Full video transcripts:

Patrick McKeown
0:04

Foreign — so, conversation all about breathing, orthodontics, where is it going, where has it come from, and I'm delighted to be accompanied by Dr. John Mew and Dr. Mike Mew. I've had the privilege of visiting their clinic in Burley, going back as far as 2009, and they were very gracious in allowing me to sit in and observe them both working with their patients. And the reason both doctors were interesting was because about 40 or 50 years ago, Dr. John Mew was one of the first orthodontists to start talking about the importance of breathing in and out through the nose, good posture with the tongue against the palate. So it's a privilege — John, I would love just to get your insight, in terms of your initial — you were working as a dentist, your father was a dentist as well, there's a lot of history here in the dental world, you then trained as an orthodontist, you were also observing in maxillofacial surgery, and you were seeing things that raised some questions.

Dr. John Mew
1:15

I think I was very lucky, my father was actually an orthodontist, although they didn't call themselves that in those days, but he treated other people's patients, which I think makes him an orthodontist. But it was he who taught me the value of expansion, and that really set me off down the road, because — obviously he died, and I looked at his study models, he kept good records, and I found that I'd been taught expansion never lasts, it always relapses. And I was actually looking at my father's cases — yes, the majority of them had relapsed, all the way — but what really surprised me was the fact that a few of them had actually gone on widening after he'd expanded them. Now you can imagine, that blew my mind. It was he who taught me there is a reason for everything, so I simply said, I've got to find the reason why some people just go on widening and some don't. And then I realized it was the position of the tongue, and that set everything off.

Patrick McKeown
2:45

Can I just draw this out just for the person who's listening in, because when you're talking about expansion, you're talking about the maxilla, which is the top jaw, and the tongue — if we were to look at the shape of the tongue, the tongue is quite U-shaped, and what you're saying is that by having the mouth closed, especially during the early years of development in children — if the mouth is closed and the tongue is resting up in the roof of the mouth, this will help to ensure forward growth of the maxilla, and also width of the maxilla, and the benefit of this is it influences the face, but you're also not going to have overcrowding of teeth. Now, I'll talk about my own personal basis — I was a mouth breather for the first 25 years, I'm not sure when I started mouth breathing, but I assume from my early photographs it was quite young, my maxilla had a very narrow V-shaped maxilla and a high palate, which was infringing on my nasal cavity, and when I smiled I had black triangles either side, because my mouth wasn't big enough, my jaw wasn't big enough to fit them. So — Mike, was your father talking about expansion, and when you then looked at your father's work, you've seen that some of them relapsed, so they went back in — why might they go back in, what is causing the after-expansion, what causes the maxilla to go inwards again?

Dr. Mike Mew
4:19

It took me a long time to realize that, Patrick, but if a baby is spoon-fed, or cup-fed, or really just not — they tend, when they swallow, to suck. Whereas if a baby is breastfed, certainly with a full tongue, they learn to push with their tongue against the breast to compress the breast and squeeze the milk out. Therefore they subsequently swallow in an entirely different way — every time they swallow they push on their palate, they don't suck, and that causes a lot of difference, not just to the width of the maxilla, but it will also cause enlargement of the buccinator, the muscles, which always looks unattractive.

Patrick McKeown
5:20

So in terms of young people — say, Mike, if you're under about eight years old, large buccinator muscles can look very cute.

Dr. Mike Mew
5:33

Yes, that's very true, it's part of the sign of an attractive baby, chubby cheeks, because they've got effective buccinators, so they're clearly breastfeeding very well. But cherubs and suckling infants are the only people who should be using their buccinator muscles, and when you stop breastfeeding you should then move to an adult style, which is different from an infantile style of breastfeeding, and then your cheek muscles should hollow out. So I've got very little buccinator, but strangely enough, my buccinators when I went to university — it was still too big, and I then worked out — I could deduce my large buccinators from the way I was swallowing, and I made a purposeful effort not to use my buccinators, and they virtually disappeared, so I have much hollower cheeks, because I have no buccinator left.

Patrick McKeown
6:35

And that would take some dedication, just like you'd take your breathing, in terms of the development of your face, because even as we look at it now, viewers will see that your face is much broader than mine is, and we can deduce — mine has got broader — it's interesting, because it's the first time we've talked on the phone, the first time we've spoken, probably since COVID.

Dr. John Mew
7:06

That's true. You know, I have asked you before, I would love to have a really good picture of you with a six-inch ruler held vertically in front of your nose, because we have at the practice a picture of you taken about five, six, maybe more years ago, and you are noticeably different now, and I'm sure that is because you have corrected your training, and it would be excellent for you to be able to demonstrate that.

