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722: How Airway, Jaw Joints, & Autonomic Nervous System Issues Are Creating Today’s Orthodontic Patients – Dr. Drew McDonald

Today, orthodontics goes beyond just straight teeth. With better technology and better imaging, we can now include joints and airway for more comprehensive care. To highlight the importance of imaging in the future of orthodontics, Kirk Behrendt brings back Dr. Drew McDonald, instructor from the Chicago Study Club, who explains how it leads to better outcomes, especially for Class II patients. Stop going in blind into orthodontic cases! To learn how imaging drives treatment and what you could be missing without it, listen to Episode 722 of The Best Practices Show!

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Main Takeaways:

  • Imaging drives treatment.
  • Never go into orthodontic cases blindly.
  • Orthodontics is more than about straight teeth.
  • Rethink symptoms you consider “incidental” findings.
  • Dentists and other specialists can't treat these patients alone.
  • Always do imaging before sending patients to the orthodontist.

Quotes:

“How we breathe, especially breathing through your nose versus through your mouth, really does affect your facial growth when you're young and growing. If you have nasal issues, sinus issues, or general problems with nasal breathing, we see maxillas don't grow properly. We see narrow maxillas. We see poor tongue posture, which can influence other growth, especially in the lower face. So, it's no coincidence that these orthodontic patients who have a crowding of their teeth and narrow jaws have nasal issues, and we're treating them as an incidental finding. That's not an incidental finding. That is a correlational finding. We 100% see these things and they are certainly part of what's driving that patient to be in our orthodontic chair.” (8:16—9:02)

“Us as orthodontists, if we take a CBCT at full volume and think, ‘We're going to correct that Class II mandible,’ or that retrognathic mandible, and all of a sudden we see joints that are flattened or not growing well, that is not just an incidental finding. That's part of what we have to treat in this patient. We cannot overlook the airway. We can't overlook the joints because what we also know from literature is that whenever you have a jaw joint issue, specifically a disc displacement in a young growing child, the mandible does not grow on that side. And if it's a bilateral disc displacement, the mandible doesn't grow on both sides, and we get a big Class II.” (9:21—10:02)

“As orthodontists, what is our whole world? At my private practice, I'd say 70% of my patients are Class II of some variety. They're either really deep overbite, overjet, or one side is asymmetric more than the other. And what I see over and over again on the MRIs that I take — not just CBCTs, but the MRIs that I take after I see a jaw joint issue on the CBCT — is that the discs are off and they're not protecting the growth center of the condyle. So, again, is this an incidental finding? No. This is part of why this patient has this bite. Those jaw joint issues cannot just be chalked up to, ‘Oh, it's an incidental finding. We'll refer to somebody else.’ We, as orthodontists, have to understand what we just saw. We also know how to take the next step, which is that if we see it on a CBCT, then the next step is we need soft tissue imaging, which is the MRI of the joint.” (10:03—10:59)

“This is common. These jaw joint issues, this disc displacement, this lack of growth of the mandible, is not something we can hide behind. And as orthodontists, if we encounter a disc that's displaced — and let's just say two scenarios play out, one of which is that the disc does not get back over the top of the condyle. Are we going to be able to help this patient grow? Absolutely not. There are very good studies that are recent and old that show that when the disc is off and you try and help that patient grow with a Herbst, a Twin Block, or some functional appliance, they actually get worse.” (11:19—11:56)

“As orthodontists, we cannot go blindly into these orthodontic cases — especially when such a population of our everyday orthodontic patients are Class II. And so, whenever you see a Class II, we have to know, is this a joint patient? How much of a joint patient is it? And the answer, sadly, is often way too much. It's scary under there. There are jaw joint issues lurking in these Class II patients, so we have to know what to do. And so, I can't say this enough. That's not an incidental finding anymore. That is 100% part of this patient, and it needs to be 100% part of how we treat the patient based off what we saw in the imaging.” (12:44—13:27)

“The stunting of our growth as a profession is that especially the loudest voices in orthodontic communities right now are very anti [joints and airway] because they weren't taught this. And this is just me personally, but I also believe it's a lot of, ‘Well, do we really want to be responsible for this if we learn about it?’ because now our world just got way harder.” (13:52—14:17)

“As a GP, what would be very helpful is if you recognize the signs of an airway issue or a jaw joint issue in your patient at their hygiene check. And if you order the necessary imaging with CBCT — and hopefully an MRI — that makes the communication with your orthodontist so much better because, for one, it's not a barrier anymore because the orthodontist is not — most offices are not geared to do the CBCT and the MRI. But as a general practitioner, if you have that focus, that's even better because now your referral comes to me as the orthodontist saying the CBCT showed they have significant airway issues. It also showed they have jaw joint degeneration or a lack of growth here. And, by the way, their MRI shows that they have disc displacement. Whether it's reducing or non-reducing, we need to land this plane with these things in mind, because if all we're trying to do is straighten the teeth but we didn't expand the maxilla to help with the nasal breathing, or if we didn't help the mandible grow forward to help with the pharyngeal airway, or if we land the bite in a spot that's off the disc where it could be under the disc, those are all very important things that — as an orthodontist, I would love to know that and not have to do the imaging myself.” (16:50—18:11)

