Transcript Greater NY Dental Meeting November 29, 2004

Thank you for attending my presentation on this hitherto never-addressed, highly
controversial subject: Orthodontic Jaw Wiring for the control of compulsive
overeating--or simply O-J-W.
OJW is treatment modality for carefully selected patients who are obese or heading
toward obesity that can help them start regaining control over their compulsive eating
habits with their potentially grave consequences.
At the outset OJW may seem extreme. However, in my experience, I can say with
confidence that it is a benign, non-invasive, alternative method for controlling weight.
Having provided OJW for more than 10 year I can testify unequivocally that it is
both safe and effective, especially when performed under the protocol I am presenting.
Under this protocol, the DOCTOR is responsible for maintaining the health of the
TMJ, Dentition and Gingiva.
The PATIENT is responsible for losing weight by dint of their passionate dedication
and adherence to a long-term, low-calorie, liquid diet.
On the following page you will also find a hyperlink to an E-handout; it contains the
documents I am going to refer to and other highly relevant information. .
1
DrTed . Com
E-Synopsis at:
drted.com/AAO OJW Synopsis.htm
Overview handout at entrance
2
Presented at the 110th meeting
American Association of
Orthodontists
Washington, DC May 3, 2010
Ted Rothstein, DDS PhD
Life-Active member AAO
Brooklyn, New York
Drted35 @ aol . com
Drted . com
3
A Protocol for Providing
Orthodontic Jaw Wiring for Control
of Obesity:
A New Role for Dental Professionals
4
Orthodontic Jaw Wiring
Table Clinics Presented:
AAO: Las Vegas, NV -- May 7, 2006
6th International Orthodontic Congress:
Paris, France -- September 12, 2005
AAO: San Francisco, CA -- May 22, 2005
ADA: Philadelphia, PA -- October 8, 2005
Greater NY Dental Meeting:
New York, NY -- November 29, 2004
5
Thank you for attending
Write Your Questions
Add an email address
Pass them forward
Enjoy the show
6
"All progress has
resulted from people
who took unpopular
positions."
-- Adlai E. Stevenson
7
We can provide a
service to help the obese
As caretakers of the mouth we are
uniquely empowered with skills and
mechano-therapies to provide services
to the overweight. Indeed, it is
our responsibility as part of a health
care team to provide our expertise
to the overweight heading towards
obesity: Orthodontic Jaw Wiring (OJW)
8
What does OJW entail?
OJW requires a careful selection of patients who are obese,
(as diagnosed by their physician), and who will provide you
with a medical-dental history and an Informed Consent (as well
as a release from their physician to begin a long-term, lowcalorie liquid diet). It requires the patient to choose a weight
goal, and that you wire their jaws apart providing an
interocclusal laxity of about 2-3mm in all directions – a position
in which they will remain for 5 weeks -- until they release the
wiring for 5 days and return to your office for examination, and
rewiring. This alternating wiring-rest-rewiring method is
repeated until the patient achieves their weight goal, or
requests that you remove the appliance.
9
Rationale for OJW
When safety, effectiveness, side effects
and mortality rate are taken into
consideration OJW will be seen as a
non-invasive conservative approach to
weight control.
My experience providing OJW has
shown that it is a safe and effective
method to help selected patients regain
control of their weight.
10
Evolution: Hyperphagimas Compulsivis
Obesity is legion and epidemic and recognized as a precursor to
a host of serious illnesses and other co-morbidities which attend it,
many of which have oral manifestations and grave consequences.
OJW is a fixed appliance and method we dental practitioners
can provide that can help selected patients regain control over
their excessive eating habits.
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30 Diseases and Side Effects of Obesity
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
type 2 diabetes (afflicts one in three Americans)
hypertension
depression
sleep apnea (snoring)
stroke
knee and hip joint dysfunction
coronary heart disease
gall bladder disease
liver disease
osteoarthritis
some cancers - colon, endometrial,
post-menopausal breast cancer
menstrual irregularities
polycystic ovary syndrome
infertility
pulmonary dysfunction
12
30 Diseases and Side Effects of Obesity
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
gestational diabetes
Post-surgical mandibular advancement
low-back pain
increased risk of anesthetic complications
carpal tunnel syndrome
venous insufficiency
deep vein thrombosis
poor wound healing
psychosocial problems
osteoporosis
- obesity is protective
stress incontinence and leaking urine
prolapse
esophageal reflux
constipation
tiredness
13
How is
Overweight / Obesity
measured ?
