Overview Articles

The Jaw Epidemic: Recognition,

Origins, Cures, and Prevention
SANDRA KAHN, PAUL EHRLICH, MARCUS FELDMAN, ROBERT SAPOLSKY, AND SIMON WONG

Contemporary humans are living very different lives from those of their ancestors, and some of the changes have had serious consequences for
health. Multiple chronic “diseases of civilization,” such as cardiovascular problems, cancers, ADHD, and dementias are prevalent, increasing
morbidity rates. Stress, including the disruption of traditional sleep patterns by modern lifestyles, plays a prominent role in the etiology of these
diseases, including obstructive sleep apnea. Surprisingly, jaw shrinkage since the agricultural revolution, leading to an epidemic of crooked teeth,
a lack of adequate space for the last molars (wisdom teeth), and constricted airways, is a major cause of sleep-related stress. Despite claims
that the cause of this jaw epidemic is somehow genetic, the speed with which human jaws have changed, especially in the last few centuries,
is much too fast to be evolutionary. Correlation in time and space strongly suggests the symptoms are phenotypic responses to a vast natural
experiment—rapid and dramatic modifications of human physical and cultural environments. The agricultural and industrial revolutions have
produced smaller jaws and less-toned muscles of the face and oropharynx, which contribute to the serious health problems mentioned above.
The mechanism of change, research and clinical trials suggest, lies in orofacial posture, the way people now hold their jaws when not voluntarily
moving them in speaking or eating and especially when sleeping. The critical resting oral posture has been disrupted in societies no longer hunting
and gathering. Virtually all aspects of how modern people function and rest are radically different from those of our ancestors. We also briefly
discuss treatment of jaw symptoms and possible clinical cures for individuals, as well as changes in society that might lead to better care and,
ultimately, prevention.

Keywords: jaw, epidemic, evolution, orthodontics, cultural environment

“ What are the causes and consequences of the

growing prevalence of crooked teeth?” is a much-
neglected question in public health. The much-neglected
tip of the iceberg—symptoms of a more serious underly-
ing pandemic. Children are increasingly walking around
and sleeping with their mouths open, snoring, and, along
answer is the same as for other “diseases of civilization”: that with adults, suffering obstructive sleep apnea and upper
industrialized humanity has developed an unprecedented airway resistance syndrome (UARS). The increase in these
lifestyle. Among many other things, that lifestyle has problems can be only roughly estimated because of various
dramatically changed the environments in which human forms of detection bias. Nonetheless, unbiased sampling
beings develop and has led to serious health problems of skulls of industrialized and hunter-gatherer populations
(Ehrlich and Blumstein 2018), including the largely hidden shows unambiguously that the former suffer a higher inci-
ones connected with human jaws. One branch of dentistry, dence of jaw problems.”
orthodontics, has become big business, and many children Obstructive sleep apnea refers to having repeated stressful
are now wearing braces and then retainers to manage mal- episodes of interrupted sleep from a temporary cessation of
occlusion. The prevalence of orthodontic treatment, largely breathing, tracing often to jaws too small to house the tongue
for cosmetic reasons, during a lifetime may be reaching 20% adequately. UARS is sleep fragmentation, often accompanied
in the United States with the “need” much higher (Brunelle by snoring, without apnea, often traceable to narrowed jaws
et al. 1996, Christopherson et al. 2009). Furthermore, (Guilleminault and De Los Reyes 2011) The prevalence
increasing numbers of people are suffering facial pain con- of obstructive sleep apnea appears to be perhaps 2%–7%
nected to their jaws, specifically where they join the rest or more in children (Lumeng and Chervin 2008), about
of the skull at the temporomandibular joint (Sessle 2015). 5%–20% in adults in general (Finkel et al. 2009), and over
In some populations, up to 10% of people are sufferers 80% in some elderly populations (Senaratna et al. 2017). The
(LeResche 1997), and a branch of medicine has developed available data have many shortcomings, but a reasonably
that specializes in treating craniofacial pain. Unhappily, conservative estimate is that obstructive sleep apnea afflicts
rampant malocclusion and facial pain are actually only the at least 1 in 20 people worldwide (Punjabi 2008), which is

