Very Dental: Airway, Orthodontics and Omissions with Dr. Matt Standridge, part 2

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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.

[00:01:08] Very Dental. Very Dental people, welcome to another episode of the Very Dental Podcast. A very special episode. Part two, the cliffhanger paid off. Dr. Matt Standridge back to talk more about the AAO's white paper that we're sort of troubled by, maybe. If you didn't hear episode one, you've got to go. This is going to make no sense at all. We're literally just starting back up from where we stopped. So go listen to the first episode. Matt, pick it up where we left off.

[00:01:37] All right, man. So we just, I mean, what were we last talking about? The last comment was, we're orthodontists. We want to give people straight white teeth. And you said, oh, except that they also work on skeletons and grow faces and stuff like that. Yeah, it says it right there in the journal. That's the deal. Pretty much that's the story. So, okay, keep going. All right. So let's keep going here. Here's another claim that most kids will outgrow it.

[00:02:01] So this direct quote, preview, pre pubertal OSA tends to resolve naturally during the transition to adolescence. Primary snoring and mild SDB do not appear to be strongly associated with progression of more severe SDB. In other words, there is a tendency towards spontaneous remission of SDB from preschool years to adolescence. Interesting.

[00:02:27] And they have, they cite two references for that, 17 and 18. So let's dive into that. Yeah. I won't lie to you. That seems really sketchy to say it just like that. Yeah. Let's dive into it. So reference 17, you know, that is published in the European Respiratory Journal in May of 2016. Mm-hmm.

[00:02:50] And it's titled Natural History of Sleep Disorder Breathing in Pre-Pubertal Children Transitioning to Adolescence. Mm-hmm. So here's what you find when I actually read it. The claim for spontaneous remission is based on an N of six. Oh, my God. Six patients. Okay. And on top of that, they made the OSA scoring rule progressively more stringent with age. So they moved the goalposts during the testing. So they defined an apnea.

[00:03:20] Yeah, exactly. Yeah. They defined an apnea as five seconds or longer if they're under 16. And then they doubled that threshold to 10 seconds or longer once the patient turned 16. Which would lead you to your cases. So of course you're going out of it. Yeah. Okay. But here's that. Even with moving the goalposts, this same paper found that up to 30.3% of snorers with mild SDB persisted or worsened over time.

[00:03:50] That's one. That same paper shows that almost a third stay or even get worse. Okay. But they're using this reference to say that they'll probably outgrow it. That they outgrow it. But that is so – that's irresponsible. It's irresponsible. Absolutely. All right. So that's one – okay. And you said there was another? Another. Yeah. So this one was in 2010 in the Journal of Pediatrics.

[00:04:15] And it's titled Incidents and Remission of Sleep Disorder Breathing and Related Symptoms in 6- to 17-Year-Old Children. Now, I want to read you something directly out of the discussion paper. Okay. Okay. Because I genuinely can't believe the author cited this in their support that kids will outgrow it.

[00:04:36] Because the paper says, quote, moreover, SDB in pre-adolescence may not spontaneously remit and significant number will develop SDB when they are adolescents. Mm-hmm. So the paper they cited to support the claim that children will outgrow SDB in its own discussion say they might not. Yeah. This is – these are not maybe the choice citations that they thought they are, I guess. Yeah.

[00:05:04] Or they're not good citations for the statement that they're making that most – that they'll probably grow out of. They contradict the very statement that they're citing that's going to support. 100%. It's very irresponsible to me. Yeah. And here's the thing. There's good research to show that what happens even in the time that they're not outgrowing, right? Or even if they do outgrow it, what's in that period, in that limbo period? What's happening? Yeah.

[00:05:31] You know, if you look at – there's a published journal of sleep in 2013. There's a study called Preschool Children with Obstructive Sleep Apnea, the Beginnings of Elevated Blood Pressure? Okay. They found that children who suffer from pediatric SDB maintain higher baseline blood pressure while sleeping and frame this as a potential first step towards daytime blood pressure abnormalities and eventually adult hypertension. Interesting.

