Note: This post may contain statements that I no longer consider true.
See: The Vivos mRNA Appliance Didn't Improve My Obstructive Sleep Apnea.
I was initially sceptical of Dr Singh’s claims that the Vivos DNA appliance uses mechano-transduction to trigger epigenetic processes which grow/remodel bone in the maxilla and mandible, leading to expanded jaws. After reviewing some science on bone remodelling, I believe it does involve epigenetics, but only to the degree that any biological growth process is directed by gene expression.
I was hopeful his book Epigenetic Orthodontics in Adults would shed some light on this but it is not available for any reasonable price and frankly didn’t impress me. It has some great case studies showing expanded jaws, but lacks scientific evidence to back his buzzword-laden claims about biomimetic epigenetic pneumopedics.
Surely, not another buzzword?!?
However, after skimming through the paper In Vitro Bone Cell Models: Impact of Fluid Stress on Bone Formation (Wittkowske et al, 2016), I’m starting to come around. Check out Figure 2, showing how deoxyribonucleic acid (what everyone else calls DNA) is transcribed into messenger ribonucleic acid (any normal scientist’s mRNA), translated into polypeptide chains, and aggregated to form collagen, which is then mineralised to form new bone.
Bone is a living tissue which adapts to the forces applied to it. The way mechanical loading influences bone structure is termed mechanostat. This is an epigenetic growth process involving a balance between bone resorption and bone formation, initiated by mechanical forces.
Osteopath Daniel Lopez also cites research showing that mechanical forces alter gene expression in his article Stem Cells in the Cranial Sutures and More: In Support of Cranial Osteopathy, using the DNA Appliance as an example.
The textbook Fundamentals of Biomechanics (Ozkaya et al, 2012), Chapter 15: Mechanical Properties of Biological Tissues, Section 15.7: Biomechanics of Bone says:
“As compared to other structural materials, bone is also unique in that it is self-repairing. Bone can also alter its shape, mechanical behavior, and mechanical properties to adapt to the changes in mechanical demand. … Bone possesses viscoelastic (time-dependent) material properties. The mechanical response of bone is dependent on the rate at which the loads are applied. Bone can resist rapidly applied loads much better than slowly applied loads.”
There is clearly a lot going on in bone biomechanics. However, many of the mechanical measures the book uses appear to be conducted on bone specimens, which are presumably no longer living tissue. They go on to say that wet bone is not as stiff and brittle as dry bone, implying greater fluidity; but I still don’t think they’re talking about living bone which is presumably even more fluid considering the active biological processes described by Wittkowske et al.
In his Masters of Philosophy Orthodontics thesis Quantifying the effects of mechanical vibration on the volume of the midpalatal suture, Dr Adrian Lok from The University of Sydney, where I currently happen to be a student myself, writes in Chapter 2: Bone, Section 2.4: Physical Properties of Bone, Subsection 2.4.4: Viscoelasticity:
“Under high loads, bone demonstrates low viscoelasticity and behaves as a brittle object. However at low loads, bone demonstrates a lower modulus of elasticity and behaves as a more viscous material.“
This suggests that living bone acts as a viscous fluid under light, sustained forces; such as those experienced with the DNA appliance. To back this up he cites Biomechanical and Molecular Regulation of Bone Remodeling (Robling, Castello & Turner, 2006), which is quite a read. I’m not sure how it supports Lok’s assertion that bone behaves like a viscous material under low loads, but in Section 1: Basic Bone Biology, they describe the action of the basic multicellular unit (BMU) in bone remodelling, saying:
“In human cortical bone, it would take approximately 120 days for the entire BMU to pass through a plane, leaving a new osteon behind.”
These are long durations we’re talking about here. In Subsection 2: Molecular Control of Bone Cell Differentiation and Fate they write:
“Further differentiation of the immature osteoclast occurs only under the continued presence of RANK-L and also requires the expression of several genes, including the AP-1 member c-fos, micropthalmia-associated transcription factor (MITF) , and nuclear factor of activated T cells, calcineurin dependent 1 (NFAT-c1).”