Dr. Mike Mew
7:39

Yes, yes, you know, you've worked hard, I can see. Well, one thing that I was working on was having correct tongue resting posture, and also during some of the exercises, tongue pops, and the different exercises in terms of Ewing, myofunctional therapy, and I do believe that my lower jaw has actually come forward, and this is often a question that people ask, especially adults — say you have a 20 year old, and it's a very delicate answer to give them, that if, for example, they have jaws that were set back, such as mine were, which compromises the airway, it can set you up with the risk of sleep apnea for life — can that be improved without orthodontic intervention, or is it too delicate a thing to say that we can't, in all instances? But can we influence the growth of the jaws — and in some ways it seems that we can.

Dr. John Mew
8:32

You know, my research shows quite definitely, but the moment you put brackets on teeth, the jaw retreats — alright, maybe just one or two millimeters, but sometimes 10 or 15.

Patrick McKeown
8:57

Okay, yes, sorry, so just so there's — an intervention can, at times — and I'm not saying it always is, okay — I'm suggesting that sometimes trying to intervene to align the teeth may cause the face to drop down.

Dr. Mike Mew
9:11

Yeah, well I've seen it firsthand with my own daughter, Lauren, because a hard wire has been put on her, and as soon as the hard wire was put on her, the gummy smile became evident, and now we're taking away the hard wire — so she's got train tracks on — something happened to drop the maxilla to show the gummy smile. Now, maybe a lot of parents wouldn't necessarily be observant of this, and I think this is why parents need to be aware of information.

Patrick McKeown
9:41

Now I'm going to come back full circle, quickly put a plug here, Patrick — it's really nice that we've got some photographs from a while ago. Parents, take good photographs, take great records — if you're worried about this and you're having concerns, simply take good photographs, good sideways photographs, preferably with a telephoto lens that's zoomed in, so the longer the distance that it takes out parallax, and with good lighting — I say always good artificial lighting, because then it's the same each time, and preferably a neutral background, preferably a white wall or something. And by the parents taking this, then they can follow the progression of their child's orthodontic intervention, to see if there's changes to the shape of the face — is that what it is?

Dr. Mike Mew
10:38

Yeah, okay, there's more — I mean, just to understand, not only if you're going to try any intervention, so you're going to try — and sometimes, you know, I don't want to knock orthodontics too much, sometimes orthodontics can get a fantastic outcome, I've seen it frequently, that they can even sometimes — I've seen a face, you unit a little bit of expansion, someone gets their tongue up there, they change for the better, I've seen some really beautiful facial outcomes with conventional orthodontics — but either way, there's this controversy that you can hear, there is — pay, good records, and even if you're not going to do orthodontics, you're going to do something like mewing, something like Buteyko breathing, something like the mealtime exercise, or just try and encourage your child to stand up straight and shut their mouth — then what you need to know is if it was doing anything, is it working, is it not working — take good records, picture tells the story.

Patrick McKeown
11:42

Coming back to my breathing and the importance of correct tongue resting posture, and I might just put this out to the two of you — I was preparing, or thinking, you know, I knew of course I was going to be chatting with you today, and I went in on PubMed yesterday, and I did a simple search, and this can be a search that's done by any parents — just go into PubMed, and PubMed is the database of pretty much most papers, clinical trials, etc. And I'm just going to do it now, and I'll share it — so when I went in there, I put in two words, I put in "mouth breathing" and I put in "malocclusion," and it revealed some — yeah, it was something like — I've got 563 results here. I started going through these results, and I couldn't find papers without a connection that when the child had their mouth open, their teeth were crooked. Now any parent can check this out for themselves with such an array, and you can see where I was checking, and all I was doing was just randomly clicking on articles, okay, and then looking, and pretty much, I would say, the vast majority of papers, it was shown, if there's a problem with swallowing, there's a problem with tongue thrust, if there's a problem with nasal breathing, that it had a negative effect on the development of the face. Now, disinformation is not new — I remember reading an article that was published back in 1909 in the journal Dental Cosmos, and it talked about the child with the mouth open in school, the teachers are accusing the child of being inattentive, their face looks dull and expressionless — and yet this has been debated. My question, as a layperson looking in, I'm not a dentist, I'm not an orthodontist, I work with simple breathing — how has this been overlooked? And this is not a criticism, this is only a question that I would like to put out there. I was a mouth-breathing child — 25 to 50 percent of study children are persistently mouth breathing, either during wakefulness or during sleep — I have never come across any paper that hasn't said that mouth breathing has some negative impact on the development of that child. Why is it being ignored?