[00:06:00] So they're saying cardiovascular risk could be starting in preschool. Mm-hmm. And then you look at the American Heart Association in 2021. Their journal had a study, sleep disordered breathing and cardiovascular disease in children and adolescents. And their finding was even mild pediatric SDB is associated with adverse cardiovascular, metabolic, and autonomic effects that can persist into adulthood.

[00:06:29] So the AHA is saying that even mild SDB can persist into adulthood. Yeah. So, okay. That seems like – Or cause of adverse effects into adulthood. Okay. And so you're saying that that was not cited by the AHA. Okay. No. Conveniently left them. Yeah. Yeah. Yeah. And I mean, this is – that's not specifically about mouth breathing. That's specifically about like adverse effects of potential sleep problems in kids. Right. Well, this is just saying that they're going to outgrow it.

[00:06:59] Yeah. Yeah. So, yeah. That's so gross. I'm sorry, but that's just like – it's wild. So they got two citations that were not great citations, and there's a lot of other data out there that would go against what they're saying. Right. Now, you'll get a kick out of the next gear that – something that grinds my gears here. You know, CBCT. Okay. Okay. Let's move on to radiographs.

[00:07:22] I'd said in the early – in the first episodes that they're basically – they're poo-pooing the effect of like the – any kind of diagnostic value of any kind of x-rays or scans. Yeah. Okay. Right. So on that executive summary list I mentioned earlier, conclusion number five is, I quote,

[00:07:40] imaging analysis of the upper airways such as widths, volumes, and areas using cephalograms or CBCTs is not suitable for diagnosis, risk assessment, or outcome assessment of intervention in SDB. Mm-hmm. And they cite that reference 34, that big-ass 600-page article to support that conclusion. Well, okay. Okay.

[00:08:05] Let's read what it actually says because here's a direct quote from that reference. Similar to cephalograms, CBCT can be of value as an adjunct in the anatomic evaluation of OSA. Okay. That's a direct quote from that.

[00:08:35] Right. So it doesn't give a representation of what their airway looks like when they're laying down in a sleep. Well, there's that argument and then there's also the argument that you can't diagnose OSA or SDB, you know, off of this stuff. And I don't know of anybody who's saying that. No, no one's making the diagnosis off this because this diagnosis is sort of – you look at a lot of different things. I mean – Right. Right.

[00:09:01] And so, you know, here they're saying SDB, CBCT has no value. And then, you know, their own reference says that it does. But, I mean, when you look at it, there are tons of things that we can look at on a CBCT. There's turbinates. There's adenoids. There's tonsils. There's septal – you know, deviated septums. There's just transverse deficiency. There's all these findings that we can find. Right? Yeah.

[00:09:28] And so – all right. Let me look at this here. Let's talk about a study published in Imaging Science and Dentistry in 2024. It was titled Correlation Between Cone Beam Computed Tomographic Findings and Apnea Hypopnea Index of Obstructive Sleep Apnea Patients.

[00:09:50] And their finding was CBCT provides an extremely accurate assessment of craniofacial and upper airway anatomy, including volume, surface area, cross-sectional area, angles, and shapes. These features are critical for determining the origin, severity, and prognosis of airway dysfunction. Interesting. Okay. So, here they're saying CBCT has no real benefit to it. And we know the opposite. So, there's that.

[00:10:19] And put a pin in that because that will come into play later. Okay. You asked about what their position is as far as, like, working with a physician and all that stuff. And the white paper does say, and I quote, when there is suspicion of possible SDB, the orthodontist should refer the patient to a physician for a definitive diagnosis before any intervention. Interesting.

[00:10:48] So, that is a direct quote before any intervention. And so, again, going back to the access of care issues, the time, are you really going to wait a year if it takes that long to get into them? Because, again, if a child has transverse scalable deficiency, expand the arts because it needs to be expanded. I was just going to say, that's something that orthodontists would treat without getting a permission slip from a sleep doctor. Right. Like, that's what orthodontists do.