“Body Mass Index”
BMI
Weight (Kgs) / Height (Mters)2
14
BMI: 18-24 = Normal
BMI: 25-29 = Overweight
BMI: 30-35 = Obese Class I
M5’10”/240; F5’4”/200 = (BMI 34)
BMI: 35-39 = Obese Class 2
BMI: 40+ = Morbid Obesity
15
CONSIDER:
2009: Normal life expectancy US
Males 75.4 -- Females 80.7
The life expectancy for the
chronically Overweight / Obese
is: three to five years less
16
WHY CHOOSE OJW?
COMPULSIVE OVER-EATERS BEGIN TO
FEAR they have lost all control of their ability to
eat sensibly. In their minds they have failed at all
the methods of losing weight they have tried,
and they are depressed. They see OJW as an
approach which is more aggressive than fad
diets and less menacing than weight control
using pharmaceuticals with their sometimes
unknown and unpredictable side effects.
Moreover, the thought of surgical intervention-be it liposuction, lap-band or bariatric surgery,
horrifies them.
17
THE ANTECEDENTS OF
ORTHODONTIC JAW WIRING:
IVY LOOPS
First used by oral surgeons for
inter-maxillary fixation
The patient was placed under
general anesthesia since the wire
had to be threaded between the
teeth (and sometimes the gums as
well).
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19
OJW: The appliance
Brackets are bonded
bilaterally
Jaws methodically
wired apart :
2.0mm to 4.0mm
using .012” -.014”
deadsoft wire
20
Note the interocclusal
separation of 2-3mm-approximating the
physiologic rest position
in which the mandible is
“weightless”
21
Is Orthodontic Jaw Wiring
a service within
the scope of dentistry?
See E-handout
www.drted.com/AAO OJW Scope of
dentistry.htm
22
Following is a direct quote provided by
Dr. Milton Lawney, the Executive
Secretary of the State Board of
Dentistry, given to Dr. Rothstein on
Thursday, October 14, 2004 in answer
to the preceding question:
[Interpretation of NY State Article 133, §
6601 as it relates to the practice of dentistry,
and to the dentist who chooses to provide
OJW to patients who meet the selection
criteria.]
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“…It is not within the scope of
dentistry to diagnose and treat
independently the condition of
obesity. Dental appliances aimed
at weight loss may be prescribed
if the condition is diagnosed by
the proper authority.” -- Interpretation of
Article 133 § 6601 – Dr. ML.
………………………………………………………………………………………………………………………………………………………………………………………………….
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The Diagnosis of Obesity
Can be made only by the
patient’s physician. Moreover,
the provider must include in
the OJW patient’s record a note
from their physician stating
that the patient may begin a
long-term, low-calorie liquid
diet.
25
JAW WIRING: THE PAST
1. Weight loss was an accidental by-product of
inter-maxillary fixation
2. No protocol for providing the service was extant
3. Jaws were wired tightly together with no thought to
TMJ stiffening or clarity of speech
4. The inter-maxillary wiring process was primitive
5. The dental professional’s role was nebulous
6. The concept of the dental professional as part of a
health care team in controlling overweight was
non-existent
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OJW TODAY
1. The jaws are wired apart via orthodontic brackets
bonded to the premolars and canines in a “weightless”
position (the physiologic rest position)
2. A robust informed consent was developed
3. Criteria for patient selection were established
4. A protocol to address the possibility of TMJ stiffening
over time was developed and applied to 100+ patients
5. A research survey to assess safety and effectiveness
was carried out
cont.
27
6. … And that the provider’s responsibility
is limited to maintaining the health of the
TMJ, dentition and gingiva.
7. While the patient is solely responsible for
losing weight by dint of their passionate
dedication and adherence to a long-term,
low-calorie liquid diet.