Dr. John Mew
14:18

I think I can answer that, Patrick. Individuals believe what they believe, they will not change that because there is evidence — you can produce paper after paper all saying the same thing, and nobody will change their mind unless they have to. Young students will grow up with a different message, the people who practice for 20 or 30 years are not going to change because someone writes a paper. In my opinion, the only way you will get change is if people are made to change — that is why I think that the law is possibly the only way that it will happen. Now, my colleagues disagree, and think that's a terrible approach.

Patrick McKeown
15:12

I could see Michael's face, he doesn't approve of that at all.

Dr. Mike Mew
15:18

But I'm quite sure that if you want to change something, you have to make it illegal. But sorry, to come — I think it's very true, if parents were aware of this, and they selected this, and they're willing to pay, at times more, for this, because these types of treatments are longer duration, and they require getting someone to change — and that was the big thing. But I think another thing is that people have tried, in studies, to get children to change, go from mouth breathing to nose breathing, they've tried to do many things, and it's really quite a difficult thing, it is.

Dr. John Mew
15:57

Yes, and this is the problem — that, you know, I can be an orthodontist, and I can have a great practice where I employ some assistants to do most of the work for me, I have a treatment plan, so I apply a treatment plan, the patients come through, and we have three or four different types of treatment, everyone understands the protocols, and this whole system runs like a machine, and it's no stress, you know, five o'clock, six o'clock, your clinic closes, you go home, there's no stress, there's no worry, you make really good money — I mean, really good money doing this — and you don't — you make people's teeth straight, that's what we do in modern medicine, you know — "doctor, here's some money, I want you to make my teeth straight for me, I want that product" — and here you have a very successful business. Trying to change swallowing, breathing, posture — well, that's hard work, that's difficult, you know, I don't clock off, I'm on call all the time.

Patrick McKeown
17:12

Yeah, I am trying to — I understand it is difficult, and I work with breathing with kids, it doesn't mean it should be ignored.

Dr. John Mew
17:18

It has not — no, no, no, no, no, no, yeah — it has been completely ignored.

Patrick McKeown
17:25

How many dentists, if I went into my local city in Galway here, and I went to an orthodontic practice, and I have asked dentists here, and I've asked them the simple question, does mouth breathing affect the development of the face — and the answer typically said back to me is no. So, in other words, if a child goes in with their mouth open, and even to their local dentist — surely, when we're thinking about oral health, it's not enough to be avoiding or minimizing sweet intake or brushing teeth, we should also be talking about the importance of nose breathing, because nose breathing ensures that there's healthy saliva, or more saliva in the mouth, which is anti-plaque. So here is the fundamental question — yes, it is challenging, but what is the alternative, if we ignore this? And if parents ignore this —

Dr. John Mew
18:12

Well, I don't think parents would ignore it if they knew the effect, that is the problem, the information isn't put out there, and I would also say that there would be a drive to encourage nasal breathing if society got behind it, if the school teacher was encouraging the children in class, if the parents were encouraging, if the pediatric dentist, if the doctor, if all of the healthcare professions — then it would be normal, and then it would be abnormal, the child going around with their mouth open. And we have to think of the bigger consequences of this.

Patrick McKeown
18:47

Karen Bonuck did a study in Stratford-upon-Avon, she published it in the journal Pediatrics in 2012, she looked at mouth breathing and sleep disorder breathing in children — she studied 11,000 children, from the ages of six months to the age of five, and children with sleep disorder breathing, if untreated, had a 40 percent increased risk of special education needs by age — I'm going to pull up this paper here now — she talked about mouth breathing as the hallmark symptom, now, when we're talking about craniofacial development and obstructive sleep apnea — so here is this paper here, 11,000 children, and a history of sleep disorder breathing through the age of five years of age, a 40 percent increased risk of special education needs by age. Now she goes on to say — she talks about pediatric sleep disorders resulting in disrupted, inefficient and inadequate sleep, both may affect brain development and cause neuronal damage, particularly during critical early developmental periods. She talks about 3 million children in the United States, aged between 6 and 21 years of age, who were receiving special education for conditions associated with sleep disorders. And then she asks, what are the classic hallmark symptoms of sleep disorders — the multi-dimensional expression of sleep disorder hallmark symptoms: snoring, apnea, and mouth breathing. Well, if the airway is compromised, is that child not going to snore? I'm sure that paper has been repeated dozens of times.

Dr. John Mew
20:27

I don't know that that's a pivotal paper, and Karen Bonuck does some really good work, but it's like she's speaking, but no one's listening.

Patrick McKeown
20:39

Yeah, this is the thing that is mind-boggling for me — as the person, and I've often said that looking into your industry, the dental industry, highly educated people — I know what it takes to get into university, to get your degree, is at a different level, at the top level.

