OJW ARTICLE SUBMITTED TO THE AJO-DO ON OCTOBER 29, 2007
Contents of Special Article
Copyright Statement 1
Table of Contents 2
Title page 5
Conflict of Interest Statement 6
Curriculum Vitae 7
Abstract <200 words 8
Main text including conclusion 10-18 (word count introduction and main text 2223)
Fig. 1: The original conception of Orthodontic Jaw Wiring
Fig. 2: Case illustration: M.M. 33 y/o female, BMI 36; chronic adult thumb sucking
Fig 3: Showing use of self-ligating brackets to extend the range of apartness of the jaws
Fig. 4: Model demonstrating use of SmartClip brackets with OJW and the range of inter-maxillary apartness achievable.
Contact information 24
NOTE: Hyperlinks are references to URLs at www.drted.com which provide detailed information too extensive to include herein and found nowhere else but in the web site.
My staff, and those who encouraged and cheered and above all the OJW patients who were always enthusiastic and tireless in their efforts to be in control of their eating habits
To my colleagues, my wife Frances, sons Lenard and Jonathan and BroJer
Orthodontic Jaw Wiring (OJW): The Dental Professional’s Role in Weight Control for Compulsive Overeating Leading to Obesity
By Ted Rothstein, D.D.S., Ph.D., private practice orthodontist
35 Remsen Street, Brooklyn, NY 11201
AAO-NESO- Honorary, and NYU Orthodontic Alumni Association. 1973-present; Ph.D., University of Pennsylvania in Physical Anthropology: growth and development of the cranio-facial components age 9-15; Complete CV and doctoral dissertation at www.drted.com
Abstract <200 words
Obesity is legion and epidemic in our country, and recognized as a
precursor to a host of serious illnesses. Indeed, Medicaid and Medicare
have classified obesity per se as a disease. These agencies are seeking
new and less expensive approaches to the costly surgeries extant.
Method: Orthodontic Jaw Wiring for weight loss is my approach to a
serious social, psychological and physiological problem that can help
some people who are obese or on a path to obesity and its potentially
grave consequences. OJW can help alleviate this epidemic in those cases
where it may be applicable to carefully selected individuals whose Body
Mass Index (BMI)* indicates they are overweight or obese as diagnosed by
their physician. Results: Providing OJW to 85 persons since 1989
has demonstrated that it is safe and effective using the protocols
developed over time, available to my colleagues gratis at drted.com.
Conclusions: Given that we are the caretakers of the mouth and
uniquely empowered with skills and mechano-therapy to provide services
to the overweight, it is our obligation and responsibility as part of a
health-care team to provide our expertise to the overweight
heading towards obesity, and those who have already reached that state.
* To calculate your body mass index BMI, follow these four steps:
Measure your height in inches (without shoes) and your weight in pounds (without clothing). Multiply your weight by 703. 2 Divide that number by your height. Divide again by your height.
These categories were established after several studies examined the BMIs of millions of people and correlated them with rates of illness and death. The studies showed that the BMI range associated with the lowest rate of illness and death is approximately 19–25 in men and 18–25 in women, so people with BMIs in this healthiest range are considered to be of normal weight. Higher BMIs are associated with progressively higher rates of illness and death. People with BMIs of 25–30 are considered overweight, and those with BMIs of 30 or higher are considered obese. Obesity has recently been further subdivided into mild (BMI of 30–35), moderate (35–40) and severe (BMI of 40 and above). Severe obesity is roughly equivalent to being 80 pounds overweight if you are a woman or 100 pounds if you are a man. Or go to http://www.nhlbisupport.com/bmi
Obesity is legion and epidemic in our country, and recognized as a precursor to a host of serious illnesses.1, 2, 3, 4 Indeed, Medicaid and Medicare have classified obesity as a disease. These agencies are seeking new and less expensive approaches to the costly lap-band and gastric surgeries extant whose mortality rate reaches 3/1000.5
Wiring for weight loss27
is an approach to a serious social, psychological and physiological
problem that can help some people who are obese or on a path to obesity
and its potentially grave consequences among which include airway
impairment and sleep apnea, whose co-morbidities are myriad.3
Dentists and orthodontists have taken cognizance of their role in the treatment of this problem, and in coordination with the patient’s physician, provide the appropriate mechano-therapy. Moreover, the AAO sanctioned such intervention beginning in 2004 by offering liability coverage for the first time for treatment of sleep apnea. Formerly, the orthodontist’s and dental professional’s role in providing mechano-therapy was frowned upon, if not highly controversial.
