INTRODUCTION

    Obesity is a major healthcare problem affecting 35% of the United States population. In more affluent countries, obesity is common not only in the middle-aged, but is also becoming increasingly prevalent among younger adults and children and recognized as a precursor to a host of serious illnesses.^{1, 2, 3, 4, 5, 6, 7} Indeed, Medicaid and Medicare have classified obesity as a disease in itself. These agencies are seeking new and less expensive approaches to the costly lap-band and gastric bypass surgeries extant whose mortality rate reaches 3/1000.⁵  Dental professionals should pay particularly close attention to the fact that Medicare is now reimbursing private

physicians for supervising weight loss programs. Typically when Medicare begins to pay providers for a service private insurers quickly follow suit.^5.5

      Orthodontic Jaw Wiring (OJW^†) for weight control is an optional approach that can help some people who are obese, or on a path to obesity, avert its potentially grave consequences among which include airway impairment and sleep apnea, whose co-morbidities are myriad.^3,8
     Dentists and orthodontists are taking cognizance of their role in the treatment of this problem, and in coordination with the patient’s physician,  can provide appropriate mechano-therapies.^8,9,10,11

    Moreover, the American Association of Orthodontists sanctioned such "not-strictly-orthodontic" interventions 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, and neglected by the dental practitioners. This author has been providing this service since 1998 and in this article presents for consideration to members of the dental profession the data and experience accumulated.

     There are some fundamental questions the reader should pose:

1. What is OJW?
2. Is OJW within the scope of the dental profession?
3. Is OJW safe?
4. Is weight loss resulting from jaw wiring new?

5. What innovations have the author introduced?
What is OJW?

    Orthodontic Jaw Wiring^{12, 13} refers to the entire domain of the OJW provider's responsibility to:

1. select patients according to specified criteria, and obtain their informed consent¹⁴ so that they are aware of the risks and limitations of OJW;

2. wire their jaws apart by a prescribed method;¹³ (See 3-5 below figures.)

Place Figs. 1-3; 6 photos below * 

Place 2 photographs here.

Fig, 1a. "Begg" brackets bonded on canines and premolars. 

Fig. 1b. Wiring accomplished either around the bracket slot as shown in Fig. 1b, or through the long axis of the bracket slot to extend the envelope of mandibular motion to 2.0mm-4.0+mm.

Place 2 photographs here.

Fig. 2a.  August 8, 2007, the case of M.M., BMI** 36.
Right and left sides are wired identically in the OJW position of physiologic rest*** using  012" dead-soft stainless steel wire consequently limiting the range of mandibular motion to 1.5mm-2.0mm in all excursions. Clear attachments on the upper canines were placed for cosmetic enhancement. Note the disto-axial inclination of the Begg brackets to facilitate wiring.

Fig. 2b. Demonstrates on a 3M-Unitek model of SmartClip® braces how "self-ligating" braces can be used as the attachments albeit more difficult for the patient to remove the wiring if/when need be.

Place 2 photographs here.

Fig. 3a and 3b  A 3M-Unitek SmartClip® model demonstrating OJW pari passu with orthodontic treatment by making use of the bracket's vertical elastic hooks to effectuate the wiring in a manner which increases the envelope of mandibular motion.

(cont'd from 2. above)

3. transmit that know-how to the patient or their significant other, especially when they are not able to return to the OJW provider, and cannot find a competent professional who will do it for them;

4. reexamine and rewire them, typically every five weeks, after examination demonstrates that their dentition, gingiva and TMJ have remained healthy over a period of time typically between three and nine months, during which time they will reduce weight by two pounds per week, and even more with exercise;

5. remove the wiring and brackets when patients indicate they have achieved their goal or desire to have the OJW device removed.

         OJW presumes the concerted efforts of the patient's primary health-care physician, who diagnoses the condition and provides the patient medical clearance to begin a liquid diet, their dentist who may or may not be the OJW provider, and when applicable a dietician, psychologist and/or psychotherapist and a bariatric surgeon when warranted.¹⁴

2. Is OJW 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.¹⁵   The bylaws governing the practice of dentistry may differ among states.  However,  jaw wiring for weight loss is not specifically prohibited in any state to the best of the author's knowledge.

3. Is OJW safe?

    Jaw wiring for weight loss has been researched and found to be a safe procedure historically and as indicated by the present study.^{16, 17} Moreover, 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, interviews with more than a score of oral surgeons could not elicit a single instance of injury to a patient who had jaw wiring for trauma or pathology.¹⁷  This is significant because oral surgeons rigidly immobilize the jaws maximizing risk to the TMJ, gingiva and dentition, while in OJW the provider applies a relatively benign appliance which allows the mandible maximum mobility while precluding the ingestion of solid food and simultaneously permitting reasonably clear speech.