Choosing patients to provide OJW
begins with information obtained
primarily from the Informed Consent
and the patient’s medical – dental
history. It allows the provider to have
a profile of all the important
information needed to know about a
would-be patient’s health, present
weight, their weight goals and the
time they would “dedicate
passionately” to being wired.
29
The Informed Consent
is reproduced at:
drted.com/AAO OJW Synopsis.htm
30
OJW SAFETY AND
EFFECTIVENESS
QUESTIONNAIRE SURVEY
COMPLETED IN 2009:
Refer to your E-Synopsis
31
OJW SAFETY AND
EFFECTIVENESS
Responses to questions: 21, 58, 63, 66
32
Question 21
My choice below represents how I feel
about OJW for the control of weight in
compulsive overeating:
OJW is both safe and effective. 70%
OJW is safe but not effective. 5%
OJW is neither safe nor effective. 10%
OJW is effective but not safe. 15%
33
Question 58
Given that vomiting could lead to the
taking of vomit back into your airway
leading to effects ranging from choking
and possibly to death, please state
your position(s) from the list below.
34
Response to 58
55.6% The Informed Consent I filled out told
me all I needed to know.
44.4% I was warned of that so I carried my wire
clippers with me at all times.
38.9% It's possible but highly unlikely.
27.8% I carefully researched that possibility
and found no instance of its occurrence.
22.2% The risk of death from surgery bothers me more.
22.2% You can die from some diet pills as well.
50.0% All of the above.
35
Safety of Jaw wiring / OJW
Conservatively speaking more than
35,000 people have their jaws wired for
trauma or pathology annually. I have
not been able to unearth a single case
of grave harm coming to any patient
whose jaws were wired by an oral
surgeon. The protocol I formulated for
OJW, further enhances the safety of
providing this service.
36
Question 63
Why did you choose the OJW
method to begin with?
37
Response to 63
78.9% My being overweight was causing me to be
depressed.
68.4% I felt this approach might help me bring my
compulsive overeating under control.
63.2% I realized that my excessive weight could have
serious health-related consequences.
57.9% I was finally able to locate a dental professional
who would provide the service.
52.6% Previous methods were ineffective for me.
52.6% I just didn't like the way I looked.
31.6% I dreaded the thought of gastric-bypass surgery
31.6% Taking over-the-counter pharmaceuticals seemed
too risky (side effects).
26.3% My physician recommended I lose weight.
21.1% All or most of the above.
15.8% I heard about it from a friend.
38
Question 66
Do you believe that it is the right and
responsibility for dental professionals to
provide this service to compulsive
overeaters?
YES 85%
39
CONSIDER:
OVERWEIGHT / OBESITY
IS EPIDEMIC
IN THE UNITED STATES.
40
Health care: $ 2.3 trillion industry in the US
14% of the health care budget
is allotted to controlling obesity…
41
CONSIDER:
…THE OJW SERVICE OFFERS
DENTAL PROFESSIONALS THE
OPPORTUNITY TO PARTICIPATE
SEAMLESSLY IN THIS SEGMENT
OF THE HEALTH INDUSTRY.
42
CONSIDER:
DENTAL PROFESSIONALS
ARE UNIQUELY EMPOWERED
TO PROVIDE OJW TO
PROPERLY SELECTED
CANDIDATES.
43
CONSIDER:
THE MORTALITY RATE FROM
BARIATRIC SURGERY IS
3/1000. IT IS NOT SURPRISING
THAT THE OVERWEIGHT ON
THEIR WAY TO OBESITY
WOULD CHOOSE OJW WERE
IT MORE WIDELY AVAILABLE.
44
PREVENT SURGICAL MORTALITY?
“If the ultimate effect of my work
was to help just one person avoid
having to undergo gastric bypass
surgery there is the possibility,
that is one in three-hundred
indeed, that this person did not
die.”