And later:
“As the matrix matures and mineralizes, and the osteoid seam moves further away, the osteocyte becomes entombed in a bony matrix and begins to mature and express a new set of genes, including dentin matrix protein-1 (DMP-1), matrix extracellular phosphoglycoprotein (MEPE), and SOST.”
I know this probably doesn’t make a lot of sense out of context, and I must admit it didn’t make a lot of sense to me in context either. I’m not inclined to read all the references that they cite, which are probably even more impenetrable for someone who is chronically sleep deprived. But clearly, while they didn’t use the term “epigenetic” back in 2006, bone remodelling does involves epigenetic processes.
Another interesting factoid from this paper is that bone growth responds to fluid pressure under the influence of gravity, which is why astronauts lose bone mass under sustained periods of zero gravity. You can adjust this effect on earth by lying down: long term bed rest causes loss of bone mass from your lower limbs, but an increase in the skull. (Robling et al, P23). When combined with the fact that bone growth happens primarily during sleep, it makes sense why the best time to wear the DNA appliance is overnight. It’s not just a lifestyle convenience thing to get you through how bloody long the treatment takes: lying down and being asleep at night fosters skull growth. Standing up during the day does not; unless you’re chewing.
Later in his thesis, Dr Lok writes in Chapter 5: Oscillating Mechanical Stimulation, Section 5.3: Importance of Mechanical Loading in the Growth of the Craniofacial Sutures:
“According to a study investigating the mechanobiology of craniofacial sutures, sutural osteogenesis is likely modulated by microscale shear stresses induced by the tension or compression forces. This study demonstrated that fibroblastic cells in sutures increase proliferation and matrix synthesis following induction of mechanical stresses with cyclic strains having the greatest effect. It has been proposed that the fluid flow in bone which is modified and induced by the strain rate and oscillatory bone strain is responsible for triggering mechanotransductive responses, whereas constant forces have no ability to induce fluid movement. As a consequence, amplitude of bone strain above a certain strain likely has no influence upon the rate of bone deposition compared to strain rate and energy”.
Robling et al discuss the influence of forces applied at frequencies down to 0.5 Hz, which is about a quarter of the speed I typically chew. Applying their research to chewing suggests that the faster you chew, the more growth you’ll get. You need to take breaks though or the bone cells desensitise to the mechanical signals promoting growth. That shouldn’t be a problem because you can’t chew in your sleep. However, they stopped at half a cycle per second when they found bone growth halted, and we’re talking a few cycles per day at most with Vivos. Dr Theodore Belfor has stated that the unilateral bite block on sibling appliance Homeoblock also provides intermittent light force that helps stimulate growth.
None of the references I’ve found discuss the biomechanical response of living bone to sustained light forces applied at such an extremely low frequency for very long periods, but the research done at higher frequencies suggests that it will flow/grow in the direction you push it, provided you don’t push too hard.
There has been some debate online about whether the DNA Appliance and Homeoblock can work without splitting the inter-palatine suture. Stretch force guides finger-like pattern of bone formation in suture is an experiment using rats which suggests that they can.
In Dr Singh’s keynote speech he says that undifferentiated stem cells in the periodontal ligament are the source of bone growth promoted by the DNA appliance through mechanotransduction, which is actually a thing. He didn’t just make it up… Robling et al use this term on page 30. However, they also say:
“The previously described BMU comprises a collection of different cell types with different origins. The osteoclast teams that line the cutting cone are derived from hematopoetic stem cells residing mainly in the marrow and spleen.”
In other words, stem cells from bone marrow can travel through the blood stream to wherever bone remodelling is required. They aren’t just talking in children either.
This implies that new bone can grow from anywhere, not just the inter-palatine suture.
It’s also why I disagree with Ronald Ead’s statement that you’ve got to split the suture… provided you’re willing to be patient. To be fair, he was using MSE at the time, and with it you undoubtedly do have to split the suture because the expansion rate typically used is so high compared to a Vivos appliance. I’d summarise the difference between MSE and Vivos as:
MSE uses high forces to do distraction osteogenesis along the mid-palatal suture very quickly.
Vivos DNA/mRNA uses low forces to do osteogenesis through the entire jaws very slowly.
