Can adolescent extraction/retraction orthodontics cause adult obstructive sleep apnea?

[greyham]

Firstly, thanks so much for this amazing forum! I’m a 51 year old male diagnosed with severe sleep apnea after a polysomnograph last year. Up until that point I thought I had chronic fatigue syndrome as I had been ill with severe fatigue, headaches and flu-like symptoms for over 10 years. Until the sleep study, nothing I tried seemed to make me well again and no doctors had any answers.

I came across this forum while exploring orthodontic treatment options for severe sleep apnea. I tried CPAP for two months, which made it hard for me to fall asleep at all and couldn’t imagine (not) sleeping like that for the rest of my life. I also tried throat and jaw exercises (https://www.youtube.com/watch?v=VdRmsJYb8_Y) and learning to play didgeridoo (https://www.bmj.com/content/332/7536/266), which led to a 20% improvement in my AHI from 49 to 39. I now sleep with a SomnoMed Mandibular Advancement Device which has reduced the severity of my daytime headaches to the point where I no longer require painkillers and reduced my daytime sleepiness somewhat.

However, a second sleep study confirmed that it is only partially effective, further reducing my AHI to 31; which is still considered severe. It also gives me TMJ pain and makes it hard to fully close my mouth during the day as my lower front teeth now hit my upper front teeth. MAD’s aren’t recommended as a treatment for severe sleep apnea but I experimented with it since my rather conservative sleep specialist didn’t recommend surgery and I hated CPAP. I’ve since discovered the research showing a negative long-term efficacy of MAD’s (https://www.ncbi.nlm.nih.gov/pubmed/26527204). I’m also concerned about the long term impact of having my maxilla pulled back every night, it’s not sufficiently effective on its own, and it’s not really treating the cause of my problem anyway.

So I ask myself the question: “What caused my sleep apnea, anyway?”. From a risk mitigation point of view, identifying and addressing (possibly by reversing) the cause is likely to be the most effective treatment with the least potential adverse side-effects. Back when I was a biomedical engineer, we called this kind of thinking a “root cause analysis”.

When I was 13, I had extraction/retraction orthodontic work to correct what I thought was some pretty mild overcrowding and crooked teeth. I had my four premolars extracted along with an infant tooth which was blocking one of my adult teeth coming down. I had the braces for about 3 years while waiting for that adult tooth to fully erupt and it was very painful much of the time.

I’m not an orthodontist, but I was an engineer and I’m pretty good at logical problem solving. If you extract teeth that nature thought were important enough to grow, retract the teeth in front of them, and stick metal wires restricting all the remaining teeth during the period of rapid growth called adolescence, it seems logical that you’re going to impede the growth of the jaws and end up with an adult mouth that is too small for the adult tongue. With nowhere else to go, the tongue can only move backwards, blocking the airway; especially during sleep. Hence obstructive sleep apnea.

This seems blindingly obvious to me; and yet many orthodontists disagree (https://kevinobrienorthoblog.com/is-the ... ep-apnoea/). They often cite this scientific study when doing so: Evidence Supports No Relationship between Obstructive Sleep Apnea and Premolar Extraction: An Electronic Health Records Review. (http://jcsm.aasm.org/viewabstract.aspx?pid=30357)

Now in truth, I don’t just care about the relationship between obstructive sleep apnea and premolar extractions, because that isn’t all that happened to me. What I really want to know is whether adolescent premolar extraction coupled with retraction orthodontics causes (or contributes to) adult obstructive sleep apnea. Perhaps I’m splitting hairs though since it appears that many orthodontists interpret the paper as if it were actually answering this question anyway.

I can find little scientific evidence to support my hypothesis that adolescent extraction/retraction orthodontics causes adult sleep apnea aside from a few studies that show that it reduces the airway somewhat. There are testimonials on forums like this one though. If my hypothesis is true, why didn’t Larsen et al’s paper identify any statistically significant difference between the incidence of sleep apnea between the groups of people who had premolars extracted and those who didn’t?