BioScience XX: 1–13. © The Author(s) 2020. Published by Oxford University Press on behalf of the American Institute of Biological Sciences. This is an
Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/
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Overview Articles

one indicator of the global extent of the jaw epidemic. We tongue. These may have been accompanied by a tendency
have found no data on the frequency of UARS, but it seems for mouth breathing as our ancestors moved onto savannahs
reasonable to assume that it is higher than the frequency of and needed greater airflow to lungs to increase endurance
obstructive sleep apnea. for pursuit hunting. If endurance running was important
In children of normal weight, obstructive sleep apnea “is (Bortz II 1985, Bramble and Lieberman 2004, Lieberman
a disorder of oral-facial growth” (Huang and Guilleminault DE et al. 2009), the shrinkage of the face may have helped to
2013, Stupak and Park 2018). The stress caused by obstruc- stabilize the head (Lieberman DE 2008). “Human distance
tive sleep apnea or lesser degrees of sleep disturbance, runners are obligatory mouth breathers (but not pant-
such as UARS, is associated with a wide range of diseases ing).” Significantly lower levels of general fitness in modern
including heart disease (e.g., Peker et al. 2006, Gottlieb et al. societies may reveal why so many people are overbreathing
2010, Taylor et al. 2017, Lopes et al. 2018), cancer (Campos- (hyperventilation) orally, becauase relatively nonstrenuous
Rodriguez et al. 2013), ADHD (Montgomery and Wiggs tasks are provoking mouth breathing because of reduced
2015), and possibly Alzheimers disease (Walker 2017a, Fultz respiratory efficiency (Tomkinson et al. 2012, 2019).
et al. 2019), as well as with deaths from errors caused by Oral overbreathing alters oral rest posture, thereby the
fatigue on the highway (Tregear et al. 2009) and in hospitals, developmental growth of the jaws. Dentists are familiar
where interns often get inadequate sleep (Walker 2017b). with what they call “long face syndrome” or “hyperdivergent
One of the potentially nasty consequences for individuals growth”; it results from hanging the mouth open and pro-
with obstructive sleep apnea is that the stress of disturbed duces a face with augmented downward facial development
sleep results in more or less constant sympathetic arousal. and restricted airway development. The cause is changes
Virend Somers and his colleagues at the Cardiovascular in habitual posture related to narrowed airways and weak
Center at the University of Iowa College of Medicine con- chewing muscles. It leads to overeruption—the teeth becom-
cluded “that patients with obstructive sleep apnea have high ing too long (Buschang et al. 2013).
sympathetic activity when awake, with further increases Keeping the teeth apart at rest alters jaw structure, caus-
in blood pressure and sympathetic activity during sleep” ing, among other things, a downward and backward rota-
(Somers et al. 1995, Usui et al. 2005, Abboud and Kumar tion of the mandible. Together with increased malocclusion
2014). Men with obstructive sleep apnea, if they also have and other changes that accompany recent jaw shrinkage,
