TLDR?: Dr. Zaghi lectures for the International Surgical Sleep Society (ISSS) in support of Myofunctional Therapy and Functional Frenuloplasty as a safe and effective treatment methodology for certain sleep and airway issues. Video below.
Dr. Zaghi was recently invited to present and contribute to a debate about the pros and cons of myofunctional therapy and frenuloplasty as part of a series of online lectures developed for the International Surgical Sleep Society (ISSS).
For those who are not aware of the ongoing controversy, a previous blog post by Dr. Eric Kezarian claims that: “There is no proven benefit to oral myofunctional therapy or frenuloplasty for the treatment of obstructive sleep apnea in adults as it is commonly practiced in the United States. If you are an adult and want to use exercises to treat your sleep apnea, go to Brazil for people that are using tested approaches."
These attempts at debunking the results we see everyday (in well over 2000 patients in just our office alone) amounts to what we feel is little more than an expression of a biased point of view (RE: the role of oral myofunctional therapy and frenuloplasty).
What is very disheartening about the standards of care in modern medicine, is the all too common resistance to consider other perspectives. Dr. Kezirian "encourage[s] practitioners to perform research" yet subsequently tries to belittle the 3-year long research project we accomplished alongside an expert team of clinicians and researchers. The author continues by stating that “there have been no objective studies examining effects on OSA since that time.” We would like to ensure our readers that we are in the process of finalizing the data collection from our objective follow-up study, however the limitations of human research during COVID-19 caused us to experience a huge set back. We as an Institute wholeheartedly believe that studying this topic systematically will benefit everyone.
Our 2019 manuscript entitled “Lingual frenuloplasty with myofunctional therapy: Exploring safety and efficacy in 348 cases.” was the largest most systematic reviewed research to date on this topic. Despite being recognized by the journal of Laryngoscope Investigative Otolaryngology (a peer-reviewed journal), in Dr. Kezirian’s “con” debate, he claims that our research was “nice” but should have been published as a case series, not a level-3 study. His statement implies that the numerous journal reviewers have overlooked or otherwise made an error in their decision making process. We however, as well as the reviewers, believe that the level of evidence for our study is indeed Level 3 because it was a consecutive cohort study of a very large number of patients. Level 4 studies usually correspond to nonconsecutive, hand-selected reports of a few case studies. Our Retrospective cohort study involved 348 of 420 consecutive patients who were treated with lingual frenuloplasty and myofunctional therapy.
We also would like Dr. Kezirian and anyone else who has been keeping up with this debate to know that beyond our frenuloplasty research, we have made great progress towards standardization by helping to bridge channels of communication amongst many different practitioners, offices and organizations worldwide.
These ongoing collaborations include, but are not limited to outstanding groups such as:
And many more...
Dr. Kezirian asked us to show him "something to change [his] mind" and openly challenged the entire field to deliver proof. We feel that as a community, we have been and and continually working on accomplishing this goal. A few examples include:
We would also like to highlight a particularly poignant comment by the late Dr. Christian Guilleminault on Dr. Kezarian’s blog post; “Ignorance of what is existing and published is not a good excuse”.
With that said, we would like to take this opportunity to honor all the research and work that was accomplished before. Despite Dr. Kezirian’s claim that Dr. Guilleminault’s research was mainly aimed at pediatric patients, the truth is that Dr. Guilleminault literally coined the term “sleep apnea” and first started curing the disorder by performing tracheostomies. The reason he took an interest in pediatric patients was purely to intervene early with his focus on disease prevention not disease management, since he had seen so many adult patients over his long career who could have prevented their current health challenges altogether if they were treated appropriately earlier in life. This is especially why our entire team at TBI is so committed to bringing myofunctional therapy to the forefront of healthcare.
We do agree with Dr. Kezirian regarding the informational void when it comes to frenuloplasties and OSA, and that objective scientific evidence is needed. We also agree that we need systematic approaches for defining exercise selection and, more importantly, studies of these protocols (hence the collaborations and programs listed above). It is our hopes that with the knowledge and evidence we are gaining daily in clinical practice and our active collaboration with the International orofacial myofunctional therapy community, we can continue to collect and organize this evidence behind this functional approach to sleep and breathing. In fact, our Lingual Frenuloplasty paper was one of the top three most downloaded articles of the year in Laryngoscope Investigative Otolaryngology.
We also want to take this opportunity to remind our readers that all debates can (and should) include an element of friendship and strong collegiality. Dr. Zaghi has an open line of communication with Dr.Kezirian and has always welcomed his input and suggested research ideas. It is important for us as a community to remember the importance of open-mindedness, and willingness to hear others perspectives, especially those with whom we disagree so as to either strengthen our own convictions, or adjust them to fit new understandings whatever the case may be.
We urge our readers to consider these wise words from Goethe:
“In the sciences, people quickly come to regard as their own personal property that which they have learned and had passed on to them at the universities and academies. If someone else comes along with new ideas that contradict the Credo and in fact even threaten to overturn it, then all passions are raised against this threat and no method is left untried to suppress it. People resist it in every way possible: pretending not to have heard about it; speaking disparagingly of it, as if it were not even worth the effort of looking into the matter. And so a new truth can have a long wait before finally being accepted.”
Society needs orthodontists, oral surgeons, otolaryngologists, MFT’s, and we must leave no stones unturned in our quest. We need to work with our colleagues in disciplines outside of our own and learn all of our options.
We thank the journal reviewers from “Laryngoscope” for supporting our research. They felt that “This is an interesting manuscript and provides good information in an area where there is limited high quality scientific information,” and we hope that if you feel the same way, you will take a quick moment to share your thoughts with us in the comment thread below. Your feedback and support is essential in moving this field forward.
Finally, we leave you with one of Dr. Zaghi’s favorite quotes:
“You're never too young to learn, and never too old to change”.
--Russell M. Nelson