[00:11:17] Right. So, again, I did not like that statement. Yeah. We can go into tongue ties if you want. Because the white paper, this is, oh, man, getting back to citations. This is a good one. Got to take a sip for this. Sure. This is just, you know, straight vodka, by the way. Yeah. You kind of need it. You kind of need it. Exactly. You kind of need it. Yeah.

[00:11:44] So, here's what the white paper says when it's talking about tongue ties. Quote, a 2023 scoping review of 26 studies greater than 1,228 patients identified associations between untreated ankylglossia and OSA risk factors, including reduced maxillary width, elongated soft palate, and retroglossal collapse. And they attribute that citation to reference 41.

[00:12:16] But that scoping, so that scoping review, it was from 2023. It's titled The Impact of Ankylglossia Beyond Breastfeeding, a Scoping Review of Potential Symptoms. And it was published in the American Journal of Speech-Language Pathology. Okay. But the thing is of it is in the reference list, that's reference number 42, not 41. 41. So, they have a phantom reference. Yeah, yeah, yeah. Because 41 is a completely different paper.

[00:12:46] Yeah. It's by Hicks et al. Mechanisms of the deep, slow-wave, sleep-related increase of upper airway muscle tone in healthy humans. Yeah. It's the wrong – so, they actually cited the wrong citation. So, it's essentially a typo in the AAO white paper. But if it's your position paper for your entire profession. Yeah, yeah. You might want to have that. Yeah. Yeah. Oh, my God. That's bad.

[00:13:16] So, what's interesting, though, is that even when you correct that typo, the Cordray Scoping Review, it doesn't dismiss – doesn't support dismissing the dismissive framing that the white paper puts around it. Because the conclusions note that multiple comparative studies found associations between ankyloglossia and OSA risk factors.

[00:13:39] And that randomized controlled trial found that phrenotomy may attenuate apnea severity. So, that's the paper. That's what the paper is saying. But the paper is citing it to imply causation can't be established. Yeah. Interesting. Yeah. Yeah. So, I mean –

[00:14:03] I might be able to get behind that for the fact that they say that a tongue tie – fixing a tongue tie might do something to the apnea seriousness or whatever. So, it's – maybe it isn't causative. But, I mean, this treatment is – yeah. I don't know. I feel like that's still pretty slick on their part. Yeah. Yeah. And, you know – and that's the thing about it. I think it's a nice little wordplay there.

[00:14:32] But, I mean, there is good data to show. Like, you know, there's – oh, well, so here's another thing that they cite. And that is what they call the American Academy of Orontology – or auto-laridology head and neck surgery. That is the word. Okay.

[00:14:54] So, it was published in 2020, which states that ancaglossia does not cause OSA. And fair enough. But, you know, that's one consensus study from one specialty in 2020. And things have maybe evolved since then because even then in sleep medicine – published in sleep medicine in February of 2020,

[00:15:18] you have the study short lingual frenulum as a risk factor for sleep disorder breathing in school-age children. And so, they found that children with short lingual frenulum were significantly higher risk for positive sleep clinical record, a validated SDB screening tool, and compared to those with normal frenulum rate, even when controlling for age, sex, tongue straight, and obesity. And so, you have that paper that they completely omitted.

[00:15:47] You have in the International Journal of Pediatric – oh, man. Yeah. Oto-rhinology. Yeah. In 2026. You know what he's trying to say. But that paper is titled Ancaglossia and it's associated with sleep disorder breathing in children. And their conclusion was current evidence suggests a positive association between Ancaglossia and pediatric SDB. So, that's a questionary-based study. I see. Okay.

[00:16:18] Yeah. So, again, with Ancaglossia, does every tongue tie need to be lasered? I'm not saying that. But, like, to say that there's no association when there clearly can be and we have data to prove it, it's just – I don't get it. And maybe it's just they're making that statement so that way – because, you know, frenectomies are kind of the hot thing right now. It's a pretty hot thing right now.