Dr. John Mew
21:05

Yeah, so we have a dentist, and you want to get into orthodontics, you've got to be at the top level.

Patrick McKeown
21:12

Totally, and then these are really, really tough qualifications — parents, any parent listening to this is going to get it, and any parent listening to this, what I would say to parents is, when you're going around your day-to-day activities, you're going into a restaurant, look at the facial profile of the kids with the mouth breathing. I want to point out here that when we're talking about mouth breathing, remember we try and look at the specific angles of this, and we're saying an open mouth posture and low tongue posture — okay, because those are the elements of mouth breathing which we think are harmful, so we — if you're watching this, be aware that we're going to use these terms, we're going to flick around these terms, we've got mouth breathing, and that's an overall sort of description, it's much more of a layperson's description — when we're talking technically, we're going to be talking about an open mouth posture of the lips, and a low tongue position, because of course, you can breathe through your nose with your tongue low and your lips apart — so that's just — that's why sometimes it's important that we think about the medical terms, or the medical signs, sometimes with a slightly better description, but of course we all know what mouth breathing is, and it makes — helps people to understand, particularly the lay public.

Dr. Mike Mew
22:50

Yes, yes — the bit that maybe here is that the child was born with a high upper palate. Now, for example, I'll give you the case of myself — my parents, broad facial structures, all of the siblings, narrow facial structures. My daughter has tooth agenesis, missing one incisor, which is relevant, or prevalent, in 10 percent of the population — the study population, modern population — go back in those ancestral groups, basically the number of missing teeth is virtually zero. So even if it was a genetic influence — and of course the environment, we're talking about epigenetics here.

Patrick McKeown
23:24

Yes, perfectly — the recognition that this child has a small mouth, which does not have enough room for the tongue, which is going to likely encroach the airway — the dentist is still in a position to do something about it.

Dr. Mike Mew
23:43

Yeah, so whether it's the genes which have caused the narrow maxilla and the overcrowding, or whether it's the mouth breathing — so is it the genetics that cause mouth breathing, in other words, or is it mouth breathing which has caused the alteration to the shape of the face — the dentist is still able to — is in a position to expand that palate, to make enough room for the tongue.

Patrick McKeown
24:08

And so it really does come down to — it's not just about straightening the teeth, it's really about the child's airway, what we should be focusing on, and that's what you've been focusing on.

Dr. John Mew
24:19

Yeah, something here — yes, because the points you're raising, Patrick, have worried me for a long time, because — I'm the same, without any doubt — but the width of a palate is due to, and cured by, the position of the tongue, and yet there is no doubt that this can — well, children can have narrow palates at birth, I know that the tongue is actually posturing during development, and maybe some children have poor tongue posture in the womb, that could explain it, but in many ways that weakens my own hypothesis, and I think that one should be able to answer that, and I really can't.

Dr. Mike Mew
25:13

No, but regardless of the hypothesis, we are still — the whole debate is all about the chicken and the egg. So, for example, just — how long should the child have their mouth open before it's clinically relevant, or has a negative impact on the growth of the jaws? How much nasal obstruction is relevant? None of this — these are absolutely irrelevant if the child has their mouth open, and the problem with this is, how do we measure — it comes back to, why do we need to have it absolutely measured in science, when common sense should be the logic here? Common sense should be the approach — if the child is having their mouth open, the tongue isn't able to rest in the roof of the mouth, and if the tongue is considered to be an orthodontic appliance, or at least it provides support — that is the only perfect orthodontic appliance, is the tongue.

Dr. John Mew
26:04

You know, one's professions go in a certain direction, it can be hard to change the direction, because you have this structure, you know, people are taught methods of straightening teeth — well, if you've been taught methods of straightening teeth, then that's what you do, and if that's what your career now is predicated upon, to buy into the alternative viewpoint would weaken your own —

Dr. Mike Mew
26:35

Yes — what you're taught, your sense of identity, you know, this — what you've become, an orthodontist, you've become a tooth straightener, that's your identity — to suggest maybe we should be doing prevention, and that's when you start to understand. So, Patrick, we talked about the "Black List" article I produced — so I went on a five, six year letter-writing campaign, to try to get a debate on — why people, you know, my specialty, the orthodontists, openly admit that they don't know the cause of the problem. Now it might surprise people, but the best textbooks in the world are suggesting that we don't know — more than 95 percent of cases — syndromes and genetic reasons account for less than a percent of that, most of that five percent that's understood, that you have thumb-suckers, your tongue-thrusters, you know, the really obvious ones, and the rest of them, you know, no one's got a clue — the whole specialty doesn't have a clue. So I thought, sensibly, we're treating a condition without knowing the cause of the problem — let's have a debate on this, let's have a debate on why teeth are crooked.

