sort of, sort of, yeah.

[00:14:32] That at least for the orthodontist role in it, right? Like it's kind of, it's kind of, yeah, it sort of wants to limit what, what, what things an orthodontist might see or intercede in that. I don't know. That's, that strikes me. It strikes me. And to me, and let me know if you think this way, but like, to me, it just seems like a big CYA statement more than anything. Yes. Yes. Well, actually the fact that the fact that there's so many different criteria they could be screening for and they limit it like that. It's, I don't know. I just seems, seems weird.

[00:15:02] Like, in other words, are the orthodontists saying the things that other people treating airway are using to screen are not accurate and should not be used? Is that what they're saying? Or are they just, are they just omitting it? They're just not saying anything. Okay. Well, which is a word, right? Like, okay. So, so that's kind of, you know, and I got to give credit where credit's due when I was really digging into this stuff, you know?

[00:15:29] Well, I just saw Jeff Rouse and Tracy Nguyen back in February at the AES meeting in Chicago. So some of their stuff was fresh in my mind. I've studied a lot of stuff from Dr. Mary Evans, a dual certified orthodontist periodontist. You got her on. Yeah. She's awesome. Yep. Um, that's who I learned, um, Marpy through, um, you know, Andre Yoon. Um, there is an orthodontist that's speaking out on this stuff and is critical of this paper.

[00:15:58] Um, Dr. Mark DeLuke, I think his name was, he has a podcast, an ortho podcast. And so, so there are some, there's some good, uh, good folks out there. Um, Dr. Um, oh, he's an Australian E and T Michael McIntosh. Yeah. Something like that. I follow him on, I don't know if I follow him on, on Facebook or Instagram, but he's, he's, uh, he takes a lot of arrows actually. Yes, he does. There's a lot of stuff and a lot of people will jump him. So, yeah. Yeah.

[00:16:26] So, so I do, I do first off want to say I'm kind of standing on the shoulders of some giants here. All right. But, um, and thank goodness for them, honestly, cause they sort of, they sort of push the ball forward a little bit. Yeah. Yeah, absolutely. So, you know, the first thing I want to get into is, uh, really this, it doesn't come out and say this, but it's basically insinuating, at least in my reading of it, that you need, uh, a PSG, poly, a polysomnography, uh, to justify doing anything.

[00:16:56] Don't do anything before they have a PSG. Okay. Uh, and, and they, and they state, you know, polysomnography combined with clinical symptoms remains the gold standard for diagnosing OSA. Sure. They make that, they make that statement. That's, and that's, when you say that, that means you're already, you have to involve a sleep doctor. Is that essentially what that's saying? Right. Okay. Right. Now that, now I'm going to get into the citations of this thing because, um, I, this is probably

[00:17:25] the most I've done a deep dive into citations in a paper before. So I want to see where are they coming up with this stuff? Okay. So document, uh, so site, um, reference 34, the one that's attached to that. Yep. I actually love this document. It's become my favorite document. I didn't even know about it until I started reading, you know, this paper. So it is, um, it was published in 2023 through the international forum of allergy and rhinology.

[00:17:54] And it's called the international consensus statement on obstructive sleep apnea. This thing is massive. It's 624 pages with over 2000 references. Nice. So it is a huge. What's that? Nice light read. Yeah. Yeah. Easy, easy read, you know, just kind of sit on the patio. Just breathe through summer. Yeah. You know, but, um, but it's a massive piece.

[00:18:20] And so, yes, it does indeed say that PSG, um, is the gold standard, but they omit this following quote. And so there's the same reference goes on to say, AHI quote, falls short as a unifying metric end quote for capturing OSA severity and prognosis. And then it says that when PSG based diagnosis isn't possible, a diagnosis of SDB is often made on clinical evaluation alone. Interesting. Okay.

[00:18:50] So that very same citation goes on to say, yeah, PSG is great. It's the gold standard. But AHI has its limits and diagnosis of SDB can be made on clinical evaluation alone. So there, so they cite the first part and don't mention the second part is what you're saying. Nice. Nice. And, and, you know, the thing is with PSG, there's a lot of stuff.