[00:16:47] And so, it's like every tongue tie needs to be released and all that stuff. I'm not there. And so, maybe they're making this claim to hedge from people just taking that ball and completely being irresponsible with it. Right. Maybe that's what's going on. I don't know. But there is an association. We have the data show association. I think that's what they're saying they should say that instead of – like, they don't really say specifically that. I don't know. That seems – again, they're –

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[00:17:39] From the sound of it, you know, not having read through it as closely as you have, their citations are sloppy at best. Right. Right. It's kind of like how they're citing this stuff considering, you know, there's plenty of literature out there that they're sort of ignoring or, you know, they're citing – I don't know. I don't know. I mean, if you wanted to make a case that they were, you know, willfully trying to ignore a lot of stuff, that's what it almost seems like. I'm not sure that we can say that.

[00:18:08] But, you know, there's no one there to defend. But I don't know, man. And that seems wild that they're going out of their way to kind of miss some of the overall science on this stuff. Yeah. Let's get into a juicy one. Do premolar extractions cause sleep apnea? Right. So they have a claim that, you know, basically premolar extraction has no airway impact. Okay. And so they cite a couple of studies.

[00:18:36] So let's kind of go through those because it's kind of interesting. Now, I get asked a lot, do I think extractions cause sleep apnea? And I say no. No, they don't. They're not the cause of it. They're just not doing anything to help it. Right. Like the issue is small jobs. Yeah. I mean, that's the issue. Yeah. And extractions might have an effect on your – yeah, exactly. Yeah.

[00:19:06] Unless if somebody was perfectly straight, perfectly healthy, and you extracted premolars and brought them back. Yeah. Yeah. You know, abnormally, like you could cause a constriction. And yeah, I could see that. But with how it's being done in orthodontics, the problem isn't the crooked teeth. The problem is the small jaws, but we're just focusing on the crooked teeth. Yeah. Yeah. It's not like somebody is going in and they have no SDB.

[00:19:35] They're breathing beautifully the night before their extractions. And then after their extractions, all of a sudden they have, you know, sleep disorder breathing. No, they already had. Yeah. Yeah. Right. And so, but let's get back to the references. So, reference 52 is one of the things. And this was published in the European Journal of Orthodontics in 2025. Okay.

[00:19:58] It's called Extraction of Premolars and Orthodontic Treatment Does Not Negatively Affect Upper Airway Volume and Minimal Cross-Sectional Area. Guess what they used to measure this? I have no idea. This study uses a CBCT imaging to evaluate pharyngeal airway volume in cross-sectional studies. Can't do it. Can't do it. The same way.

[00:20:23] The paper says CBCT has no diagnostic value for SDB risk assessment is citing a CBCT-based study to conclude that extractions don't affect airway. That's a wild take. That is, oh my God. Okay. So, I thought that was, I thought that was fun. Hard to take this seriously after all this stuff. Seriously. Right. Yeah. And then, so let's get into the second reference, which was reference number 53.

[00:20:50] So, this was published in the Journal of Clinical Sleep Medicine back in 2015. And this is cited a lot around orthodontists saying that no evidence. And so, the title is Evidence Supports No Relationship Between Obstructive Sleep Apnea and Premular Extraction, An Electronic Health Records Review. So, it's a health records review. So, this is cited a lot in the pro-extraction camp.

[00:21:17] And this, and they talk about how great the study is because it had an N of 5,584 patients. And the white paper says that this represents an extensive epidemiologic assessment. Yeah. But it's, does it though, because it's kind of, it's a singular study. But let's look at what the paper really did here. So, it was, all they did was, first off, I want to mention, it's a health records review.