5. What innovations have the author introduced?

      The "orthodontic" approach to jaw wiring was conceived of as a minimally invasive method applicable to carefully selected individuals¹⁵ whose Body Mass Index (BMI) indicates they are overweight or obese as diagnosed by their physician.

     Dental professionals are increasingly cognizant of their new role as shown by the advent four years 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.^{3,6,7,9,10,11} Moreover, Jackson University is undertaking a research project to determine if the orthodontic office is an appropriate venue to address childhood obesity.

REVIEW OF THE LITERATURE

General conclusions of the Medical and Dental literature review:¹⁶

1. Jaw wiring in conjunction with a liquid diet is generally accepted by the medical community as a therapeutically effective method to lose weight.

2.  Liquid diets are considered to be safe.^{24, 25}

3. The only study of jaw wiring on teeth, gums and jaw joints per se shows that this procedure has no permanent harmful effects.²¹

5. 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 allowing full range joint mobility, and rewiring for another five weeks, etc. Research on jaw wiring has been neglected by dentists and orthodontists for lack of a protocol and an Informed Consent, leading to serious concerns about providing OJW with regard to medico-dental and liability issues.¹⁴

6. Dentists and orthodontists are uniquely capable of providing the OJW service.²⁷

METHOD OF THE STUDY

    An invitation to take a seventy-seven question survey was sent to seventy-five former OJW patients who were by and large patients who came for the service from out-of-state as a result of searching the Web for "jaw wiring". They were accepted as "good candidates" (no compromising dental or medical problems) after a review of the Informed Consent, the dental-medical history and the typical orthodontic forms they were requested to submit.

RESULTS

    The twenty-four respondents came from everywhere in the United States, mainly because there were no other providers for the service.

The preponderance of patients were females between 24 and 44 years of age 75% of whom reported were still in OJW and whose average starting weight was 230 pounds, approximating a BMI of 36. They or their significant other were instructed how to accomplish the rewiring following the protocol for OJW wiring: five weeks wired, five days unwired, then rewired if their joint did not feel stiff for five more weeks . 

    They reported their present weight as a group to be 193 pounds representing a BMI of 32.7. They reported suffering most often pain and discomfort in knees and or hips, followed by depression, snoring, sleep apnea and finally, lower back pain. Risk and/or fear of surgery were important in choosing OJW. 85% of them reported it was impossible to find another OJW provider. 70% had been in OJW for less than seven months. 78% indicated that the OJW service was highly valuable, and 83% of the sample said it helped them to get better control of their eating habits.

    The problems they reported: The inside of my mouth felt unclean, 56%. My jaw got stiff, 44%.  Speech was impaired too much, 31%; it was too costly, 31%.  However, their social and sex lives were not impacted to any great extent. 21%, reported stiff and or painful jaws. Indeed, 21% answered that they "gave up on OJW because the jaw joint become stiff or painful". 84% of respondents felt they "did not make a big mistake by choosing OJW and that it was not a waste of time and money." 

    Surprisingly, 84% reported that having to rewire themselves was not a problem. 94.4 % of the respondents indicated that regarding rewiring themselves: "I might have continued if an easier method to rewire myself was available" indicating that for most having to rewire themselves was not an issue.  The author does not advocate that OJW patients be encouraged to rewire themselves.  Indeed, it is always preferable to have the patient return to be examined and rewired by the OJW provider.

    Question 58 was considered most important:  Given that vomiting could lead to the aspiration of vomit back into your airway leading to effects ranging from choking to death, please state your position(s) from the list below (17 respondents reported) The Informed Consent I filled out told me all I needed to know, (58.8%).  It's possible but highly unlikely, (41.2%).  The risk of death from surgery bothers me more, (23.5%).  You can die from some diet pills as well, (23.5%). I carefully researched that possibility and found no instance of its occurrence, (29.4%).  I was warned of that so I carried my wire clippers with me at all times, (47.1%0.   All of the above, (47.1%). Question 62 was also of interest: Do you believe that OJW gave you a "jump start" with your weight loss efforts? To which 16 of 20 patients responded affirmatively. 

    The responses to question 63 Why did you choose the OJW method to begin with revealed that My being overweight was causing me to be depressed (83%).  I felt this approach might help me bring my compulsive overeating under control, (72%). I realized that my excessive weight could have serious health-related consequences, (67%).  I was finally able to locate a dental professional who would provide the service, (61%).  I just didn't like the way I looked and previous methods were ineffective for me, (56%). Overall, more than 90% approved and recommended OJW. In response to question 69, If you did regain the weight you lost did you hold the OJW provider responsible? 90% reported "No". 

    Finally, in response to: If you did have an experience related to OJW with special attention to nausea, vomiting or choking please comment here: All respondents except four offered no response to this question. The four who did said "not applicable".