Connecting Heads

Breaking through the Fog by Dr Barry Raphael

January 23, 2018 at 9:56 am Leave a comment

Breaking Through the Fog

Progress is never in a straight line, especially if you’re surrounded by fog.  My journey through the orthodontic wilderness is an example.  The forest of the orthodontic specialty is populated with the tall trees of orthodoxy.  “Malocclusion is the problem”, “Never expand the lower canines”, “All cases must finish in Angle Class 1”, “Extraction of teeth has no ill effects”, and so on.  But when I became educated on the issue of sleep and the disorders of breathing during sleep, some of these concepts no longer made as much sense to me as they once had.  Instead of malocclusion being the problem (and braces the solution), it now appears that malocclusion is a symptom – a process of the teeth compensating for another problem in the jaws, face, or head.

For instance, when a baby is having trouble breathing, say, due to nasal congestion, she will position her head in such a way to open the oral airway in order to compensate. After all, taking the next breath is the most important thing we do moment to moment.  But that changes the functional matrix of the mouth, what with the tongue no longer supporting the growing palate and the lips and cheeks now active in swallowing.  Over time, the maxilla distorts in shape and when the innocent teeth erupt they have no good place to fit and just accommodate to the smaller space.  To make matters worse, she is now breathing unfiltered air and expelling too much carbon dioxide from overbreathing and her biochemistry is now out of whack, too.  And I’m supposed to fix all this with braces?  That just doesn’t make sense.

For a while, I was quite disoriented as I kept (and keep) bumping into these trees of orthodoxy.  I had to examine each orthodoxy and ask, “Is what I once learned still true?”, and “If it is true, is it still useful?”  I will always have my ethical standards to maintain, but if I’m going to be truthful with my patients, I can no longer just say, “You need braces because you got your crooked teeth from your parents” and that’s it.  I have to help my patients understand that they have issues with their health that have led them to this place and that they should at least consider taking care of themselves better.  Plus, I now feel the obligation to help them do that within the scope of my practice.

For instance, if a child is sitting in my chair with her mouth hanging open, I know she is not breathing properly and probably not sleeping well, either.  Many kids are in a fog of their own, with attention deficit and neurocognitive issues from a lack of deep sleep.  Should I just ignore that and just straighten their teeth?  What kind of healthcare provider would I be if I did that?  I have to help them learn to clean and clear their nose and close their lips at the very least.  Better yet, I can teach them to place their tongue on the palate and learn to swallow without using their lips and chin and cheeks so their teeth are not jammed together by the muscles.  After all, I am a doctor, aren’t I?

Some of the fog of my orthodontic education is lifting as I have found practical methods for helping children and adults become healthier as well as having a pretty smile.  But the fog remains for much of the dental profession.  Many professionals continue to feel comfortable in the woods with the big trees to hide behind.    Those who are making a good living from practicing in the old way, or who are running institutions whose reputation is based on the older orthodoxies, are very reluctant to let go of what is comfortable and safe.  I don’t blame them.  I was like that, too, for a long time.  I remember hearing specific voices (Robert Ricketts, Leon Kusic, Duane Grummons, and John Mew, to mention just a few) challenging me to recognize this information but refused to heed the call for first 27 years of my 34-year career.

Now the fog is lifting for others, too. The American Dental Association – not often known for progressive positions – has nevertheless come out with a position paper on the role of dentistry in treating sleep and breathing problems.  Their statement that dentists have the obligation to help children “develop an optimal physiologic airway and breathing pattern” is perhaps the most forward-thinking policy I could imagine and sets the stage for our profession to advance dramatically in the mission for children’s health.

This is a most exciting time to be in dentistry.  I see the sun shining on a bright, fogless future.

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