[00:19:17] Um, there's a lot of stuff wrong with it, especially with, uh, especially with kids, because like if you go into the other literature, you know, the journal of sleep in 2010, had a paper titled, uh, differences in overnight poly not a polysomnography scores using the adult and pediatric criteria for respiratory events and adolescents. So what they found basically just distilling this down is that children have faster respiratory

[00:19:43] rates than adults, which means that they're less likely to experience an apnea or hypopnea lasting 10 seconds or more, which is a threshold, right? For AHI. Um, but shorter events, they did find that shorter events in children can still lead to significant comorbidities. So a child can still be suffering even if their AHI comes back completely normal. So that was, that was published in journal of sleep in 2010. But again, it's omitted here. Why it wasn't considered. I have no idea. Yeah. Yeah.

[00:20:12] You have stuff like by Christian Guillaume, um, many consider him like the godfather of sleep, of sleep medicine. Yeah. Um, you know, he published in 2015 in the sleep medicine reviews that even, even when a diagnostic PSG is done, there's, there can be a poor understanding of abnormal breathing patterns in children. Okay. That leads to underscoring. So the test can still be missing stuff that's happening. Right. Yep.

[00:20:40] And, and so, um, and so there's, there's good literature showing the, the shortcomings of PSG and kids. Mm-hmm. And then there's just, there's, there's, um, just kind of real life issues going on access to care. I mean, if you're in a rural area or an underserved area, you don't have a pediatric sleep lab on every corner. Yep. Crazy Dental already has some of the lowest prices on dental supplies anywhere, but you know, it's even crazier free shipping.

[00:21:08] Head over to crazydentalprices.com, load up your cart and use coupon code very ship. That's very ship for free shipping on every single order. Plus every time you use that code, crazy dental kicks back support to the very dental podcast network, save money, get free shipping and support the show. Use code very ship today. Yep. And you don't have access to a sleep physician. And a lot of these guys are booked out six, 12 months. Exactly. I was just going to say that the time that even if you, even if you have someone to go

[00:21:37] to, it's not like they're going to get you in next week necessarily. And it puts you, I mean, like literally for a kid, six to 12 months, you could miss a huge window of opportunity to treat them on some level. You're just waiting for them to give you the go ahead on that level. Yeah. Orthodontists, orthodontists don't wait for anyone else to tell them that they need to do braces on a kid. They need to do ortho on a kid. Like, so it's very frustrating to hear them say, well, we, we can't, you know, there's, we have to wait.

[00:22:07] We have to get this diagnosis. That's a little interesting. Yeah. Well, and so another thing, um, thinking about the application of PSG. So if you take a kid for a sleep study, um, how many nights typically is that study? Uh, one probably. Right. Or two. Yeah. Right. Yeah. The vast majority of the time it's been night. Yeah. The thing is with that, again, going back to sleep medicine reviews published in 2012,

[00:22:34] um, there's an article that, um, refer by Dr. Yoon and colleagues that, um, referred to something called the first night effect. And so what they found was ideally you need three successive nights in a sleep lab to get accurate data with kids. And, and because, you know, children are in a foreign environment, they're hooked up to these electrodes. They're not getting the kind of sleep that you can monitor them properly. Right.

[00:23:00] And so they say basically to disregard that first night's data. That's a problem. I mean, that's a problem. When I was, when I was at, uh, when I was at Tarun's place, God, a hundred years ago, he sent everyone home with a, with the home test. And of course, I mean, even the home test, it's just super weird. You got all this stuff stuck to you and everything like that. I'm like, I could probably, and we all decided that it would make a ton of sense to do this two, three nights in a row after you just get used to this stuff.

[00:23:29] You might be able to sleep like you normally do. So if it's not a representation of how you actually sleep, the data is not probably worth a whole lot. Exactly. And then we can also look at our other medical colleagues, right? So like in 2023, the British Thoracic Society came out and they, and they basically, they basically cautioned clinicians against using AHI alone in their decision-making for, um, PSDB.

[00:23:55] And they said that clinicians can also use video audio recordings alongside clinical observations to support intervention. Yeah. Um, there was a French multi, uh, multidisciplinary consensus published in 2023 and they went further and stated that, um, a sleep study is not required if at least two nighttime symptoms, including snoring are observed. Oh, wow. Okay.

[00:24:20] So here we have the medical community moving away from the hard rule of getting PSG. Yep. And yet the AAO paper is like wanting to yoke towards it that much stronger. Yeah. Yeah. And so I just, I don't understand that. Well, I mean, you know, in a, you know, we don't have anyone to, but like they're, they're sending a lot of, they're sending a lot of signals with a lot of this stuff.