45
OJW: TWO CASES
drted.com/OJW Two Cases.htm
1. ALONE
2. WITH ORTHO TX
46
OJW protocol in brief
1. Provider receives an inquiry requesting OJW
2. Provider requests Informed Consent and MedicalDental forms
3. Provider agrees / declines to provide OJW
4. Provider establishes doctor-patient relationship by
telephone
5. At OJW appointment provider examines patient, takes
records and applies OJW and…
6. Gives patient the Reminders / Precautions Notice
7. Patient removes wiring every 5 weeks for 5 days and
returns to office for examination and rewiring, etc.
8. Upon achieving goal weight, or patient's request, the
appliance is removed
47
Implementation of the Protocol
www. drted . com / OJW Two Cases .
htm
48
1. Provider receives an email
inquiry requesting OJW
2. Provider responds with email
requesting a completed
Informed Consent and MedicalDental form
drted.com/AAO OJW Synopsis.htm
49
PROVIDER’S RESPONSE TO A WOULDBE OJW PATIENT’S INQUIRY:
•
•
•
•
1.
•
Dear would-be OJW patient:
IN BRIEF: Jaws are wired APART about this much |--| . Wires are to be
released every 5 weeks for 5 days to permit jaw joints to move fully
The number of OJW providers is small indeed: List of providers. I provide this
service with pleasure, and truly believe in it, having provided it to many
patients. I endeavor to constantly improve it. Here is the follow-up study I did to
see how my patients fared with their OJW:
http://www.drted.com/ojw_questionnaire_survey.htm . When you examine the
responses to the queries you will find by and large the respondees were most
pleased by their experience with OJW service I provided.
The OJW fee at present is $2685. It is a one-time non-refundable fee. This allinclusive fee includes maintenance of the appliance from placement to removal,
rewiring every 5 weeks until goals are met or patient requests the
OJW be removed; and 24/7 support and contact with the Dr. Rothstein. An initial
fee $685 twenty four hours in advance confirms the appointment and the balance
is due when the OJW is placed. Lacking the initial payment the appointment will
be cancelled.
If you are considering coming to my office in Brooklyn, New York then please
familiarize yourself with the information provided at:
http://www.drted.com/index.html.bak2/jaw_wiring.htm . If you are still interested
complete: The Informed Consent for OJW and email it to me, and then
download, complete and fax to me the two other documents requested on it.
When I receive all three I will call you. Complete the Informed Consent and 50
be
sure to sign/initial it in all four places requested.
Patient completes informed Consent requested
DIRECTIONS:
Carefully read the Informed Consent then fill in the data requested (*
information requested is mandatory). Place your initials/name in all places
requested and email the Informed Consent to [email protected]. Then just
below see hyperlinks to the "Adult Acquaintance" and "Adult Medical History"
forms. Download and complete BOTH forms and mail or fax them to the office
(fax 718 852 1894 evening best). When I have received ALL THREE
FORMS I will call you without further delay. With care, Dr. Ted Rothstein.
• Date: / / 2010
* Name:
* Age:
Date of birth: *
• Height:
* Present Weight:
* Goal
Weight:
(click on link)--->*Present Body Mass Index (BMI):
* Activity Level (Life style): (Circle one) inactive, mildly a., moderately a.,
very active
*Number of months you are initially willing to dedicate passionately to the
jaw wiring (OJW) approach to weight loss: 2 3 4 5 6 9 (3 months/ 21
pounds, assuming 5 pounds first week then 1.5 pounds each week
thereafter)
*Address:
*City:
*State:
* Zip:
*Occupation:
*Home Telephone:
*and Work Telephone (Other):
* and
Cell/ Mobile Telephone:
*Email Address: Dr. Ted will not contact you if you do not provide this
item.
* Your dentist's name:
Address:
* Telephone number:
51
• CONTINUED
3. Provider agrees / declines to provide
OJW based on information
noted in the Informed Consent and the
Medical-Dental forms
4. Provider establishes the doctorpatient relationship by telephone or at
consultation exam, and appoints
patient for OJW
52
5. Provider examines patient,
takes panoramic and photos and
applies OJW
drted . Com / OJW Two Cases . htm
53
OJW Alone
54
55
56
6. Patient is given
“Reminders
and Precautions
Notice”
57
Reminders and Precautions
•
•
•
•
•
•
•
•
•
Reminder 1. It is highly recommended to have your jaws wired properly, i.e., to
have the lower jaw placed and wired in the "semi-mobile rest position called
"Rothstein’s OJW rest position"©, which allows the jaw to move 2.5 millimeters
in all directions.