OJW is highly controversial.11 It has provoked some professional colleagues to declare that it is an inappropriate treatment modality for dental professionals to provide,12 when in fact it is non-invasive and has been shown to be safe and effective unlike gastric surgery with its substantial cost, high mortality rate13 and post-operative surgical complications.2,5 Indeed, my effort to promote the appropriateness of such treatment has occasionally sparked vigorous debate and opposing views11,12 for which I am grateful because those views helped me to clarify and improve the Informed Consent, the protocol and the standards for providing the service.15,16,17
I am exploring the orthodontic approach to help alleviate the problem in those cases where it may be applicable to carefully selected individuals15 whose Body Mass Index (BMI) indicates they are overweight or obese as diagnosed by their physician.
I call it the orthodontic approach because it makes use of orthodontic attachments bonded to the teeth and the protocol requires the patient to return every five weeks to be rewired, similar to the time period orthodontists typically have their patients return to the office for adjustments. Moreover, in some cases, it can be provided pari passu with orthodontic treatment26 and, finally, because it is possible to segue directly from active orthodontic treatment into retention in conjunction with orthodontic jaw wiring.27
It is obvious that dental professionals have already becoming increasingly cognizant of their role as shown by the advent four yeas ago of a removable appliance called the DDS System and, most recently, a fixed device invented by Jan Renders in conjunction with an orthodontist, Rene Linders, ready for clinical trials in Philadelphia.3,6,7,8,9,10
Consider that we are the caretakers of the mouth and amply endowed with the skills and mechano-therapy to provide services to the overweight with compassion and intelligence not is individuals, but as part of the health-care team already serving the overweight heading towards obesity, and those who have already attained obesity with its attendant co-morbidities.
To the naysayers, I ask that you maintain an open mind on a new way dental professionals can improve the lives of their patients; indeed, even as far as saving a life that might have been lost as a result of surgery itself. If there is a safer and more effective way we can help combat the obesity epidemic, surely we should not withhold our expertise in achieving such a meritorious goal.
Since we will be working with physicians to help the overweight and obese (and even upon occasion, the morbidly obese when they are referred to us by the bariatric surgeon for pre-surgical preparation), we must inform these members of the health-care team that we are able and willing to provide this ancillary service just as we did for those suffering from snoring sleep apnea. Otherwise, how will they know we are part of the health-care team providing services to the overweight and obese?18
What is Orthodontic Jaw Wiring?
Orthodontic Jaw Wiring23 refers to the entire domain of the OJW provider's responsibility to:
1. select patients according to specified criteria, and obtain their informed consent15 so that they are aware of the risks and limitations of OJW;
2. wire their jaws apart by a prescribed method;25
3. transmit that know-how to patients (especially if they are not able to return to your office and cannot find a competent professional who will do it for them);
4. re-examine and rewire them, typically once every five weeks, after examination demonstrates that their dentition, gingiva and TMJ have remained healthy over a period of time lasting 3-9 months during which time they will reduce weight by two pounds per week;
5. remove the wiring and brackets when patients indicates they have achieved their goal.
OJW presumes the service is provided under the auspices of a health-care team which would well include input from the patient's primary-care physician, dentist, OJW provider, dietician and, when applicable, psychologist and/or psychotherapist as well as a bariatric surgeon when indicated. 14
Fig 1a. Left photograph: Brackets are typically bonded on the canines and premolars on both sides.
Fig 1b. Right photograph: Jaws are methodically wired apart (not obvious in this photo) to allow 1.5-2.0 mm or more of mandibular movement in all excursions.
Fig 2. August 8, 2007, the case of M.M 33 y/o female with: BMI 36; attended by an adult chronic thumb-sucking habit. Note: Both right and left sides are wired to create an equally balanced feeling. When a patient is wired correctly the upper and lower teeth do not touch. This position is named “Rothstein’s OJW position of physiologic rest”. Here I have used .012” dead-soft stainless steel wire to suspend the lower jaw from the upper jaw allowing the lower jaw to move 1.5-2.0 mm in all directions (extendable to 4.0+ mm for patient comfort on demand). Note also the use of clear attachments on the upper canines for cosmetic enhancement.
Fig 3. Left side and right side of teeth demonstrating on a 3M-Unitek model of SmartClip® braces how self-ligating braces are used as the attachments in the OJW system of weight control. Use of these brackets extends how far apart the jaws can be wired, thus providing the patient more comfort on demand See Fig 4b.20
Fig 4a and 4b. 3M-Unitek SmartClip model demonstrating use of SmartClip brackets with OJW and the range of inter-maxillary apartness achievable pari passu with orthodontic treatment.