[00:21:46] History of previous orthodontic treatment was not part of the inclusion criteria. I'm just going to say, health records are, I mean, ugh. So, there was, there wasn't any confirmation that missing premolars were due to orthodontic treatment. These patients could have been congenitally missing premolars. They could have had extractions because of perio, whatever. We don't know because the study didn't even ask. And the authors themselves in the conclusion described the missing premolars as, I quote,

[00:22:16] presumed indicator, presumed, presumed indicator of past extraction orthodontic treatment. Well, that is a huge stretch. So, they're guessing that these patients had orthodontic extractions. Okay. But there was no evaluation of imaging mechanics. They didn't look at incisor retraction. They didn't look at tongue space between changes between these groups.

[00:22:39] So, is using a retrospective EHR study and really an extensive epidemiologic assessment? No. No, absolutely not. But on top of that, on top of that, like using health records that human beings put together over time and perhaps, I mean, there's like so many things I can poke a hole in that. Like, health records are an imperfect thing.

[00:23:07] Like, God, you know, you'd like to think that you got everything every time, but how do you know? And like, there's so much that's not there. What if the person wasn't evaluating for that? What if the health record you're looking at was done by a practitioner that just didn't know anything about this stuff and just didn't mention or didn't examine or anything like that? So, that's not a great, I wouldn't lean on that at all. I feel like there's so many holes in that. Yeah. Yeah.

[00:23:33] And the last thing, and we'll make this one a little bit shorter here, but the last thing I want to talk about was palatal expansion. Mm-hmm. So, you know, so when you look at the palatal expansion section, the white paper says, quote, although using skeletal anchored palatal expanders is expected to increase the magnitude of skeletal expansion, impact of that additional skeletal expansion rate on breathing function has not

[00:24:02] been objectively assessed. Okay. Okay. Um, and so the executive summary later on takes it further and says, I quote, there is no evidence to support the prophylactic use of pediatric palatal expansion as a preventive measure for STD at any age. Okay. So, um, you know, that, that, that's a pretty strong statement.

[00:24:29] Um, especially when we, we go back, they weren't citing reference 34. That 600 page document. They weren't citing that for this, but that here's a quote from reference 34. Patients with OSA and maxillary constriction are the best candidates for RME rapid maxillary expansion. RME was shown up to, uh, shown up to result in a 70% reduction in AHI in children and 95%

[00:24:58] reduction in AHI when performed in addition to T and A tonsils and adenoids, or when tonsils were not hypertrophy. Children with small surgically removed tonsils benefits more from expansion than those, uh, do with large tonsils that undergo RME without TNA. So here a study that they used to, they cited earlier, that same, that, that study shows that RME is beneficial.

[00:25:26] Uh, 70% reduction of AHI and 95% reduction when combined with tonsils and adenoid removal. Mm-hmm. But they say that the impact of maxillary expansion on breathing function, quote, has not been objectively assessed. It's so wild. It's so wild. Uh, I, they're going out of their way. I don't quite understand. Okay.

[00:25:52] So what, what this does is more than anything, they're basically saying that it's saying what, what orthodontists should not do instead of what they could do to help here. There's basically, they're poo-pooing anything that has been brought up as that, that, that may help grow faces get, you know, make, and it's, it's essentially saying what ortho, orthodontists shouldn't do. Right. Like, like all the stuff that these things don't have evidence you shouldn't, I don't

[00:26:22] know, man. I feel like they're going out of their way to, to try and like take orthodontists out of this treatment modality. They don't want to be, they don't want to be responsible. Like you said, it's a covering your ass thing. It's like, essentially we can't, we don't have that much to do with this is what that's saying. Instead of saying, what could we do? What, how could we help this? It seems wild to me that an entire, like this, their profession, their, their specialty is basically weighing in on the fact that, eh, we don't have that much to do with this stuff. That's wild.