insomnia that involves high sympathetic activity (Nunn this has made the airway more susceptible to blockage or
et al. 2016), are also at greater risk for depression or hyper- collapse and children more susceptible to choking if they
tension than those with either condition alone (Gupta and try to talk and eat (swallow) simultaneously. But preceding
Knapp 2014, Lang et al. 2017). Moreover, the disruption of evolutionary changes toward smaller jaws also (Harari et al.
sleep that is a typical consequence of obstructive sleep apnea 2010) provided presumed advantages, such as allowing the
increases the risk of cardiovascular disease (Palma et al. evolution of speech with syntax. As all the structures short-
2013, Li et al. 2018), most probably arising at least in part ened and descended, the physical structure for such speech
from the increased sympathetic tone (Bisogni et al. 2016). became possible (Lieberman P 2007).
Complicating the whole picture is that stress itself is a cause The selection pressures causing these changes as archaic
of disturbed sleep, a dangerous positive feedback system Homo sapiens genomes evolved into modern Homo sapiens
(Han et al. 2012). genomes over thousands of generations have been specu-
During the 2009 swine flu “epidemic,” about 0.5%–2% lated on (Lieberman DE 2008) but not identified with any
of Americans developed flu symptoms (Reed et al. 2009). certainty. The original reduction in jaw size that occurred
It therefore seems reasonable to call the array of orofacial millions of years ago as hominins evolved from ape-like
(and related airway) problems now afflicting people in the ancestors has resumed over the last tens of generations,
industrialized world a jaw epidemic, of which malocclu- moving much too rapidly to be attributed to genetic evolu-
sion is but one symptom. The oral and facial alignment and tion. Comparisons of Medieval and modern skulls demon-
developmental issues in the childhood population can be strate this dramatically, with tooth crowding considerably
traced specifically to poorly developed jaws. Nonetheless less frequent in the Middle Ages (Moore et al. 1968, Helm
shrunken jaws are not being viewed as a medical issue of and Prydsö 1979, Luther 1993), and there has been rapid
major consequence but rather as one of cosmetic concern. change in jaw morphology in that brief period (Goose 1981).
With very rare exceptions, hunter-gatherers had roomy jaws.
Origins: Evolutionary and environmental causes of Malocclusion and noneruption of third molars (wisdom
the epidemic teeth) and crowding of the tongue were close to nonexistent;
The root causes of our jaw problems go back several hun- preindustrial jaws were simply roomier than those of people
dred thousand years as the crania of archaic hominids exposed to modern lifestyles (e.g., Price 1939, Proffit 1975,
evolved into those of modern Homo sapiens. Major features Helm and Prydsö 1979, Gibson and Calcagno 1993, Luther
of that transition included moving to a more globular brain 1993, Kaifu 1997, 2000, Evensen and Øgaard 2007, Rose and
case with a shrunken face tucked under it, dramatic short- Roblee 2009, Lieberman DE 2013, Kahn and Ehrlich 2018).
ening of the human jaw, and backward movement of the The jaw epidemic is therefore a recent phenomenon and