Is weight loss resulting from jaw wiring new?
Not at all. Oral surgeons have long wired their patients’ teeth together with surgical arch bars to facilitate healing in trauma or pathology cases, with the consequence that their patients were required to exist on a liquid diet, resulting in the patient inadvertently losing weight.31 By conservative estimate more than fifty thousand patients have their jaw wired each year in the United States. Weight loss is a common unintended collateral side-effect. That is how the public at large came to be aware of “jaw wiring” for weight loss.
What is new about OJW? 23:
1. a jaw wiring approach
has been specifically applied to the goal of weight loss/control;
2. the jaws are wired through the medium of orthodontic attachments bonded to the premolars and canines and the teeth and jaws are wired apart in a position named “Rothstein’s OJW position of rest”;
3. the delivery of jaw wiring is provided according to a defined protocol to be followed by the practitioner16 and an informed consent provide by the patient;15
4. a protocol was created which defines who may be considered for OJW and who should be excluded;
5. a protocol was created which takes cognizance of the possibility of TMJ stiffening over time.
6. An OJW Questionnaire Survey was created to measure how patients fared following the protocol.
Is orthodontic jaw wiring safe?
Jaw wiring for weight loss has been researched and found to be a safe procedure. Moreover, my personal research in dental and medical literature as well as an extensive search of legal archives by an attorney fail to identify a single instance of harm coming from the jaw wiring itself. If harm has come to a patient it has not been reported in the literature. Finally, I have personally spoken with more than a score of oral surgeons who could not report a single instance of injury to a patient who had jaw wiring for trauma or pathology.22 This is important to note because oral surgeons totally immobilize the jaws maximizing risk to the TMJ while in OJW the goal is to provide fixation with the maximum allowable mobility possible which concomitantly prevents ingestion of solid food.
General conclusions of the literature review: 24
1. Jaw wiring is generally accepted by the medical community as a therapeutically effective method to lose weight.
2. The only study of jaw wiring on teeth, gums and jaw joints per se shows that this procedure has no permanent harmful effects. 13
3. Behavior modification that results in maintenance of weight lost is extremely important.32,33
4. There are no studies that have examined the health of the TMJ using a long-term protocol requiring immobilization-rest/exercise and immobilization over a period of time as long as six to nine months as the OJW protocol advocates, viz. five weeks wired followed by five days unwired with jaw exercises, and rewiring again for another five weeks, etc. Research on jaw wiring has been sadly neglected by dentists and orthodontists for lack of a protocol and an Informed Consent, leading to serious concerns about medico-dental and liability issues. I suggest it is time this is remedied.14
5. Dentists and orthodontists are uniquely capable of providing a service that no other professional can deliver as safely, efficiently and competently.28
Is jaw wiring within the scope of the dental profession
Dr. Milton Lawney, the Executive Secretary of the New York State Board of Dentistry responds:
“If the condition is properly diagnosed and a lawful treatment plan is prescribed by a professional authorized to do so, the fitting and attaching of appliances could very well have dental health implications and a dentist may be involved in those services.
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.21
Members of the dental profession are uniquely positioned to work as part of a team with other health-care providers to help the overweight/obese achieve a healthier weight by providing orthodontic jaw wiring using the protocol and Informed Consent created especially for the delivery of OJW to carefully selected patients.
The health-care team includes: weight control hospital clinics, general practice physicians/internists, bariatric surgeons, nurses, registered dieticians and psychotherapeutic counselors.
Dentists, as part of a health-care team, are uniquely empowered to help those who are obese or are reluctantly heading towards it as diagnosed by a physician.28
My advice to dental practitioners is to offer OJW, but choose patients with due diligence and follow the OJW protocol. Strive to educate the detractors and inform the non-dental medical community that we dental professionals are disposed to provide our expertise to carefully chosen overweight and obese patients with tendencies to compulsive overeating.
I have provided OJW
for many patients without incident and with great success depending on
how success is defined. If it is measured by whether the patient
achieved permanent behavior modification regarding eating and
exercise habits, I cannot say assuredly that OJW was a success. However,
if it is measured by gratitude expressed and weight loss reported, the
service was indeed successful.18
OJW patients will applaud and praise your effort to help them; they will not begrudge you if they regain the weight post-treatment, 30 a problem encountered with every weight- loss method without exception.
. OJW providers are responsible for the maintenance of the health of the TMJ, dentition and gingiva.