R2. When wired properly your upper and lower teeth do not touch.
R3. It is highly recommended to remain wired the entire 4-6 weeks and then
remain unwired for 4-6 days to allow your joint to recover from any stiffening it
may have suffered. METHODS AND INSTRUMENTS TO REMOVE THE WIRES
R4. The jaws must be exercised for at least 5 days.
R5. If the jaw joint feels stiff (pain on opening with 3 fingers inserted 1” into
mouth) wiring should be left off 5 more days or until the jaw joint no longer
feels stiff.
R6. Have your teeth, gums and jaw joint examined for any possible problems
that could be developing as result of the jaw wiring, ex. night grinding.
R7. Always carry your wire cutter and be aware of other instruments (a fork)
that could be useful to remove the wiring if an emergency suddenly developed.
R8. The first 10 days may be very difficult so read A.T.’s story (OJW directory:
item #2).
CONTINUED etc., etc
58
7. Patient removes wiring every
5 weeks for 5 days and returns
to office for examination and
rewiring
59
PROTOCOL FOR MAINTENANCE
OF TMJ HEALTH
JAWS ARE WIRED APART 2.0 mm-4.0
mm and released every five weeks for
five days to permit TMJ to recover from
any loss of mobility and rewired if
mobility is within normal limits.
60
Normal TMJ Mobility
61
OJW with Orthodontics
62
63
OJW using Unitek SmartClip
brackets and a variant of the
wiring pattern
64
Methods patients can use to
remove the intermaxillary wiring
65
66
WHAT ARE THE LEGAL AND
LIABILITY ISSUES?
THEY HAVE YET TO BE DEFINED.
YOU WILL NEED TO SPEAK TO
YOUR LIABILITY CARRIER AND
HAVE THEM ADDRESS THE RISK
ISSUES FROM THEIR POINT OF
VIEW.
67
Why provide OJW?
1. You believe that OJW is safe and
effective
2. You believe dentists are professional
health providers who can / should be
helping the overweight
3. You feel strongly that OJW puts you at
no greater risk liability-wise than you are
already
68
Post Script
I have provided OJW to
more than one hundred
patients many of whom
expressed their gratitude
in no small terms…
69
…Most of the
compulsively overweight
will applaud your efforts
to help them, and they will
not hold it against you if
they regain the weight.
70
CONCLUSIONS
We are uniquely positioned as part of
a health care team to help the
overweight / obese to achieve a
healthier weight by providing the OJW
service using the protocol and
Informed Consent presented herein.
The health care team includes:
weight-control hospital clinics, GP
physicians, bariatric surgeons,
nurses, registered dieticians and
psycho-therapeutic counselors.
71
If we step forward and recognize our right
and responsibility to care for selected
patients who meet the criteria of being
overweight or obese, based on the
diagnosis of the patient’s physician, the
leaders of the AAO and ADA will be
obliged to clearly define the dental
professional’s role in providing this
service, just as they did when problems of
snoring and sleep apnea first came to the
attention of dental professionals.
72
73
TO MY COLLEAGUES
Select your patients carefully. Do the OJW
methodically and be responsive to your
patient’s needs. It is my fondest hopes that
OJW patients will reach the goals they set out
for themselves when they signed the Informed
Consent. If they do, they can expect to lose
1.5 – 2.0 pounds each week and even more if
they exercise. Providers your sole
responsibility is to maintain the health of their
TMJ, dentition and gingiva.
74
The evolution of Homo Sapiens
Subspecies: Hyperphagimas Compulsivis
75
Note the interocclusal
separation of 2-3mm:
(approximately the
physiologic rest position
in which the mandible is
“weightless”)
76
OJW: The Skill Needed
Almost as easy
as tying your
shoelaces
77
THANK YOU
A Protocol for Providing
Orthodontic Jaw Wiring for
Control of Obesity: A New Role
for Dental Professionals
THE END
www. drted. com/AAO OJW
Synopsis . htm
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