[00:24:48] I don't know what those signals necessarily are, but clearly it's, I don't know. I feel like they want to narrow, narrow their, uh, I hesitate to say responsibility, but they're like, they, I think they just don't really want a piece of this. Yeah. Yeah. And that's honestly, that's kind of my general feeling about this too, because like, if you look in the same issue that this white paper was, um, what was published in that same

[00:25:14] issue, there's an editorial by the editor in chief of the AJO, um, titled the orthodontist role and sleep disorder breathing from screening to collaborative care. And he wrote that when orthodontic treatment improves SDB quote, outcomes should be verified through physician ordered sleep studies rather than relying on subjective improvement. Okay. So he, he's basically calling for that.

[00:25:44] We, you, you have to work with a, a physician, you know, get a physician ordered sleep study and do all this stuff. Have you ever talked to sleep physicians? They're freaking busy. They don't want, they don't, they don't need more on their plate. No, they don't. We don't, they don't answer calls. They don't like, they got, they got a lot going on. That's exactly right. And so, you know, and, and so that's, that's my thing on PSG.

[00:26:10] Um, we can move on to mouth breathing because this is a big one, right? Uh, and this, you're going to get a kick out of this study, man. So, okay. A quote from the paper here. Um, there is no standardized universally accepted method for assessing mouth breathing. Although some mouth breathing is normal, the proportion of mouth versus nasal breathing that triggers a physiological response remains unknown.

[00:26:38] So they're kind of saying like, ah, we don't know if it's really important. We don't know how much. Yeah. Yeah. We, and we don't know what the ratio is of nasal breathing versus mouth breathing. And, you know, and is, is mouth breathing even all that detrimental to, you know, to, um, to the system. And so they cite one study for that. And this is where I just, my blood pressure started to raise reading this paper.

[00:27:07] Reference 26. Um, so what is reference 26? Let's look into it. It is an article published in the international journal of exercise science in 2017. You go on to look at the author list. There's four authors. Three of them have asterisks. And that asterisk means denotes undergraduate author. Oh, wow.

[00:27:34] So this is an undergraduate led college paper study. Okay. That is. Okay. Wow. Yeah. So four authors were undergrad, uh, uh, four authors, three of them undergraduates. And I'm no pro no problem with college students doing research. That's great. But let's now let it look at the study itself. Guess how many, uh, test subjects there were, how many patients they observed? I, I hesitate.

[00:28:04] It's probably not very many is my guess. Nine. Nine. That's. So they have an end of nine. Yeah. Yeah. Nine adults. And the study had them perform a wind gate anaerobic cycle test on a stationary bike, alternating between nasal only and mouth only breathing. Mm-hmm. And they measured anaerobic power output. And they concluded that breathing mode doesn't significantly affect anaerobic performance.

[00:28:34] So they, they took these people, had them by, they plugged up their nose. Yeah. Had them bike mouth breathing, took out the plugs, tape their mouth. Now they're breathing through their nose only bike again. And they couldn't see a statistical difference in output. That's the study that they're citing. Yeah. And that, and that, but more than that, there's the citing the study, but they're also extrapolating that, that they're not sure if mouth breathing or nose breathing has that much effect.

[00:29:01] Meanwhile, when you think about that, you can't extrapolate anything from that research design of nine. Right. Yeah. I mean, like, like the other thing is, it's an exercise. It's in adults. It's in like, I mean, I can literally hearing it for the first time, I can point out like 10 things that wouldn't, wouldn't be applicable. And, and they're, they're trying to talk about this with, with pediatrics for the most part, which is like a whole other, I mean, and every dentist who's done a periodic exam on a

[00:29:27] child can pick out a mouth breather from a mile away because there's about 10 things you'll see right off the bat. And, and, but it's, but it's nothing. That's nothing. So, so let's look at some of the studies on mouth breathing, right? That might be more pertinent to the conversation, right? So like, you have the only thing that was that the only research that they used for mouth breathing? Was that it? No, they had some other stuff going on, but that was the, that was the study that said that

[00:29:56] they basically linked, ah, we don't know if mouth breathing versus nasal breathing has much of an effect. Okay. So, but so like, look at the EJO. So the European Journal of Orthodontics, kind of the sister organization to the AJ, right? You know, in 2018, they released the panic study, which they followed 412 children between the ages of six and eight. And then they reevaluated them again between, what is it? Nine and 11. Yeah.