There’s no way bone remodelling would accomodate rapid expansion in an adult without splitting sutures or tipping teeth. However, the fact that slow expansion can work in adults is demonstrated by the Brazillian Cephalometric study of alterations induced by maxillary slow expansion in adults, which showed average maxillary and mandibular expansion of ~2 mm in adults over 5 months. The researchers noted:
“As to the mechanism of maxillary expansion in adult patients, our results do not support the hypothesis that maxillary expansion occurred due to dental tilting, as suggested in the literature.”
So there is scientific evidence that slow maxillary expansion works in adults, beyond Dr Singh’s published research.
Of course the real question potential users like me care about isn’t:
“Does it work via epigenetics?”, or even:
“Does it work?”, but more importantly:
“Will it work for me?”
Changes in 3D Midfacial Parameters after Biomimetic Oral Appliance Therapy in Adults (Singh, Heit & Preble, 2014) demonstrated average increases in intramolar width and bone volume of 2.3mm and 1.7cm³ respectively over 18.4 months in 11 adults with midfacial underdevelopment aged over 21 using before-and-after CBCT scans. I wish they had been more specific about their ages and the skeptic in me suspects they were only just over 21 and notes that the paper was published in an Indian journal despite being backed by Dr Singh’s USA-based company of the time; but the device appears to work.
Obviously that doesn’t guarantee that it will work for me, but no other treatment is guaranteed either. However, the idea that a sustained, light force, applied at a very low frequency, over a very long period of time can remodel and reshape bone by initiating multicellular growth processes that involve epigenetic expression appears to be consistent with scientific evidence.
I get my mRNA on Wednesday, so I’ll let you know how it stacks up in practice over the next couple of years.
Italics in quotes are my emphasis, not the author’s. Thanks to Slowly Suffocating for assistance with research for this article.
23 Comments
melinda · February 2, 2022 at 2:24 PM
I am just now highly considering the Vivos system. I too have moderate to severe sleep apnea. Hubby is waking me up either due to obnoxious loud snoring, or because he can’t hear me breathing. I’m curious where you stand now with your Vivos procedure Graham. The office has pretty much sold me, but I’d love to hear from someone, such as yourself, who has been through or very close to completing the process. Thanks for sharing your knowledge
Graham Stoney · February 2, 2022 at 2:43 PM
It’s a little hard to say because I had a mid-treatment CBCT recently which upset me because it showed my teeth are tipping, but I haven’t had a sleep study since commencing treatment yet, and that’s the acid test. Whether it will work for you depends on the unique shape of your airway and where the obstruction is. You can see my latest update here. Cheers, Graham
Joe · February 7, 2021 at 12:19 AM
Graham et.al., first & foremost, thank you for taking the time to log your treatment. I’m intrigued and curious as to how your treatment with the DNA appliance is going. I’m 47 and have been on a frustrating course with sleep apnea; sleep, anxiety, hormone/chemistry, gastric and memory/concentration issues. After having gone to several doctors who didn’t want to test me for OSA, because I was, “fit and didn’t fit the profile”. Thus was diagnosed as “depressed”. I ignored that and was finally prescribed a sleep study that proved OSA. I gave the CPAP an honest try but to no avail. My issue lyes with my soft palate, tongue posture and crowded teeth. Not with inhalation but, my soft palate shunts (flaps) closed when I’m relaxed and exhale.This lead me to visit several ENT’s who (again) acted as though I was crazy. Each having their own, varying ideas of surgery ranging from UPP (no guarantee) to MMA (barbaric). Recently, I’ve discovered the DNA & FAGGA appliances but they seem to be limited on treatment success information. That said, I will be following your progress. As of today, how is your treatment going?
Graham Stoney · February 7, 2021 at 7:44 AM
Hi Joe,
I hear your frustration; it’s a minefield trying to navigate this illness given the mainstream medical community have their heads stuck in the sand. I didn’t fit the profile either, but that’s because the profile they use lacks awareness of orthodontic extractions, retrognathia and craniofacial dystrophy as risk factors for obstructive sleep apnea. As of today I’m feeling a little frustrated that my lower appliance is impinging on my gums again so I’ll need to visit my provider for another adjustment this week; but aside from the it’s going well. For more information, check my latest monthly update here.