[00:26:51] I mean, it's something I heard from Mark DeLuke, um, orthodontist, he was on a rant and he was like, he basically said something to the effect, I'm paraphrasing from memory here, but said something to the effect to like, name another medical profession that tries to see less on our patients and do less on our patients. Yes, exactly. That's wild. And mind you, general dentistry has, is slow to pick up a lot of this stuff because airway

[00:27:18] stuff is complicated and a lot of, you know, a lot of models are not, but the reality is like, these are, this is where the, they're evaluating the evidence base and they've walked away from a 2019, was it 2019 or 2017? 2019 was that first wife. The original one and they're, they're, they're literally saying less from the, there's, that's amazing to me. Oh my gosh. Well, and let's talk about that evidence-based issue because like, you know, when we look,

[00:27:48] um, evidence-based medicine, uh, that term has been around roughly 30 years. It was, it came from the British medical journal, um, in 1996 in a, um, in a article or, you know, titled evidence-based medicine, what is it and what it isn't. And, um, you know, Sackett, who's the, the godfather of the creator of, uh, EBM, basically,

[00:28:14] you know, his whole thing was EBM is quote, not restricted to randomized trials and meta-analysis. Mm-hmm. Basically, you know, if no RCT has been carried out for our patient's issue, then we quote, must follow the trail to the next best external evidence and work from there. Yeah. And he also includes for his, is for his EBM model, there's the studies, but also it's like a Venn diagram, right?

[00:28:45] Sphere one is the studies, but sphere two is the, the clinical judgment and expertise of the provider. Mm-hmm. And then the third, the third one underneath is the patient's values and preferences. And where all of those things intertwine, that's EBM. Mm-hmm. But so here you have all these people saying that's not evidence-based, that's not evidence-based. Well, do RCTs exist for it?

[00:29:10] Well, if not, then we have to go to the next level, but we also have to take these things into consideration. And then my question would be, how much do we do in dentistry or orthodontics that are backed up by randomized control trials? Oh, so little. So little. Like there's- How- Yeah. I love a good class one occlusion. I love it. Mm-hmm. That's why I always try to, always try to strive for.

[00:29:35] How many RCTs exist to demonstrate better function, TMJ health, or long-term stability of a class one occlusion? Zero. Yeah. Zero and one. Yeah. Also, they always- Orthodontists love CEPs. Yeah. How many RCTs exist backing up the use of, showing that this CEP analysis is better or that it leads to better outcomes? Really good question.

[00:30:04] Really good question. Yeah. Where did CEPs come from? How, what was the data, what are the studies that back up CEPs? They're all observational and normative population data based on Tweed and Steiner going back to the 40s and 50s. Exactly. That's so much of orthodontics, honestly. All the way around. Evaluating faces, all that stuff. It was normative from populations. That's exactly right. That's exactly right. Invisalign, for example.

[00:30:33] You know, Invisalign came out, what, 99 or something like that? And it started off basically with just orthodontists. Only orthodontists had access to Invisalign. Well, when did the first high-quality RCT come out with Invisalign? Not till 2015. Mm-hmm. So you practice 15, 16 years without, you know, any RCT-level evidence. How much, how many RCT interproximal reduction?

[00:31:00] How many RCT, how much RCT data is available to show interproximal reductions in long-term safety outcomes? Mm-hmm. It's, it's interesting because they, they sort of pick and choose what standard of evidence they want to put out there depending on, it seems like depending on what they want, what they want the outcome to be, what they want, what they want their statement to be. Yeah. I mean.

[00:31:25] There's no RCTs backing up prescription of brackets of archwire sequence, initial archwire, which one you use, all that. All the things that orthodontists do every single day, 98% of what they do has no backing through RCTs. But if you want to do this, if you are concerned about a kid's breathing and you want to maybe expand their palate or develop, or take them through myofunctional therapy, you're going

[00:31:54] to have to show RCTs to prove that that's beneficial. Yeah. It's not. Yeah. It's, well, yeah. And on top of the fact, like orthodontists have been, have been treating these conditions, not, not related to breathing for how long? For forever. I mean, essentially they, you know, they want ideal arches, you know, just so happens that they're ideal arches and they're not thinking about the breathing effects of it. It's weird. It's a weird take. It's a weird take. So let's wrap this up a little bit. What do you, what do you think? What do you think becomes this?