Patrick McKeown
27:53

So if you scroll to the very bottom of that article — yeah, go to the very bottom, the last paragraph —

Dr. Mike Mew
28:00

Is here, so it says: I challenge the orthodontic profession to debate, to test the hypothesis that malocclusion is caused by the environment and modified by the genes. If this is upheld, then an independent investigation on the theory of orthotropics should ensue — because, you know, this concept — so whereas we talk about orthodontics as "orthos" correct, or straight teeth, "orthotropics" is "orthos" correct growth. So, effectively, I'm saying, rather than straightening the teeth, if we get the face growing very well, then the teeth should be naturally straight within the better-developed space.

Patrick McKeown
28:41

Yes, we go one step back — this gets emotive when we talk about faces, but —

Dr. Mike Mew
28:47

People with great facial form, you know, the best facial architecture, tend to have straight teeth, broad smiles, and space for all of their teeth. People whose facial architecture — well, what do we say, this is emotive — didn't grow as well, tend to have crooked teeth and less space for all of their teeth. Now, conventional wisdom is growth is largely genetic, what you're going to do is straighten teeth in the space you've got, and orthodontists are generally brilliant at doing that — no, this is my professional hat off to them, they're brilliant at arranging the teeth within the given structure that someone has grown to. Well, we're saying, or we could go beyond that, we could try to change the very structure, the very growth of the structure, so that you gain good architecture and naturally straight teeth. You don't need retention — I don't even use fixed appliances to make teeth straight, because I don't want to force teeth into position, I want the individual to align their own teeth, they may not do quite such a good job, but it's likely to be more stable, and the resultant shape to the face.

Dr. John Mew
30:13

I'm just going to put up this — this can be replicated by any parent as well watching in — I went into Google and put in "adenoid faces," now, how many times have we seen these faces? And again, when I look at, for example, this boy here, his nose seems quite large, his maxilla is set back, his mandible is very set back — so already then you have to ask the question of his airway. The question here to ask is, will these children have straight teeth, or will they have overcrowding of teeth? In all likelihood —

Dr. Mike Mew
30:53

Yeah, I mean, in all likelihood — but it goes beyond that, Patrick, yeah, because — well, when we're looking at the adenoidal face, yes, well, this is the great crossover with — the village idiot, okay, yes — now, again, this is emotive stuff, but when we start looking at what Karen Bonuck was just saying about mental effects of snoring and mouth breathing, and then, the village idiot look — just like adenoidal faces, these are just those guys that Karen Bonuck is talking about, who's getting lack of good neurological development, yeah, because — well, the village idiot, don't they — yeah, and you know, these are big things, because we've gone here from talking about crooked teeth and facial aesthetics, and these things that a lot of people could write off as being — not linked, we're just talking aesthetics, it's looking pretty — now we're moving into sleep apnea, neural development, and, you know, I had a chat with a senior ENT, laryngology surgeon, about 18 months ago in North London, and I said, I thought, about 10 percent of the British population, although that could be drawn from most westernized populations, but I said 10 percent of the British population were going to be dying about 10 years younger because of sleep apnea and its consequences, and he went, "why, more like 20."

Patrick McKeown
32:24

And that's one in five.

Dr. Mike Mew
32:29

And remember, I qualified in '93 for dentistry, in my undergraduate, and sleep apnea wasn't in the syllabus — this has gone from not being in the syllabus in '93, when I qualified as a dentist, to killing 20 percent of the population 10 years early. Now —

Patrick McKeown
32:54

Wow, that's — I was like, what — '93 — next year's 2003, that's — 30 years — hello, well, wake up, smell the coffee, yeah, what the hell is going on. There's another aspect here as well, where I think the dental — has a fundamental role to play, Mike — I'm a middle-aged man, I don't go to my doctor very often, as a fact, I went to my doctor about two weeks ago, and the last time I was at my medical doctor was in 2012. I don't think I'm unique — I could have had all of the classic hallmark symptoms which I do for sleep apnea, but I'm not going to my medical doctor, so I'm not going to get that diagnosis. 90 percent of the population, according to studies in the United States, are undiagnosed with obstructive sleep apnea — at 90 percent, only 10 percent are getting treated. If a dentist was trained in the evaluation and recognition of the risk factors associated with obstructive sleep apnea — because I go to my dentist every six months, but I'm not in the chair very often — the dentist is in an ideal position to check the high palate, the scalloping of the tongue, the jaws that are set back, and this is something that the dental profession — it would be tremendous, as an educational campaign about sleep, knowing that we know the effects.