There are some potential flaws in their research, like:
• They assumed that people with premolars missing had had orthodontic extractions, without confirming this
• They didn't determine what kind of orthodontic treatment the people with missing premolars had had
• While they acknowledge that up to 80% of people with sleep apnea are undiagnosed yet didn’t limit the study just to people who have had a polysomnograph to rule it out
• They didn’t check that people in the group that retained premolars had not had potentially jaw-growth-limiting orthodontic work done nevertheless
• They didn’t limit the study to people whose orthodontic work was done in adolescence
• They assumed that the group of people in the study represented the general population
• They did find that people with missing premolars had a greater incidence of sleep apnea, but not significantly so
• They didn't consider whether people who retained their premolars had had expansion orthodontic work and what impact this had on their incidence of sleep apnea

Some of these flaws could be explained because the researchers were attempting to answer a slightly different question to the one that I’m interested in, and attempting to correct some of these flaws may well have made the study impractical; but hey, doing really good science is hard. Have I missed anything else here?

The question is important to me because I like to have my beliefs and actions backed by scientific evidence. I’d like to know that if I embark on another potentially long, painful and expensive orthodontic treatment that it’s likely to be successful in curing my sleep apnea because I know it is treating/reversing the cause. At the moment I’m leaning towards palatal and mandibular expansion because I prefer the idea of reversing the effects of previous bad treatment to embarking on a new treatment such as surgery that may just lead to even more unanticipated problems down the track.

Any thoughts?

(Also posted on The Great Work forum at https://the-great-work.org/community/ma ... eep-apnea/)

[djspeece]

Wow, such an interesting read! I don't think you have missed anything in your analysis of the research. Of course, as you well understand, orthodontists are not likely to conduct research that connects extractions etc. with obstructive sleep apnea and would likely be inclined to interpret research findings in a way that supports their work. I am an RN, but have no experience or special knowledge about sleep apnea, so my comments should be taken in that light.

I don't know how well designed the research studies were -- if any included a control group, for example, or sample sizes, or age ranges. That would seem to be extremely difficult. I think you touch on that issue on your last bullet point in your excellent post. I assume you have also looked at the issue from the sleep apnea perspective for associations or causation. And not to sound ignorant, but i am not certain that orthodontics changes the size of the jaw, but rather moves the teeth within the existing bone structure. Granted, even shifting teeth could impact the airway to some extent; I don't have a feel though for how clinically significant that might be. Also, I would not give nature too much credit -- you stated that

If you extract teeth that nature thought were important enough to grow,...

because nature also appears to have a lively sense of humor when it comes to accommodating lots of teeth while evolving a smaller jaw.

I don't know that anyone could, or should give you reassurance that orthodontics will relieve your issues. I may have missed it in your post, but have you consulted with a physician who specializes in sleep disorders? Now that would be an interesting conversation, given your background and knowledge!

In any event, best of luck to you!

[greyham]

[quote=djspeece post_id=508219 time=1575645226 user_id=20342]
I don't know how well designed the research studies were -- if any included a control group, for example, or sample sizes, or age ranges. That would seem to be extremely difficult.
[/quote]

Thanks for your reply. I get that this is challenging from a research point of view, and orthodontists who routinely use extraction have a vested interest in believing that they're doing the right thing. I suspect that shifting to expansion orthodontics would probably be just as financially lucrative, since you can sell the client a palate expander, but changing someone's belief system can be hard especially without solid evidence. It's not practical to set up a double-blind controlled study where you submit one adolescent group to extractions, another to expansions, and a control group where you do nothing about their tooth crowding, wait 20 years and see who develops sleep apnea in middle age. Which is why the study I cited was retrospective using existing data instead. I'm not convinced that it actually proves the outcome they claimed but I'm not entirely sure how to solidly debunk it either.