“As an orthodontist, our world gets much easier if that [imaging] work is done ahead of time. And it becomes a collaborative approach to orthodontics in this patient's occlusion because you, as the general practitioner, me as the orthodontist, probably some other people like myofunctional therapists or other people that are part of the team, we all know what we're treating now and it's not just “straighten the teeth”. The goal is much bigger. Let's help this patient on a bigger level with potentially airway, joints, and the whole system working where it should be.” (18:19—18:51)

“Dr. Mark Piper is the first person I ever heard say this, and ever since I heard him and saw what he was talking about, it changed my look on so many things with growth of kids and also with pain. Sadly, the pain part is the end stage — and I want to get them when it's just a growth issue, as an orthodontist. But essentially, what I see over, and over, and over again is that when we have upper cervicals off, especially C1, C1 does not move freely back into place. If C1 is out and continues to put pressure on that nervous system on one side over, and over, and over again, what I see is we get bad facial development on that side. We have tighter muscles, we have tighter muscle pull, we have less nutrients going to one side of our skeleton in our muscles. And I see asymmetric faces, especially the midface. Not just the mandible, but the midface gets very, very asymmetric in this type of situation.” (22:41—23:37)

“I just had a patient last week that was three-and-a-half years old, referred for an airway issue. His neck was terrible. If we don't get to the heart of his issues at three-and-a-half — he had big tonsils, adenoids. Of course, we're going to work on that. The other things are structurally expanding. But if his nervous system doesn't get corrected, this kid is not going to sleep well, he's not going to grow well, and it's going to be more and more trouble.” (23:38—24:05)

“How does our airway drive our sympathetic nervous system? Dr. Jeff Rouse talks about this all the time that if we're not breathing well, if our body is starving for oxygen, we flip into stress mode. So, classically, whenever we have mouth-breathing kids or adults, or patients with very small pharyngeal airways, they're not getting oxygen. And those patients don't sleep well because our body is in fight-or-flight. We need oxygen. We're going to fire away our sympathetic so that our heart rate picks up and we pump more blood with more oxygen to our body to make up for this. And also, we're going to essentially come out of normal rest because, as humans, our natural drive is to get oxygen and we have to wake ourselves up sometimes to do that. And so, if your sympathetics are firing because of an airway issue, especially at nighttime when you should be sleeping, there's no way you're getting good sleep. It's like drinking ten cups of coffee and trying to fall asleep and stay asleep. It just doesn't work. And so, from an autonomic standpoint, things that can drive up our autonomics are our airway, injuries to our upper cervical, and the newest foray is our diet. And not newest — that's been understood for a long time. But if we have issues with foods, if we have sensitivities to foods, if we have gut microbiome imbalances, that gut-brain situation fires away too. So, we have multiple sources of gasoline on this fire in terms of the sympathetics. What picks it up is a lot of things. And if that's firing away in ways it shouldn't be, especially in the head and neck area, we're going to see growth issues, we're going to see muscle tightness, we're going to see sleep issues — all of it. So, 100%, we have to know what we're looking at. And a lot of times, the CBCT shows us those things too.” (24:12—26:08)

“Every patient that comes into my office, we have done for a while, especially at the new office, sleep screenings. We do basically, not the Oura Ring, but I was doing a different device there for a while that I would have kids wear for at least two nights, if not three. And good lord, you've never seen worse sleep on the youngest of kids who need the most sleep. Their brain development, their overall growth — if they're not sleeping well, they're not growing. And you see it. It's so sad because you see it present in two different ways, often. One is the kid that's tiny for their age or is very, very skinny — kind of looks like they can't put on weight. And sadly, the other side is that the kids — and there's lots and lots of research that correlates pediatric sleep apnea to obesity. And so, sadly, the two situations come up very often in today's orthodontic patients, especially the young kids. If we can be part of helping recognize more than just a teeth problem for our patients and steering them in referring or working collaboratively with other practitioners to help this all get better, we've done a much bigger job than what we thought we should have done.” (27:08—28:21)

“My good friend Dr. David Manzanares, who is a dentist in Albuquerque, took me to the study club. That weekend changed my life. It changed how I practice. It changed everything because I could not stop seeing joint issues, at the end of the day, on all of the scans. And I was somebody who had a 3D X-ray in my office, but I would take it very limited. I would take it only to, ‘Oh, yeah. We've got an impacted cuspid. I should probably see where that is in 3D. But are you okay with me taking a 3D X-ray?’ was kind of my conversation. I wasn't confident with it because I wasn't taught it. And then, as soon as I saw that, I was like, ‘Why am I not taking full volume on every patient?’ because all of these issues need to be assessed.” (30:34—31:17)