[00:30:26] So 412 patients, they reexamined 329 of them two years later between ages nine and 11. And they concluded that among children, mouth breathing has implication in pathophysiology of sleep disorder breathing. So that's from the EJO, their sister orthodontic journal. And why, why isn't this cited anywhere? Right. Good question.

[00:30:51] And then in 2026, and I can give some grace because this was released in 2026, but the European archives of otorhinolaryngology came out with a systematic review and they reviewed 3,722 articles on the relationship between mouth breathing and pediatric OSA. And their finding was mouth breathing is an early marker of pediatric OSA and plays a key role in both early diagnosis and treatment efficiency.

[00:31:21] So here you have a systematic review of 3,722 articles versus nine adults on a stationary. Yeah. Yeah. Like, that's wild that that's the choice they make in that it's, it's like they, I mean, anyone kind of just taking a look at this from 10,000 feet is like, they don't want, they don't want, they don't want orthodontics to be able to be part of this. They just don't want it. It's like they, they're true.

[00:31:51] They're going out of their way to make it so, so orthodontists are not part of this, this, I don't know. It's what it feels like to me. It's weird. Yeah. I don't know if I'm, I'm reading into that wrong, but that seems weird to me that they, they, uh, I don't know. I don't know. And then there's, and there's tons more stuff on mouth breathing, you know, um, European journal of rhinology and, uh, allergy in 2023 went through the, the issue of mouth breathing.

[00:32:17] Like, uh, Dr. Howard Stupak gave this kind of cycle of how, uh, sleep disorder or how, um, mouth breathing leads to sleep disorder breathing. And then there's also studies on ADHD with mouth breathing. There's microbiome studies with mouth breathing. And so why not include some of this into this review? I just, I don't understand it because chronic mouth breathing, it matters in children. And we have a lot of literature to show that.

[00:32:45] And so here they're just using a study of nine adults on a bike by three undergrad students. I don't understand this. Like that just, it quite frankly just pissed me off. Yeah. Um, so, all right, let's keep going because there's, there's quite a bit here. Um, one thing that I found interesting was that, um, and so they have an executive summary towards the end.

[00:33:11] And so conclusion number four, they say in quote, no currently known craniofacial, facial phenotypes can identify the presence of SDB. Interesting. Um, now this is interesting. Um, now I get it. You can't just say you have SDB if you see this phenotype. Yep. I, I get that. But, you know, when somebody reads that they're like, oh, phenotypes don't matter. And they absolutely do.

[00:33:41] Let's go back to reference 34, that 600 page document in that own, in, in their, in that very document, it states that craniofacial, uh, craniofacial anomalies common in patients with OSA includes mandibular deficiency, narrow posterior airway space, steep mandibular plane angle, and long anterior facial height. So that study that they referenced for PSG as being the gold standard, that same study also

[00:34:09] says, yes, there are craniofacial phenotypes to be on the lookout for. And it's interesting because even in the 2019 white paper, the one that they're supposed to be updating in that document, they quote, they say, and I quote, certain craniofacial morphologies can increase a child's risk for having OSA. For instance, mandibular retrodinathia, long and narrow faces, narrow and deep palate, steep

[00:34:37] mandibular plane angle, anterior open bite, mid face, uh, and, and mid face deficiency may predispose a child to develop OSA. So they were saying that in 2019 and here they completely disregard that. Yeah. That seems so calculated. I don't know, man. I, not that I get what the calculation is, but that seems very like on purpose. Yeah. That's wild. Yeah. And so, and, and, you know, and so they, there's actually well-established things about

[00:35:06] those phenotypes, right? Even going back to the AJO in 1981, where you have the infamous Harvold study, where he basically took monkeys, rhesus monkeys, and he plugged up their nose with silicone and sewed these silicone plugs in and monitor their growth changes over two years. Yeah. And these monkeys developed narrower dental arches, longer face heights, more dental crowding, more malocclusion. That's amazing.

[00:35:35] And then when they removed the plugs, the growth started to normalize again. Yeah. And so I, and, and, and, and so we have that going all the way back from 1981. Now what's interesting is in 2011 of the AJO, the very journal that this, this, uh, organization, you know, publishes, they had, um, a study, uh, titled associations between sleep disorder,

[00:36:02] breathing symptoms and facial and dental, uh, morphometry assessed with screening examination. So they had 604 human subjects, mouth breathers had narrow arches, high vaulted palates, more vertical, uh, more vertical growth, severe crowding, uh, severe upper and lower crowding and more severe malocclusions. I mean, does this sound familiar? And this is from the AJO back in, back in 20, 2011.