Dr. John Mew
34:18

May I make another point — sure — we really need to talk a little bit about why so many people have their mouths open. Now, I have very little doubt that it's due to the fact that we live in houses. Houses are full of dust, not just a little dust, but in every bedroom particularly, the air is stuffed full of allergens, masses of them, breathe them in, and you will have allergies. Now, the most sensitive time is soon after birth — children are put in a bedroom full of fluff and everything else, they develop nasal rhinitis, they have runny and blocked noses, they can't breathe, alright, it tends to be spasmodic, but the important thing is that over time, they get into the habit of mouth breathing, that becomes a permanent habit, and it's because we live in houses, and the only cure is to sell your house and go and live in a cave.

Patrick McKeown
35:37

We are taking the conversation a little bit off topic — wonderful, but you're just adding things in —

Dr. John Mew
35:43

But I'm not — we're getting — getting blocked noses is — it doesn't — we don't have to be the ones that define the causes of the blocked noses, we know it's happening.

Patrick McKeown
35:50

And the risk is that if you put your neck out and make comments like that, those are the comments that people trying to disprove your argument will focus on.

Dr. John Mew
36:02

Maybe, but it is the truth, and one day we'll realize that.

Dr. Mike Mew
36:07

I'm sure that holds a lot of water, Patrick — can I just come back on your comment of the dentist — dentists are also uniquely positioned to take sideways facial photographs, lateral facial photographs, of all of the children in their care, they can monitor the growth of the face, and I think it should be mandatory for dentists, during a checkup, to take a lateral clinical facial photograph of the child's face, just to monitor what is happening. The number of times I get patients to come here to see me, and let's say they're 12 years old — honestly, don't — 12 year olds, you're pretty much finished growth with a 12 year old girl, more or less finished — but I want to understand what's happening, so I said to them, have we got any lateral facial photographs, and they don't have one, even this day and age where you've got so many photographs — I mean, I had about 20 photographs taken of me in my childhood.

Patrick McKeown
37:18

Well done, that.

Dr. Mike Mew
37:18

My kids must have 20,000 photographs of them now. Sometimes what we'll resort to is taking an image from a video, as they turn their head — just this is just for interest's sake, of what's gone wrong, how could we have predicted it, how could we have — this is science, this is what — my mission is to get the spotlight of modern medical research to focus on this area, because we've got some ideas, we've got some interesting points, okay, and what the doctors keep turning around and saying is, "show me your evidence."

Dr. John Mew
38:03

What has happened — chase, first, refuse to the maximum all the evidence that's already been researched, set up some protocols, on public money, because that's what it takes, and then do some research. Or, if you want to do it the other way around — if you want to say, "oh, show me the results of your cases" — great, but can we do some comparative research? So rather than you focusing on the teeth, saying, "oh, but you haven't got perfectly straight teeth," which of course I don't, because I'm not making the teeth straight, I'm asking the individual to straighten their teeth, I'm unlikely to ever get perfectly straight teeth, and it's never going to happen — so if you want to demonstrate that I can't get the teeth as straight as you can, oh, wonderful, what does that achieve? But if you were to add the facial before-and-after photographs, as well as the dental before-and-after, now we can have — I just — you know, we've got an open setting.

Patrick McKeown
39:00

We're down — when did you start challenging people to comparative research?

Dr. John Mew
39:07

Oh, a long time ago, I think probably in 1972.

Patrick McKeown
39:20

Okay, so from 1972 — because you've mentioned that, I'll even write that down — so from 1972 we've been asking for comparative processes. Okay, can we — can we just — I realize that you can see the effects of posture.

Dr. Mike Mew
39:41

Oh, also — what do we mean by orthodontics that's observant of the airway, or what was the phrase you used?

Patrick McKeown
39:47

Well, what I would like is that an orthodontist is not just embarking on straightening of the teeth, but also taking into consideration the airway itself — so my facial profile, for example, my forehead, and then my nose, which is crooked, my maxilla is set back, and my mandible is set back, and my airway is compromised, because I had a lot of challenges in school, I left school initially at 14, out of a total sense of frustration with the education system. I went back one year later, I did get my grades, I got into university in Dublin, and I had to work really, really hard — it could have been a lot easier.

Dr. John Mew
40:30

I want to come back just — two things that are kind of niggling me a little bit — one is the facial profile here —

Patrick McKeown
40:41

They — just to explain it to people, adenoids are lymphatic tissue at the back of the nose, which impedes airflow, and it forces the child to actually breathe through their mouth — it's not the adenoids per se which has caused this facial profile, but the adenoids which block the airflow, so that the child wasn't able to breathe adequately through the nose, the child then switches to mouth breathing, when they switch to mouth breathing, their tongue drops — this is a medical term, and I'm not sure when this term was coined, "adenoid face" or "adenoidal face" —

Dr. John Mew
41:19

Back in the early 1900s, yes, well, it's been around a long time, and we will see these faces around quite often.