I have proposed the formation of a research arm under the 501c3 not-for profit corporate status that would seek funds to carry out research in the domain of the subject of orthodontic jaw wiring beginning with 14 OJW and behavior modification as well as post-OJW effects on the TMJ.
If members of the dental profession step forward and recognize their right and responsibility to care for selected patients who meet the criteria of being overweight or obese based on a diagnosis of the patient’s physician, the leaders of the AAO and ADA will be obliged to clearly define the dental professional’s role providing this service just as they did when problems of snoring and sleep apnea first came to the attention of dental professionals.
Today it is even more urgent that we as orthodontists examine our role in providing this service to those who meet the criteria. "We must do what we conceive to be the right thing and not bother our heads or burden our souls with whether we will be successful. Because if we don't do the right thing, we will be doing the wrong thing and we will just be a part of the disease and not a part of the cure." -- E. F. Schumacher
The gates of the Future are patrolled by a thousand guardians of the Past. --Anon.
1. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report First guidelines developed by the Federal Government to address overweight and obesity-conditions that affect an estimated 97 million Americans and are the second leading cause of preventable death in the United States http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm, NHLBI produced publications 228 pp. 1998.
2. Freudenheim, M, Other perils of overweight. New York Times, 2005: May 27. C1.
3. Davidson, T.M. The role of the dental professional in the diagnosis and treatment of Sleep-disordered breathing. Dentistry Today, 2005; September, p.118.
4. Freking, K. Obesity rates climbing. Amhealth. 2005; p. 24, August 24.
5. Kolata,G, and Grady, D. Weight-loss field awaits change in Medicare policy. New York Times, 2004; July 18 http://drted.com/OJW insurance coverage.htm
6. Loyd, L. Fighting against obesity one bite at a time. The Philadelphia Inquirer, 2007; Sept. 17, Business Section D5.
7. Malmache, L. Help your patients eat less! Dental Economics, August 2004 in “columns.”(re the DDS System).
8. Saib, Bilal. Dental
Weight Center of North Carolina:
Introducing the newer, kinder
and more humane alternative to weight loss surgeries. Jaw wiring for weight loss. http://www.dentalweightloss.com/entry.html. 2006.
9. Renders, Johannes, et al. United States patent #6,138,679, A method suitable for influencing the ingestion of food by humans via the mouth cavity. 2000; October 31.
10. Florman, MJ. Oral appliance and method for use in weight loss and control. Application for a utility patent submitted to the USPTO 2003: April 24. Application subsequently abandoned.
11. Piehler, C. Orthodontic Jaw Wiring: A Roundtable on a controversial weight-loss procedure. Orthodontic Products Magazine, February, 2005, p. 36. See also: http://www.drted.com/OJW Roundtable article OPM PDF.pdf
12. Rothstein, T. http://www.drted.com/index.html.bak2/Jaw wiring pros and cons.htm. 2002, January 5.
13. Rogers, S., et al. Jaw wiring in treatment of obesity. The Lancet, p. 1221, 1977; June 11. p. 1221.
14. Rothstein, T. Dentist Providers of Orthodontic Jaw Wiring: a would be 5013c organization for research and furtherance of knowledge regarding jaw wiring for weight control/loss. http://www.drted.com/OJW DPOJW Course.htm
15. Rothstein, T. The Informed Consent for OJW (English version).http://www.drted.com/index.html.bak2/Jaw wiring Informed Cconsent.htm last modified 2007: September 26.
16. Rothstein, T. http://www.drted.com/OJW protocol report responses.html 2003; September 22.
17. Rothstein, T. The principles, guidelines and standards for providing the OJW service for patients who are medically cleared to begin a liquid diet and have chosen OJW as an aid to treat the medical problem of overweight and obesity resulting from compulsive overeating http://www.drted.com/Jaw wiring principles for providers.html 2006; July 8.
18. Rothstein, T. What is success when it comes to weight loss? http://www.drted.com/OJW Julie to Robin.html
19. Rothstein, T. A letter sent to 20 bariatric surgeons indicating the consideration of OJW as a viable antecedent to the surgical alternative of gastric surgery. http://www.drted.com/DPOJW note Bariatric Surgeons.html 2004: mid August.
20. Rothstein, T. Documentation of the use of self-ligating attachments to increase the intermaxillary distance the jaws can be wired apart. http://www.drted.com/OJW using self ligating brackets.htm 2007; September 22.
21. Lawney, M. Direct quote in response to the question: Is jaw wiring within the scope of the work of the dental professional. http://www.drted.com/OJW The question.html
2004: October 14.