[00:36:30] And so, sorry, I got to take a breath here. No, I get it. I get it. Yeah, it's a lot. And so, um, so that's why I just don't understand is like, why, why are we, why are we omitting this stuff? Why are we omitting stuff that's been published in our own journal? Wow. It's, it's wild. And they're going back on the original take. And so then the question, like, like clearly there's a lot we can talk about. We've been going for a little while.

[00:36:58] My thing is like, why do you think, what do you, I mean, obviously neither one of us knows what's going on behind the scenes, but what, why do you think, why did this happen? Why did they do this? You know, I, it just seems to me like, quite honestly, it seems to me like they don't want to, uh, you know, they don't want to shake the apple cart. They don't want to, they don't want orthodontists to have to change or feel like they have to change their model or.

[00:37:26] My thing is that orthodontists really want to, they want to give, uh, oh, this is so bad. They want to give rich white kids straight teeth. That's what they really want to do. Did I just say that? Wow. I can't believe I just did that. But I mean, the reality is like they're, they're, they have a model that's been working pretty good. And, and, and, and the idea, honestly, the model that's been working pretty good, I hate to say this, but it's a lot of cosmetic stuff on some of it.

[00:37:50] And the reality is what, what we're talking about here is where potentially, and I'm not going to say potential, I'm going to say orthodontic interception early on could make a huge difference medically for these people for their entire life. And they're sort of, they're sort of like, man, but we don't really know that they can do that. I hate that. I hate that for, for everyone. And then, and the other thing is, is then like, so what's the reaction been? Have you, have you just in your, you know, in you taking the temperature, what's the reaction been to this? What are people saying?

[00:38:21] Um, you know, there are, I have to give, you know, I, I am friends with some orthodontists, um, and there are plenty of them that have been a little bit more privy to the airway stuff lately. Yeah. And they, and they, they, they see it as kind of the same as you and I do. I mean, it's a, it's a big, just kind of, um, CYA paper. Yeah. That just, it just very, very poorly done.

[00:38:47] Does paper prescribe to orthodontists that they should not do anything? I mean, is it, is it okay? So I literally just recorded earlier today on the pre-medication for joint and literally the, finally the AAOS, the orthopedic surgeons have finally said, you should not prescribe medical antibiotics for you. You shouldn't, unless there's a very specific reason. So it's taken a long time to get there. So they're prescribing that you don't do this.

[00:39:14] Does this white paper prescribe that you should not do this? Or is it just, uh, we're not sure that it really, that we can really do very much. It's more, it's, it's more of the latter. And, and it really stresses that if you make the claim that you're doing it because of sleep disorder, breathing, um, then you need to, uh, you know, get a PSG, you need to get a diagnosis, you need to do all that stuff. And so, and, and, and I get that because like, to me, I'm, I don't treat airway. Yeah.

[00:39:44] I, I treat them dentally and I say, Hey, these things could be linked. We may see a benefit in doing this, but I'm going to focus on my controllables and my controllables are these arches using objective measurements and data and goals. Right. Like, I mean, but I got to say too, you also kind of treat them skeletally. Okay. Yeah. For sure. For sure. The reality is, is it's more of this to me, it's more of the skeletal aspect that's, that

[00:40:13] might affect airway. And that's, but, and I almost wonder if that's kind of where they're getting at, like, you know, nice straight teeth are what we do. Uh, we, we can't make, we can't make claims about growing their face or anything. You know what I'm saying? Like, is that, was it, am I saying it? Let's dive into that because this is the AJO DO, American Journal of Orthodontics. What's DO stand for? I don't know. What does the DO stand for? Dento facial orthopedics. Okay. Okay. So yeah. So yeah.

[00:40:43] Yeah. So anyway, um, are you going to keep going? Cause I've still got some more stuff we can talk about. Like this is going to be, we're going to go into, we're going to do two episodes worth. Okay. Okay. So let's just do this. Okay. We're wrapping for episode one. If, uh, I kind of figured you would, we're going and we still got a lot more. So we're going to talk more about the, this white paper in the next episode. So I'm, I'm going to wrap it up for Matt and for Al. Thank you for listening guys. We'll catch you on episode number two.