Cheers,
Graham
Greg · November 24, 2020 at 11:53 AM
Just though to add: “That shouldn’t be a problem because you can’t chew in your sleep.”… unless one maybe has sleep bruxism?
Graham · November 26, 2020 at 6:40 AM
Sleep bruxism is tensing the jaw muscles in an attempt to open the airway. I recently heard a speaker suggest that the incidence of sleep disordered breathing could be even higher than usually estimated because when bruxing is successful at reopening the airway, it isn’t counted in your AHI.
G · January 26, 2021 at 5:00 PM
Wow, I thought I was the only one looking at that specific aspect of sleep bruxism. I would very much like to find out who that speaker was. I have been looking at this for years. I have been working out the exact mechanism of how this happens. Not much research in this specific area, for sure. Especially, “the incidence of sleep disordered breathing could be even higher than usually estimated because when bruxing is successful at reopening the airway, it isn’t counted in your AHI. This is so true from what I see and most people are not aware of this possibility. Also, sleep bruxism/clenching is not always recorded, or the electrode(s) is placed on wrong muscle. Thank you for sharing this observation.
Graham Stoney · January 26, 2021 at 5:16 PM
I think it was Dr. Felix Liao, author of 6 Foot Tiger, 3 Foot Cage speaking at the Vivos Breathing Wellness Conference. He’s very clear that bruxism is a usually-overlooked symptom of sleep disordered breathing. The video has since been removed from the Vivos Therapeutic Vimeo Channel, so if anyone from Vivos happens to read this: I get that Dr. Liao may be something of a competitor now but I think you’re doing your company a disservice when you host world-leading experts who advocate for DNA Appliance therapy, and then take their videos down from your channel when they go their own way. The fact you hosted the conference demonstrates that you guys are the leaders in the field; you’re shooting yourselves in the foot by not having videos of your competitors speaking favourably about you available.
Shannon · November 18, 2020 at 1:28 PM
I’m very curious how your journey goes as I just learned about this appliance and am excited about it. I will look forward to your updates.
Graham · November 18, 2020 at 1:37 PM
Thanks Shannon. Please subscribe to my newsletter and I’ll keep you updated on my progress. Cheers, Graham
John · October 18, 2020 at 11:40 AM
I was watching some of the Vivos videos with Dr. Singh and he fields a question at the end of his talk about myofunctional therapy and discusses its importance through out treatment around 1:27:00
He doesn’t give details about the exercises but says you should be doing the myofunctional exercises during the day.
Graham · October 19, 2020 at 2:08 AM
Interesting… thanks for this reminder John.
John · October 18, 2020 at 9:21 AM
Thanks. I’ll watch the video and try to incorporate the exercises into my routines. I’ve been doing these:
Graham · October 19, 2020 at 2:06 AM
Thanks John; I’ll check this out too.
Sean · October 1, 2020 at 1:23 AM
An excellent write-up of your findings. Very informative and helpful. The way you are able to dig and find answers reminds me of how my mind used to be able to work. It’s a catch-22 for TMD-OSA patients; we need answers, but we’re on a downward spiral of decline which impairs our ability to find them.
Graham · October 1, 2020 at 1:55 AM
I hear you Sean. I hope you find a solution that works for you. Cheers, Graham.
John · September 20, 2020 at 10:47 AM
Have you received and started using your DNA appliance? Wondering how its going so far..I had my impressions this week and they said 5-6 weeks before mine arrives
Graham · September 21, 2020 at 4:44 AM
Not yet; I’m expecting to pick it up on Wednesday. Let me know how yours goes!
John · October 17, 2020 at 8:24 AM
I got my DNA appliance yesterday. There’s no extension thingy on the back like on yours originally. The biggest issue I’m having is adjusting to the amount of saliva my mouth is producing with it in. I have to do a bunch of slurping because the upper appliance blocks my tongue. The dentist said this would go away after my body got used to it and didnt think it was food.
The other interesting thing was he said to get at least 10 hrs a day in. When I asked about the 16hr target Dr. Singh has stated, he indicated he felt like that wouldn’t be necessary.
