There is a common and serious misapprehension about malocclusion. As one friend said, “We take it for granted that malocclusion is genetic—we’ve always considered my son got his crooked teeth from my wife.” As you will see, virtually all the evidence shows that the oral-facial epidemic can be traced not to our genes but to changes in our culture, particularly to ones in how and what we eat and where we live. These have changed greatly from those of the Stone Age, in complex patterns starting around the time people began to settle down and practice agriculture. 17 As anthropologist Clark Larsen put it: “There has been a dramatic reduction in the size of the face and jaws wherever humans have made the transition from foraging to farming.” 18 W. Proffit, H. J. Fields, and L. Moray. 1998. Prevalence of malocclusion and orthodontic treatment need in the United States: Estimates from the NHANES III survey. Int J Adult Orthodon Orthognath Surg. 13: 97–106. E. Josefsson, K. Bjerklin, and R. Lindsten. 2007. Malocclusion frequency in Swedish and immigrant adolescents—influence of origin on orthodontic treatment need. The European Journal of Orthodontics 29: 79–87.

Jared Diamond, Professor of Geography at UCLA, is the Pulitzer-Prize-winning author of Guns, Germs, and Steel and other books.

Contributing factors

While new studies and books are making headlines about the rising epidemic of poor sleep, none have examined its startling relationship with poor jaw development until now. Jaws: The Story of a Hidden Epidemic uncovers this serious, mounting, but virtually unknown public health crisis. Reading Jaws, I couldn’t stop thinking the brief lessons I once had on Hatha yoga. In Hatha yoga breath-control exercises, known as pranayamas, can help quiet the mind and reduce anxiety and stress. Nasal breathing is an extremely important part of the Hatha yoga. During this process, you slow down and control your breath. You inhale and exhale through your nose. Ehrlich hopes that increased attention and research geared toward the jaws epidemic can turn the tide. Another example: We know from fossil evidence that hunter-gatherers had big, well-developed jaws. Snoring is a symptom of your tongue being too big for your jaw and we speculated that individuals with small jaws wouldn’t have survived since snoring would have attracted leopards, which hunted them. What we do have are natural experiments, anecdotal evidence and speculation. For example, in Jaws, we show pictures of a grandfather who was raised in a traditional habitat with traditional diets, then his son who moved into an industrialized area – with much softer foods – and you can see the deterioration of the son’s face and jaws. His grandchild then had even more problematic jaws.

In Jaws , the authors present the biological, dietary, and cultural changes that have led to a rapid shift in oral evolution towards smaller jaws and crooked, crowded teeth. They explore the serious health implications of such afflictions including sleep deprivation and heart disease before concluding with simple adjustments that people can actually follow! Forwardontic (orthotropic) research, investigating the techniques used by John Mew and his colleagues, faces these problems and then some. Orthodontics is at least a clear-cut, professionalized, medical/dental treatment, engaging a large group of practitioners, and has thus been the subject of more or less standard medical research. Forwardontics is primarily a postural discipline, pursued by a small cadre of orthodontists and dentists. It is harder to practice than conventional orthodontics and less likely to be financially profitable, and its successes are highly dependent on patient cooperation. For those reasons forwardontics (as orthotropics) has been relatively ignored by the research community, and conclusions about forwardontics often need to be drawn from small samples, certain types of anecdotes, photographic histories of patients who sought help (not, then, a random sample of individuals), and the like. The “cures” for the jaw epidemic are simple in outline. First, we must return childrens’ diets to much chewier foods, perhaps even supplementing them with special tough chewing gums. We must also modify some current orthodontic techniques to emphasize forward movement of both jaws and avoid extractions.In his lecture “The melting face”; retrieved on February 20, 2016, from www.youtube.com/watch?v=NvoX_wEtwDk.

The major claim of the book is that you and Sandra Kahn have unearthed a hidden epidemic in which people’s lifestyles are affecting how their jaws develop, with many downstream health consequences. What do you feel is the most convincing evidence of that? Assuming that genetics are chiefly responsible for the sudden modern rise of these dental maladies does not make sense, said Ehrlich. “There’s not been enough time for evolution over the span of only several generations to have made our jaws shrink,” said Ehrlich. Nor is there any evidence of selection pressures that would have favored smaller jawed-people producing more offspring – and thus perpetuating the trait – than regular-jawed people. Dr. Mew and his insights were portrayed with some fondness. I was especially moved by the included photograph of his lone petition for policy change outside the BDA. The qualitative case studies and research cited could have been valuable, had they not been diluted with pedestrian accounts. I feel the urgency, but it was difficult to gain depth through the repetitive, almost nagging tone of the book. Dr. Kahn is a graduate of the University of Mexico and the University of the Pacific. She has 25 years of clinical experience in orthodontics and is part of craniofacial anomalies teams at the University of California, San Francisco and Stanford University. She can be reached at forwardontics.com. Figure 6: A photographic calibrated superimposition of the before and after treatment, which demonstrated the powerful result of postural and Forwardontics treatment of young patients.

Introduction

I found the book largely anecdotal, based on the author's experience as a practitioner and a parent, with little data to support her or Dr. Mew's opinions. While I understand that the book was written with a lay audience in mind, if you are going to propose a complete upheaval in culture and healthcare, then it needs to be supported with data. Figure 3: Cephalometric radiographs comparing the size of the airway before (a) and after (b) Forwardontics treatment. Humblest apologies to the authors for any harsh criticism, but thank you for writing this. I want to say that I am on your side. But the material needs to be taken to much, much further depth even for myself as a general audience. I hope this succeeded in planting the seed for change, and I am sure this is only one among your many commitments to health in our times.

As a book, I want to give it 1-2 stars. This does not invalidate the subject's critical importance in long-term health and childhood development/habit formation. Snoring, mouth breathing, soft/processed diet, among other signs may be worth observing and discussing with a health provider (without being a hypochondriac about it). You rely on anecdotal evidence and some clinical outcomes and are upfront about the level of speculation in the book. Why are you talking about this now instead of waiting for more robust studies? The bottom line of our narrative is that your health and happiness, and more likely that of your children, may be at risk due to habits to which most of us never give a second thought. So here are some of the key questions you could be asking yourself: Figure 5: Occlusal results, before (a) and after (b) upper arch, and before (c) and after (d) lower arch.Pause for a moment to look around and note how industrialization has changed your everyday life. The way we eat, the way we work and play, the way we sleep, and even the way we die are all fundamentally different for us than for our ancestors. In the breakthrough book, Jaws: The Story of a Hidden Epidemic, pioneering orthodontist Sandra Kahn and evolutionist Paul R. Ehrlich come together to explain how industrialization is also contributing to a silent epidemic that is right under our noses. Smile Direct within five years will do more orthodontics than all the orthodontists in the United States combined,” said orthodontist Bill Hang, DDS, MSD. “Every practice will be devastated.” A bold and provocative title. The subject matter deserves that, and much, much more. What is the subject? I found myself wondering time and again.