[00:32:22] I mean, clearly I'm glad to hear that you're saying you're hearing even from some orthodontists that there's a lot of pushback. What do you think? What do you think is the, how do you think this shakes out? Oh, I mean, at the end of the day, not much is going to change. The folks who want to have their head in the sand on it will continue to do so. But personally, I, I'm excited about it because more and more orthodontists and general dentists and ENTs even are opening up to the new, to the new data and to the new literature.

[00:32:51] And, and so I think for those people, there is, there is, um, there's a big opportunity ahead. So for the folks who aren't interested in changing, nothing's going to change is what it is. But there's more public awareness about it. You have more of your whole foods moms that are on Facebook groups asking, Hey, do I really need take out teeth? Are there orthodontists or somebody around that can do this without taking out teeth?

[00:33:20] Do my kids need an expander? Does my kid's tongue tie need fixed? Who, who in our area? And those folks that dedicate themselves to getting good at this and be, and become the, the, the authority in their area on this. Um, I, I think there's a huge opportunity for them. I really do. And it'll get people functioning and breathing better. Yeah. I mean, in this talking about, even if, even if, even if this paper is controversial

[00:33:49] and pisses a bunch of people off, it's probably a good thing to stir the, like, honestly, it brings awareness. Like I, this is not something I was thinking very much about. And then, and then this came out and I'm like all of a sudden paying attention to it. So honestly, whatever their goal might've been, it may, it may be backfiring because just because it gets, it gets, it gets people's ire up a little bit when they're like, this is really, this is really irresponsible on some level. It's interesting. I hadn't thought about it that way. So maybe instead of the black pill, maybe there's, maybe there's some, something good at the end of this deal.

[00:34:19] I think there was a bit of white pill there. I totally do. Absolutely. That's awesome. Matt, you, you covered this really well. I know. I appreciate you doing the work because I know when this came out, you were diving in deep. So I think we covered it pretty well. I, and here's the other thing. I didn't say this in the first episode. I'm going to make sure that all of the links to the different papers we talked about and, and, and, and the, and the main paper with the bibliography and everything like that is available. I'll put it in the show notes. You guys don't have to go looking for it. We'll find it. It's some of it's, some of it's a heavy slog read. Some it's not as bad. Some it's okay.

[00:34:48] And Matt has really covered and summarized it quite well. I think that. I've never paid for so many journal articles because some of them were free access. And I'm going through these citation lists and plenty of them were behind the paywall. I probably paid like over $300. Wow. Of journal articles. Cause these things cost like 40 bucks or something to get access to. So I'm glad someone was doing it for you. What's, what's interesting too. I will say this.

[00:35:18] I've not heard a lot of run of the mill orthodontists necessarily defending this or having a strong feeling about it either way. So it's, it is interesting that, um, you know, I, you're not hearing orthodontists coming in. Oh no, this is, this white paper is exactly where I, I don't, I haven't heard a lot of that. I don't know that maybe I'm not in the right position to listen for it, but it's interesting. This is a very interesting conversation. So Matt, thank you again for being on. This was, this was a lot. If people have questions or comments, let's talk about it in the very dental Facebook group. Uh, if you're not a member, you need to go join, uh, ask for an invitation.

[00:35:47] Give me one of a whole bunch of passwords. Let's throw some out here. We got Papa Randy. We got Lipscomb. We got McQuethy, Timmerman, Gary, Frank, BioClear, Hornbrook. Any of those will get you in. We can talk about this stuff. Nice thing about the very dental Facebook groups. It's not a complete shit show. And the only people I let in are people who listened to the podcast. So it's a smaller group, but it's a group that's already engaged in a way that if you've made it this far into two episodes, you're pretty engaged in this stuff. You're probably not going to, you're not going to stir too. If you're not going to stir the pot too much, we don't want to let that happen in this group.

[00:36:17] So, uh, go join there. Matt's there. We can talk about this stuff and, um, this is a good conversation. It's interesting stuff. Well, thanks for having me on. I appreciate it. You bet. We'll talk to you later, Matt. See ya.