Patrick McKeown
41:30

Coming back to the growth of the human face — now this is a paper from 1953, but I have one as recent as 2013, and any of these papers will talk about the most critical growth period in children being typically between age one and five years of age, and that's why I suppose this is something that needs to be considered, in terms of — if that child has a mouth-breathing posture, many of them do, early intervention is very, very important, if at the very least, to encourage the parents to be observant of their children, and working with different childcare professionals, to understand and change the pattern.

Dr. Mike Mew
42:07

Yeah, well I'm just waiting for you to finish, but no — I'm just going to pull up this one here — this is a 2013 article, so 1953 to 2013 — they were looking at 210 kids here, sorry, yeah, 30 subjects, 15 males, 15 females, but 210 x-rays of the head — after five years of age. So basically the conclusion was that the overall linear growth changes that occurred between six months and five years of age — a span of four and a half years — were generally greater than the changes in maxillary growth that occurred between five and 16 years of age, a span of 11 years. In other words, the growth of the maxilla is double the speed from age six months to five years of age, as it is from five years of age to 16 years.

Patrick McKeown
43:14

Yeah, most papers, in terms of — but it's quite understood — are still in agreement that the critical growth spurts in children are early on, informative years.

Dr. John Mew
43:20

Yeah, it puts it in very simple terms — once the incisors have erupted, it is very hard, or much harder, to change the pattern of growth of the face.

Patrick McKeown
43:40

The implications of this — sorry, may I cut across here — the implications of this then is that if habits have not been addressed early on, as the child's face is growing, can we see — does it continue to have that adverse growth in the child's face? In other words, the question may be for parents — you could have a child that's 13 years of age, should we be encouraging that 13 year old child to start breathing through the nose, with the tongue resting up in the roof of the mouth — if we don't, can we — can we have an adverse reaction even at that age?

Dr. John Mew
44:18

I have been impressed with how much change you can create right up to the age of 20, alright — not in every child, but if you correct posture at 16, 17, you can get big changes — when I'm talking big, I mean forward growth as much as 25, 30 millimeters, now that's huge compared with the size of the face.

Dr. Mike Mew
44:53

But sorry, it gets exponentially, disproportionately more difficult as you get older, and it seemed to be the keystone points — the age when the molars and incisors finally come in, sort of five, five and a half, the six to six and a half — the point where the maxilla stops — seems to stop growing anywhere from sort of 10 years old to 12 years old, and then sort of 18 to 25 years old — with 25 years old being roughly the top end, you know, by the time all your growth hormones — they've gone — you know, you finish growing as a boy maybe a little bit at 17, 18, but you still have enough growth hormone carrying on to 25, so you've got some change in you. And then after that —

Dr. John Mew
45:44

Patrick, after that, if you had a stroke, one side of your face would drop down — that would happen right up to 80 years old. So is it actually the skeleton, the bones, that are preventing change, or is it just — you've become a creature of habit — the muscles?

Dr. Mike Mew
46:03

Yeah, well I don't — I know there is a difference between growth and change.

Dr. John Mew
46:10

Yes, it's a great — yeah, yeah, there is, there's a big difference — I mean, you're fully grown, most girls by 12, most boys by a sort of 14, 16 — in the whole body, the face generally — the head is ahead when you're born, you're more head-disproportionate than you are the rest of your body, and so your head is ahead, and it finishes growing before everything else, often quite a long way before everything else, but you can still gain change, and this is what these kids, these "mewing" kids, are doing.

Dr. Mike Mew
46:42

So I came out with this — I put my ideas online, they were swallowed hook, line and sinker by the young adolescent community, and they took my exercises and they kicked it out of the ballpark — I mean, it's just amazing, because what you then get, and what I then observed, was these young men, really — mainly young men, women as well, but predominantly young men — working really hard to change how their faces grew. Now, I'd love to show — because we're talking about faces changing, we're talking about these guys with adenoidal faces, and there's something I'd like to put this in a bit more perspective, do you mind if I share the screen for a second —

Patrick McKeown
47:29

A co-host — now you are.

