The Good, Bad, & Ugly of the AAO White Paper Update on SDB and Orthodontics [Ep.156]
The DOC PodcastShow Notes
In this episode, Dr. Mike breaks down the 2024 update to the 2019 AAO White Paper on obstructive sleep apnea and orthodontics, published in the AJODO in April. After presenting to hundreds of medical, dental, and myofunctional therapy colleagues across the country, he recorded his full presentation for listeners worldwide. Timestamps 0:00 – Introduction, episode overview & why Dr. Mike recorded this presentation 1:17 – Context: Presenting across the U.S. (Houston, Bronx, Long Island) — the near-universal reaction was shock at the document's flaws 3:07 – THE GOOD begins 3:07 – Good #1: Acknowledges the full spectrum of sleep-disordered breathing (SDB), not just OSA 3:55 – Good #2 & #3: Calls on orthodontists to screen all pediatric patients for SDB, emphasizes early detection, and acknowledges multifactorial etiology requiring interdisciplinary care 5:07 – THE BAD begins 5:07 – Bad #1–2: Author panel was 8 orthodontists + 1 librarian (no physicians, no myofunctional therapists); document inconsistently uses "OSA" vs. "SDB" throughout 8:03 – Bad #3–5: Minimal screening guidance (32 signs & symptoms largely ignored); only briefly mentions comorbidities; never discusses the importance of nasal breathing 13:00 – Bad #6: Overall focus is on what not to do rather than guiding orthodontists on how to help patients 14:00 – THE UGLY begins 15:01 – Ugly #1: Reliance on PSG-confirmed OSA to justify intervention — challenges with pediatric sleep studies (access, sensitivity, first-night effect, lack of standardization); what Reference 34 actually says vs. how it was cited 22:40 – Patient case study: Child with AHI of zero but severe signs of airway disease — the ENT said "what does the orthodontist know about sleep medicine?" 26:34 – Ugly #2: "No way to determine if a patient is a mouth breather" — justified by a study of 9 adults on a cycle ergometer; Dr. Kandasamy's 2025 AJODO editorial; what the actual research shows (European OJ, AHA, ADHD literature, microbiome) 36:51 – Ugly #3: "No craniofacial phenotypes can identify SDB" — directly contradicted by Reference 34 and the original 2019 white paper; Harvold primate studies, Hew et al. (2011), Principato's tongue mechanics explained 43:03 – Ugly #4: "Most children with SDB will outgrow it" — both cited references (Refs 17 & 18) actually contradict this claim; cardiovascular, neurocognitive, and ADHD consequences of waiting 53:03 – Ugly #5: "CBCT has no diagnostic value for SDB" — contradicted by Reference 34; what CBCT can detect; the radiation argument debunked 57:29 – Ugly #6: Must refer to a physician for diagnosis before any intervention — ignores lack of access to pediatric sleep physicians; a formal diagnosis does not change the orthodontist's treatment plan for normalizing craniofacial growth 1:00:00 – Ugly #7: Misleading analysis of tongue tie (ankyloglossia) and PSDB — references were miscited; what the scoping review (1,228+ patients) and 2026 systematic review actually concluded 1:07:27 – The evidence-based medicine argument: what David Sackett (founder of EBM) actually said — and how Class I occlusion, ceph norms, clear aligners, and IPR are held to a different standard than airway treatment 1:19:20 – Ugly #8: "Orthodontic extractions have no impact on airway" — the Larson article debunked (patients didn't even necessarily have orthodontic treatment); extractions treat the symptom and ignore the underlying etiology 1:28:20 – Path forward: "Straight teeth bias," the need for a paradigm shift, and the vision for a profession that creates both beautiful smiles and healthy nasal breathers Resources Mentioned AAO White Paper Update: Sleep-Disordered Breathing in Orthodontics (https://www.ajodo.org/article/S0889-5406(26)00035-1/fulltext) Dr. Mike's OrthoTown article: Defining Evidence-Based Orthodontics (https://www.orthotown.com/magazine/article/9835/defining-evidence-based-orthodontics?fbclid=IwY2xjawP14fxleHRuA2FlbQIxMABicmlkETFrVWE3M3EwYWJTRWpEdENTc3J0YwZhcHBfaWQQMjIyMDM5MTc4O
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