Warning To Parents On The Potential Risks Of Orthodontic Treatment

When I was 13 years old, I had orthodontic treatment to correct my crowded teeth which involved removing four otherwise healthy bicuspids and fitting metal braces which pulled my front teeth backwards to close the resulting gaps and straighten my remaining teeth. This routine process involving premolar extraction and retraction orthodontics (PER) contributed to me developing obstructive sleep apnea (OSA) by further reducing tongue space in my already undersized mouth with the result that my tongue is forced backwards into my airway during sleep.

Obstructive sleep apnea has had a devastating impact on my life, and the orthodontic treatment I was subjected to as a teenager is one contributing factor. Proper bone development relies in forces from surrounding muscles, and in the case of jaw bones this force is generated by chewing the tough foods our ancestors ate. The overly soft diet we feed modern children means most kids have underdeveloped jaws causing crowded teeth. Weston A. Price had documented the link between the modern diet and malocclusion in his book Nutrition and Physical Degeneration in 1939, yet many orthodontists in the 1980’s still falsely believed that the cause was genetic, and PER was routinely offered as the standard of care treatment. Some orthodontists still practice it routinely even today.

Orthognathic surgeons refer to PER is as “camouflage orthodontics” because it hides one of the most obvious signs that a child may be at risk of developing a sleep breathing disorder and doesn’t address the underlying problem of underdeveloped jaws that causes crowded teeth in the first place. While orthodontists don’t cause crowded teeth, they do have an opportunity to correct the underlying developmental problem before it fully manifests by using expansion techniques which provide sufficient space for retaining healthy teeth, improve the patient’s airway, and reduce or eliminate the risk of them developing OSA. They can also educate parents on the importance of nasal breathing, proper tongue posture and a chewy diet for further craniofacial development.

Despite the experience of many patients who end up requiring orthognathic surgery to restore their airway, many in the orthodontic profession still deny the association between PER and OSA. They don’t see patients coming back to them complaining that they developed OSA as a result of the treatment because the symptoms of OSA often don’t occur until middle age when the loss of muscle tone in the patient’s airway becomes the straw that breaks the camel’s back. OSA is a complex and multi-factorial problem, and even my sleep specialist didn’t recognise the connection between adult OSA, infant and children’s diets, and teenage orthodontics.

By the time I realised why I was so tired all the time, got diagnosed with OSA, looked for an underlying cause and discovered the connection to the orthodontic treatment I had 35 years prior, my orthodontist had retired. He’s probably dead by now. The feedback loop is simply too long for those in the profession who practise PER to get the message that it damages their patient’s airway and long-term health. Astonishingly, no long-term randomised controlled trials have been conducted to verify that PER orthodontics is safe and effective, and does not contribute to health problems such as OSA. Instead, orthodontists who practise the procedure rely on a flawed statistical study to justify their false belief that PER does not contribute to OSA.

The long-term consequences of PER compared to expansion treatment haven’t been studied scientifically due to the challenges such a study would face. As William Proffit writes in his textbook Contemporary Orthodontics (2013, p 13):

“Unfortunately, randomized trials cannot be used in many situations for ethical or practical reasons. For instance, a randomized trial of extraction versus nonextraction orthodontic treatment would encounter ethical concerns, would be very difficult and expensive to organize and manage if ethical difficulties could be overcome, and would require following patients for many years to evaluate long-term outcomes.”

PER is a lucrative procedure for orthodontists who practice it, so they are reluctant to give it up. Extracting teeth and fitting braces is quicker than using expansion appliances so they can treat more patients, and is cheaper so it is easier to sell to naive parents. If parents were told the downside risk of their child developing OSA after PER treatment though, they would be more willing to spend the extra money on having them treated with an expansion approach that will correct the underlying problem and avoid the need for jaw surgery or CPAP later. With the financial incentive compromising the orthodontic professions objectivity, most parents aren’t told of the risk, but there is still plenty of money to be made in orthodontics by treating patients with expansion techniques. It doesn’t need to be a profession which continues to prey on vulnerable children by extracting healthy teeth based on a flawed premise.

13 year old children aren’t in a position to give informed consent, and when an orthodontist is in denial or simply not forthcoming about the risk of OSA associated with PER treatment, the duty of care falls on the parent to make an informed decision about a treatment that can compromise their child’s airway and potentially lead to them developing OSA and all the devastating health problems associated with it in later life. Karin Badt has written an excellent and well-researched article describing the risks of premolar extraction/retraction orthodontics to help counter the belligerence of some in the orthodontic profession who deny the damage PER does and continue to practice it. If you are a parent whose child has crooked teeth, I implore you to read this article before deciding on the treatment to give them: Extracting Premolar Teeth for Orthodontic Treatment: The Risks