[quote=djspeece post_id=508219 time=1575645226 user_id=20342]
nature also appears to have a lively sense of humor when it comes to accommodating lots of teeth while evolving a smaller jaw.
[/quote]

The change in jaw size that has led to the epidemic of children needing braces has occurred too quickly in evolutionary terms to be due to genetic variation. There are dentists like Dr Steven Lin who believe it's an epigenetic response to the softening of the western diet, as described in this podcast: https://chriskresser.com/how-dental-hea ... teven-lin/ and functional orthodontists like Mr. Mew and Sandra Kahn agree. Check out this interview with Sandra Kahn and Paul Erlich who wrote the book "Jaws: The Story of a Hidden Epidemic" about this: https://www.youtube.com/watch?v=-TaCeym1N-I.

Yes, I've seen a sleep physician who oversaw my sleep studies. However he seems kind of old-school and just wanted me to use CPAP. He didn't seem so interested in investigating what caused the sleep apnea so that I could address it without needing to sleep with a machine for the rest of my life. When I see him next, I'm going to show him this paper from Vivos, the makers of the DNA device: Biomimetic Oral Appliance Therapy in Adults with Severe Obstructive Sleep Apnea (https://www.vivoslife.com/assets/biomim ... -apnea.pdf), and see how he responds. I've also booked appointments with a dentist specialising in sleep medicine, and an ENT who (hopefully) understands airway remodelling.

Thanks again,
Graham

[bbsadmin]

That's because he was spamming our board quite aggressively a number of years ago. We had to ban him and do that with the spam filters. Sorry for the confusion! Call him Mr. Mew and it won't be censored, LOL

Anything that narrows the airway might cause sleep apnea. Aging and weight gain can also be a factor.

Don't be so resistant to using a CPAP. Both my husband and I have sleep apnea; he has severe obstructive and I have mild to moderate (which got worse after menopause because of fat deposits in my neck, which my sleep doctor told me is quite common). Using a CPAP is really no big deal once you get used to it.

[americaninparis]

Dear Greyham,

Let me begin by saying I am impressed with your troubleshooting of the research studies denying the relationship between extraction-retraction and sleep apnea (and airway issues). I am working with a lawyer on a class action suit based in trouble-shooting how research published in the AJO-DO deliberately misrepresented the jaw-extraction relationship, particularly in the AAO commissioned articles post the Brimm lawsuit of 1986 (which determined that extraction-retraction causes jaw issues and in which the plaintiff won 1.3 million dollars). Lately, the research bent is on denying the connection with airway and apnea.

There is--according to my interviews with doctors (including the Mews, but also ENTs and sleep specialists in the US) a clear correlation between obstructive sleep apnea and extraction-retraction. Extraction-retraction leads to a reduced palate, and the tongue has no choice but to go back in the throat: and block the trachea.

Dr. Stanley Liu, inventor of DOME, has stated to me that he sees an inordinate amount of patients with severe sleep apnea who have had extractions in his sleep lab at Stanford University.

Extraction-retraction orthodontics was done in 50% of all ortho cases up until 1986. After the infamous landmark Brimm case (which terrified the orthodontic community, as copy cat lawsuits would wipe out the industry), the extraction rate when down to 25% in the 1990s.

There has also been a boom in sleep apnea in adults in the last twenty years. Cold this boom in sleep apnea be correlated with this high 50% figure? Orthodontics before the 1970s was a rare "luxury" of the upper class. Now fifty percent of all Americans have orthodontic procedures as adolescents.

Please see this survey on the health consequences of premolar extractions: 40% of responders reported sleep apnea or other breathing issues. 86% report having the same four symptoms.

https://drive.google.com/file/d/1O0_EIJ ... be7Yx/view

Back to the first statement I made about troubleshooting research articles: might you be up for reading some of these suspicious orthodontic articles from 1992-2000? I have a team of volunteers reading these articles, and seeking for flaws in the research and the way the research is set up. Would much appreciate your eye.

Thanks for your thorough overview and analysis.