Last night was pretty rough from a sleeping standpoint. I woke up at 12ish and didn’t get back to sleep until 2:30 or so because of the above problem and bc i was worrying about all kinds of stuff. Waking up in the middle of the night is normal for me at this point but I’m hoping this will be improved with the device and other efforts.
Graham · October 17, 2020 at 8:50 AM
I get a lot of salivation too, but I use it to practise proper tongue posture during swallowing rather than slurping. If I can get my tongue to push up against the appliance when I swallow, it should help train proper tongue posture for when I remove the appliance. I don’t know where your dentist got the idea that 10 hrs is OK from. I consistently see the 16 hrs that Dr Singh quotes repeated. My dentist said to aim for 14-16, but 14 is clearly a compromise and don’t want to compromise on my health. You find my post about the optimal daytime usage pattern helpful. I get a lot of anxiety because of my sleep apnea and some childhood issues I’m working through, so I found it a bit hard to sleep last night too.
John · October 17, 2020 at 9:01 AM
Yeah I’m definitely going to shoot for 16 hrs. I don’t want this to drag on extra months. My schedule actually works out pretty well for a 4pm to 8am wear time with a long commute.
There has also been talk about tongue exercises with the appliance, but they didn’t give me any written instructions or details. So I’m not sure whether its just “mewing” with the appliance in or myofunctional tongue exercises with the appliance out. Do you know of any DNA specific tongue exercises or what direction to press on the appliance with the tongue? Or should I just do like you say and try to practice proper tongue swallowing with it in.
One thing that gave me confidence this morning was that after I removed the appliance, I actually felt like something was different and wider in my upper teeth. I don’t know if its a placebo effect or not, but it felt good.
Graham · October 18, 2020 at 7:57 AM
I attempt to practice proper tongue posture with the device in, particularly during swallowing. I don’t mew hard because I don’t want undue pressure on the appliance, but I do try to maintain the basic good oral posture of mewing. I haven’t had any formal myofunctional therapy yet and don’t know of any DNA-specific tongue exercises, but there are some tongue exercises in this Sleep Apnea Exercise Training video that you might enjoy.
G · January 29, 2021 at 4:00 PM
You both are right. Slurping is one of the techniques promoted when using DNA appliances. This increases epigenetic signaling throughout the maxillary arch as it vibrates the 3D axial springs. When the 3D axial springs are properly activated by the providing dentist, the vibration caused by slurping transmits epigenetic signaling successfully. So, taking advantage of the initial adjustment period 2-3 weeks when hyper-salivation occurs is advantageous. As the adjustment period ends, there is less opportunity to slurp as salivation will decrease. As for hyper-salivation, there are multiple theories. Yes, the longer the wear, the better it is. But some providers are more realistic than others as many patients are not compliant or unable to be compliant for 16 hours wear due to types of occupation they have or other inevitable important issues. For oral myofunctional therapy, you want to make sure that it is done during the day with or without (if unable to use during the day) the appliance. It can also be done at night, especially before falling asleep. But, if you remember that this is therapy to get better and become free of machines and devices. You have to plan for days without plastic in the mouth unless you want to be married to an appliance for the rest of your life or get addicted to it. So, intermittent neuromapping without the device is especially important during the treatment. This can be done throughout the day when not wearing the device. You want to avoid the brain mapping the arch surface to include the hunk of plastic perpetually and start to make room for it. So, the point is, be aggressive with daytime oral myofunctional therapy and tell the brain where the palatal surface is and where the tongue is. Let the two surfaces communicate so that the brain has an accurate anatomical image of the palate and the tongue surfaces. This also can hold the epigenetic gain achieved during the night by successfully occupying the space and holding in shape.”Cave” exercise is good for this upon waking in the morning and throughout the day. In cave position, you want to push the palatal arch during the day (not the teeth, the palate), and in the evening and night, you want to create suction in the palatal arch so that the tongue will be comfortable going there, and make the palate a comfortable resting place. The tongue should attain the ability to stay there with a built-in vacuum and suction pressure so that this will be your nightly posture when the treatment is over.