22. Shephard BC, Townsend GC, Goss AN. The oral effects of prolonged intermaxillary fixation by interdental eyelet wiring. Int J Oral Surg,1982 Oct;11(5):292-8.
23. Rothstein, T. United States utility patent application #11/534, 225, Orthodontic Jaw wiring, a fixed intra-oral device and method to limit jaw opening, thereby preventing ingestion of solid food. 2007: September, 22.
24. Rothstein, T. All the literature on the subject related to jaw wiring. http://www.drted.com/index.html.bak2/Jaw wiring for weight loss literature references.htm last revised 2007; June 24.
25. Rothstein, T. The protocol for providing OJW. http://www.drted.com/ojw_protocol.htm.last revised 2007; June 7.
26. Rothstein, T. The first attempt at combing OJW and orthodontic treatment simultaneously. http://www.drted.com/Iris Pierre OJW n Ortho.htm 2007; June
27. Rothstein, T. Orthodontic Jaw Wiring. http://www.drted.com/index.html.bak2/jaw_wiring.htm 1999; Feb 18.
28. Rothstein, T. A letter to orthodontic colleagues summarizing the rational for embracing the concept that is the right and responsibility of dental professionals to embrace efforts to help the overweight on their way toward obesity. http://www.drted.com/OJW protocol report.htm 2003; September 22.
29. Rothstein, T. Transitioning from active treatment to Class III retention with OJW: A table clinic presented to the AAO in Las Vegas, NE 2007; May 6. http://www.drted.com/OJW AAO Table Clinic 2006.html
30. Garrow, JS, Gardiner, GT. Maintenance of weight loss in obese patients after jaw wiring. Br Med J (Clin Res Ed) 1981 Mar. 14; 282(6267):858-60.
31. Brody, JE. Study finds a liquid diet works (but not for the 50% who quit it. New York Times Science Section, 1992: May15. http://www.drted.com/Liquid diet Brody article.html
32. Wansink, B. Mindless eating. Bantam, 2007.
33. Wansink, B Mindless Eating Secrets and Stories web site: www.MindLessEeating.org
Ted Rothstein, DDS, PhD
Cosmetic Orthodontist for Adults and Children
American Association of Orthodontists
Founder DPOJW www.drted.com/DPOJW.html
35 Remsen St., Brooklyn, NY 11201
Word Count: 2250 (introductions main text and conclusion)
Figures: Four figures consisting of two photos each all in *.eps format*
Fig. 1: The original conception of OJW
Fig. 2: OJW with cosmetic and functional enhancements on a female patient started August 8, 2007 having a BMI of 36 attended by chronic adult thumb sucking
Fig 3: showing use of self-ligating brackets to extend the range of apartness of the jaws
Fig. 4: Model demonstrating use of SmartClip brackets with OJW and the range of inter-maxillary apartness achievable
*Each of the eight figures will be sent as a separate file.
Attention: Dr. David L. Turpin, DDS, MSD,
Editor-in Chief American Journal of Orthodontics and Dentofacial Orthopedics
University of Washington
Department of Orthodontics,, D-569
HSC Box 357446
Seattle, WA 98195-7446
OJO-DO editorial manager website ees.elsevier.com/ajodo
Fig 1a. Left photograph: Brackets are typically bonded on the canines and premolars on both sides.
Fig 1b. Right photograph: Jaws are methodically wired apart (not obvious in this photo) to allow 1.5-2.0mm or more of mandibular movement in all excursions.
Fig 2. August 8, 2007, the case of MM: BMI 36; attended by an adult thumb sucking habit of 33 years. Note: Both right and left sides are wire to create an equally balanced feeling. When a patient is wired correctly the upper and lower teeth do not touch. This position is named Rothstein’s OJW position of physiologic rest. Here I have used .012” dead-soft stainless steel wire to suspend the lower jaw from the upper jaw allowing the lower jaw to move 1.5-2.0 mm in all directions (extendable to 4.0 mm for patient comfort on demand). Note also the use of clear attachments on the upper canines for cosmetic enhancement.
Fig 3a. Left and 3b. right side of teeth demonstrating on a 3M-Unitek model of SmartClip® braces how self-ligating braces are used as the attachments in the OJW system of weight control. Use of these brackets extends how far apart the jaws can be wired, thus providing the patient more comfort on demand. See Fig 4b.
Fig 4a Left and 4b. right, a 3M-Unitek SmartClip model demonstrating use of SmartClip brackets with OJW and the range of inter-maxillary apartness achievable pari passu with orthodontic treatment.