“We have responsibility as dentists and practitioners for limiting radiation. But with today's technologies, if you take a pano and a lateral ceph, and even a frontal ceph, you've got more radiation in those three, two-dimensional images than you do in just one spin at the light mode of a 3D X-ray. And so, I feel like we can stop with that argument that we're being irresponsible by taking 3D X-rays because the technologies we now have available are less than most 2D imaging systems that are still around — at least the convergence of how many images we had to take to look at certain things.” (31:20—32:00)

“The airway stuff, I was seeing that already on two-dimensional images. You can see, even on a pano, if the nose is blocked. But ultimately, 3D X-rays show us how much and, does this patient need ENT involved in their life? Do they need other supportive therapies? I haven't even talked about tongue-ties yet. Good lord, that's a huge part of our life, at this point. But ultimately, the imaging drives the treatment and, ultimately, we have to have a good, sound diagnosis to make good decisions.” (33:19—33:53)

“We all speak imaging. I know that sounds funny, but the common denominator of everybody who is treating these patients is, when you see something on an image, that's a black-and-white truth right in front of you. And as soon as everyone sees those and shares those together, we know what we're dealing with. We're not guessing and going off of symptoms. We're going off of hard pictures in front of us. And so, for me, back to communication, every time I take a 3D X-ray and I put it into my presentation that I show the patients, they see it, their dentist sees it, anybody else I'm referring that patient to, whether it's a surgeon, myofunctional therapist, whoever — we all need to see these images for our patients to understand what are we really treating.” (33:55—34:39)

“Our world, as orthodontists, is so much bigger than teeth. We also need to understand what piece we play and also what responsibility other people as part of the team have too. Because again, we can't do this alone. The people we work with can't do it alone too.” (36:00—36:17)

“When we see, as an orthodontist, a malocclusion, we need to start looking at how deep does this rabbit hole go, and who else needs to be involved. And one of the easiest ways that we can start that conversation with our team, and also with the patient, is with the imaging.” (36:54—37:10)

“You become a quarterback when you take the imaging, whether you're an orthodontist or a GP. But really, the bottom line from today is that our world is way deeper than the surface, and we have to feel comfortable living under the surface here because it's a little rough down there. But if you know how to navigate it, we're going to be safe, we're going to do good treatment, and we're going to help people.” (37:45—38:05)

Snippets:

0:00 Introduction.

4:14 Why this is an important topic.

6:06 Nothing is an “incidental” finding.

13:32 The need to evolve as a profession.

15:38 GPs are the front line.

20:17 Autonomic nervous system issues, explained.

26:09 The importance of sleep on growth.

28:33 Imaging drives treatment.

35:35 Final thoughts.

38:16 About Chicago Study Club and Pediatric TMJ Study Club.

Dr. Drew McDonald Bio:

Dr. Drew McDonald is a board-certified orthodontic specialist with a strong focus on airway and temporomandibular joint-focused treatment planning, surgically facilitated orthodontic treatment, and providing complex interdisciplinary care for patients. He lectures internationally on these topics and has contributed to literature and textbooks in these areas. He is dedicated to advancing the profession of orthodontics and dentistry as a whole.

Born and raised in Tucson, Arizona, Dr. McDonald’s love of baseball brought him to Albuquerque, New Mexico, where he played as a catcher for the Lobos from 2006 to 2008. While attending the University of New Mexico, he met his wife, Emily, a New Mexico native. He also fell in love with the Sandias, green chile, and the near-perfect weather. He graduated from the University of New Mexico in 2008 with a Bachelor of Science degree in biology and a minor in chemistry.

Dr. McDonald attended dental school at the prestigious Creighton University in Omaha, Nebraska. Known for its rigorous academic curriculum and intense clinical training, he received many academic accolades while at Creighton, including inductions into Omicron Kappa Upsilon (National Dental Honor Society) and Alpha Sigma Nu (Honor Society of Jesuit Universities). He also served in leadership positions as class president and student body president, and on alumni relations committees.

After graduating cum laude from Creighton, Dr. McDonald was accepted as one of only three residents nationwide into the University of Missouri-Kansas City Orthodontics program, a renowned two-and-a-half-year, full-time residency known for its clinical excellence. He graduated in December of 2016 with his certificate in orthodontics and master’s degree in Oral and Craniofacial Sciences.

When away from the office, Dr. McDonald is a “girl-Dad” to two daughters, a self-proclaimed grill master, and minimally talented yet enthusiastic golfer. You can find him taking in a Lobos game and spending time outdoors with his family. 
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