Dr. Mike Mew
47:36

Okay, so what I'm going to do is I'm going to put that out big on that screen, and then I'm going to go — share screen — I will go — share that screen — there, I must go before too long, but okay — okay, well, I've shared this screen, yes — and okay, so what I've got here is — I won't go to slide view, because then it gets much more complex, but you see, this is someone in the sort of prehistoric period, this is someone going back to — hunter-gatherer, maybe, you know, before, or simply, the medieval period — someone living a much more natural lifestyle, chewing heavy things, using these muscles, mouth closed, easily able to breathe. And then, as we go into the modern world, the face starts dropping down, okay, so you've got weak muscles from modern food, we've got blocked noses, we're hanging our mouths open, both of those is causing the face to drop, and we get down — and this one progresses down into the classic adenoidal pattern. But it doesn't happen that way for everyone — we've got these classic three classes of malocclusion, and as faces drop down, they go to about a halfway point, and then they change into various different directions. So what we've got here is — this is someone who's dropped straight down, what we call class one. There's someone who's dropped down with the jaw going back more, so they've tended to breathe like this, that method of coping with the situation is to push the tongue forward and hang it out, so they tend to grow in this type of direction — forward head posture, I think they all get a forward head posture, because that's just, you know, when your face collapses, you need to hold your head open to open the airway. But the last one, the class three, these people tend to drop their tongue and the mandible, and hold the mandible forward, and that's a really good way of coping with this situation. But it means, depending on how you respond, you are going to get a different pattern, or even what we would expect, a different phenotypic expression, is what you would call it medically, but you end up in a different place depending on how you respond to the problem, and that's what slightly complicates these discussions — you know, the one here being that classic adenoidal face, but everyone you're going to meet in a modern world is slightly down to one, everyone's down, you know, I'm flat round here, my face has dropped down a little bit — basically everyone, the people who are least affected, they're the people adorning magazine covers, and actors and people, and I don't think it's — that genetically related. I mean, I think — and this is a controversial statement to make — but I think almost everyone was designed to have a really healthy face that looked aesthetically pleasing, and that is, in a way, our inheritance, and that's what, in a way, we should be getting back to — and I know that's such a controversial statement, and everyone should be happy the way they are.

Patrick McKeown
49:58

So he's published several papers, and one of these papers is: establishment of nasal breathing should be the ultimate goal to secure adequate craniofacial and airway development of children. Now here you have one of who's considered to be one of the top founding fathers of sleep medicine, pretty much saying what you've been saying to some degree — if we just look at the title, nasal breathing should be the ultimate goal to secure adequate craniofacial — he's talking about the face, and he's talking about the development of the airway, and how it develops. He talks about chronic mouth breathing during active craniofacial development of a child may result in anatomical changes that directly affect the airway, these changes may result in a greater airway to be — becoming collapsible, that potentially leads to other problems later in life, such as sleep disorder breathing. Prior investigations of children with mouth breathing have shown a correlation with abnormal orofacial growth. So surely we cannot ignore what a person — considered the founding father of sleep medicine — I mean, all we're asking, really, is for a debate.

Dr. Mike Mew
51:16

Yeah, yeah, I want a debate on why teeth are crooked, you know, and also the bigger debate on what John was saying, that we have to be considering the face, we have to be considering the airway.

Patrick McKeown
51:27

And I'm going to bring it to a close, because I think it has been a tremendous conversation, we started with the cause of crooked teeth and worked upwards to these other subjects.

Dr. Mike Mew
51:33

I could say a lot about the actual cause of sleep apnea, but that is another subject, and I think it's related to the cause of crooked teeth — this whole thing, we're talking about one structure, and I'm saying, if you've got crooked teeth, then there's a high — this structure, there was something wrong with the growth of this structure — if you have crooked teeth, or you don't have enough space for all of your teeth to align naturally, then something's gone wrong with the growth of your face, and that will have other health knock-on effects.

Patrick McKeown
52:57

That is true, yeah, so even with the phenotypes of sleep apnea, it is still a recognition that anatomical compromise is the single most common factor which is causing obstructive sleep apnea, there are other phenotypes as well, loop gain, upper airway recruitment, etc.

Dr. Mike Mew
53:20

Yeah, there's an intimate interplay between all of those as well.

Patrick McKeown
53:34

Yes, yes, yes — so, thanks so much for your time, and any parents, any people listening to this, I would love to bring some support to Dr. Mike Mew, he has had, I would say, a rough journey, I really feel for you in terms of putting this information out there. And I think ultimately the decision-makers here — it should be about the parents, it's the parents, and it's the parents' children, and I think for any of us as parents, we should be viewing how we are having our children treated, orthodontically and with dentists, but also knowing the information.

Dr. John Mew
54:13

Yeah, you can break most of what I'm saying, we're saying, to — stand up straight and shut your mouth, now there's a good start.

Patrick McKeown
54:24

Okay, choose from your mouth, okay — so we'll close at that. Thank you so much.