[greyham]

It does seem remarkable to me that CPAP, currently considered the gold standard of treatment for obstructive sleep apnea, was only invented in 1980; at a time when the baby boomers who had orthodontic treatment in the 1960's & 1970's were reaching middle age. It's now an $8 billon/year industry in the USA. I think it's complicated though because the soft western diet and short breastfeeding duration are probably the initial cause of our underdeveloped jaws, and the defence lawyers in your class action might latch onto this. Extraction/retraction orthodontics clearly made the problem worse, but I don't know how to prove by how much. Obviously the appropriate orthodontic intervention when faced with a child like myself is palate/jaw expansion as practised by Derek Mahony and his peers but not all orthodontists agree. I am curious how you plan to deal with defense arguments in your class action when there are so many orthodontists who will swear that there is no connection between adolescent extractions and adult sleep apnea. I doubt they're going to just take it lying down, especially when so many orthodontists genuinely believe that they are not at fault. It's hard to show that someone is lying when they think they are telling the truth.

Have you considered lobbying the American Association of Orthodontics to change their clinical practise guidelines? at https://www.aaoinfo.org/d/apps/get-file?fid=12939

I notice that the current guidelines actually give very little guidance, possibly because it's an obvious starting point for litigation if an orthodontist violates them. They don't even list Obstructive Sleep Apnea as one of the risk factors related to orthodontic treatment currently, and while it is listed under Diagnostic Considerations, that section says nothing about how to consider it. There is also a very broad disclaimer earlier in the section that "The influence of functional abnormalities on dentofacial development is variable, and cause and effect relationships are difficult to determine." They are probably going to claim that the relationship between adolescent extractions and adult sleep apnea is also difficult to determine; which in fact it is if you want a double-blind placebo controlled study proving it. How could you even do such a study given the long follow up times (20 years) and the ethical implications?

It's ironic to me that so little research appears to have been done into the safety and efficacy of conventional orthodontic treatment. They see straight teeth when the braces come off and just assume that it's working fine. It's not evidence based at all. But when you suggest that they change anything, conventional orthodontists respond with: "Show me the scientific evidence!" I suspect orthodontists who understand the connection like William Hang (https://facefocused.com/category/what-w ... rome-errs/) are too busy helping patients needing reversal treatments to spend time doing solid scientific research into something that is screamingly obvious to them. Meanwhile, conventional orthodontists just stick to their existing beliefs. Kevin O'Brien's orthodontic blog is a good example of this: https://kevinobrienorthoblog.com/orthod ... eep-apnea/

So you may have a challenge ahead, but I wish you luck.

My orthodontist has recommended I get DOME and MMA, so that's interesting what Dr Liu has said. I noticed that the Stanford surgery guidelines mention orthodontic extractions as a risk factor, so why the flower don't orthodontists? I suspect it's because they are trained in dental school not medical school, and don't talk to their medical colleagues. Plus, there is potentially a very long latency between when the extraction/retraction work is done and when the patient hits middle age and gets sleep apnea. Sleep apnea is multifactorial and I can't guarantee that my airway would be fine if my teeth had been left alone, I do believe that if I'd had expansion orthodontics instead of extraction/retraction, I wouldn't have sleep apnea and would probably never have developed Chronic Fatigue Syndrome in the first place. You can see my collapsed airway in my CBCT scan, and an orthodontist and dentist could see narrow jaws just by looking in my mouth. An ENT experienced in sleep apnea could spot that I have a retrognathic maxilla just by looking at my face. For orthodontists to continue denying this connection is just ludicrous.

For me at the moment I'm focussed on how to fix the problem, and knowing what caused it is most relevant to that. Mostly I just want my life back. I'd be happy to support your work down the track though once I'm not feeling so fatigued all the time, have fully recovered, and have more spare time on my hands. Meanwhile I'll keep following your work. I have done your survey and got your recent email with extraction reversal treatment options. I found that really helpful, since that's where I'm at right now. So thank you for your advocacy work. Keep me in the loop and I'll help out when I can.

cheers,
Graham