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 Overview Articles

temporal and geographic correlation strongly suggests that but, rather, of maintaining the necessary negative pressure
it can be traced to changes in environmental factors due for long periods after a swallow, which is only possible in
to agriculture and industrialization, but exactly what those a closed compartment with that correct oral posture. The
factors are and how they operate remain uncertain. Indeed, critical area seems to be the rear of the tongue, which is
environmental influences on skeletal growth are largely parasympathetically innervated, meaning the posture can be
ignored by the orthodontic profession, which often accepts sustained without voluntary muscle action through passive
jaw skeletal development as genetic in nature, although the light suction.
teeth themselves are recognized as subject to environmental In any case, the importance of muscle posture and func-
influences (Proffit 1978, Tulloch et al. 1998, 2004, Dolce tion in skeletal morphogenesis is well established (Henderson
et al. 2007, Siara-Olds et al. 2010, Ehsani et al. 2015). and Carter 2002), although full understanding of the com-
The strong correlations in time and space with the course plex mechanical and biochemical processes influencing how
of the jaw epidemic and the agricultural and industrial bones develop remains elusive (Ornitz and Marie 2015, Wu
revolutions has naturally called attention to softening diets et al. 2016). The preponderance of evidence suggests the epi-
and a reduction in the amount of chewing required for demic is caused by environmental modification of the pat-
adequate nutrition (Lieberman DE et al. 2004, Buschang tern of gentle and persistent pressures that signal the normal
et al. 2013, Kahn and Ehrlich 2018). In the course of dealing development of the bones of the maxilla and the mandible—
with the genetic explanation of the epidemic, we now think the upper and lower jaws (Woodside et al. 1983). That is
too much emphasis has been put on the chewing function seen in animal studies (such as blocking a monkey’s nose or
and not enough on oral posture. Current evidence suggests using a device to change the pressures its tongue applies to
that alteration of oral postural influences on skeletal growth its palate; Harvold 1968) where changing the environment
is the main cause of malocclusion. It results from changes disrupts normal jaw development. Also, when the teeth are
in the persistent but gentle forces that appear to influence not kept in contact during rest, the tongue spills out over the
phenotypic skeletal development—soft tissue positioning teeth (as it does when the jaw is hung open) so the whole
molding bone shape and size (Sankey et al. 2000, Mew pressure system fails. Jaws shrink, but the tongue does not;
2004, 2015a, Buschang et al. 2013, Buschang and Jacob indeed, it may grow larger in an obese individual (Nashi et al.
2014, Pisani et al. 2016). Bones grow (and change shape) 2007). The tongue may flow back into the throat, especially
under light but persistent pressures. Those created by oral when an overweight individual is supine, partially blocking
posture—the positions of the jaws and tongue in relation to the airway (channel for air in the throat) and contributing to
each other when a child is not eating or speaking—consti- snoring or, if blockage is complete, obstructive sleep apnea.
tute signals that, among other signals, guide the growth of Reshaping of bones by persistent gentle pressures is also
the jaws. What Mew (2004) postulated and more recently demonstrated by the fate of toe bones in Chinese women
Engelke and his colleagues (Engelke et al. 2011, Knösel et al. subjected to foot binding (Zhang et al. 2014) and changes in
2016) have demonstrated as “correct” oral posture is holding skull shape from head binding (Bridges et al. 2002; see also
the teeth lightly together, with the tongue positioned against https: //bit.ly/2LRiBwN).
the palate; clinical studies show that this posture results in an The most obvious results of disruption of normal infor-
adequately roomy jaw (Wong 2018). mation flow between developing soft tissues and developing
The Engelke team began to elucidate experimentally the jawbones in modern people have been the shrinkage of the
details of pressure differences within functional “compart- human jaws, their backward movement accompanied by
ments” (formed by the positions of the lips tongue and soft crowding and misalignment of teeth. That leads to a reduc-
palate) of the closed mouth, especially the way that, at the end tion of space for the tongue, mouth breathing, and loss of
of a proper swallow, there remains a self-sustaining negative tone in orofacial muscles (Harari et al. 2010), as well as other
pressure in the key compartment. They concluded (Engelke changes in facial morphology (Bresolin et al. 1983).
et al. 2011) that subjects (largely free of malocclusion) who A big requirement in understanding the epidemic and
swallow using the actions of fully closing their mouths prior treating its victims is to uncover exactly which of a num-
to an upward tongue pump generate a negative intraoral ber of possible factors disrupt correct oral posture and by
pressure system. This, in turn, is shown to develop a natural how much? One obvious candidate that has received much
biomechanical equilibrium of forces surrounding the dental attention is the effects on jaw musculature on switching to
arches as well as to reduce the upper airway resistance to a diet that requires less chewing (Sakashita et al. 1996, Hall
nasal breathing. Importantly, once this negative pressure is 2010, Limme 2010, Le Révérend et al. 2014, Sella-Tunis et al.
created, little if any further muscular input is required to sus- 2018). That environmental transition had an “impact on the
tain this closed posture, thereby providing what could well be human speech apparatus (and) spoken language” (Blasi et al.
the biologically optimal therapeutic rest position. 2019); that is, our occlusion changed from edge-to-edge to
This basically says actions just before and after swallow- overbite and overjet over the last 6000–8000 years. That
ing caused by environmental changes produced aberrant switch also appears to foster an incorrect (or reverse) swal-
swallowing that may hold the keys to the etiology of the jaw low. Incorrect swallowing can result in open compartment
epidemic. The problem is not a function of chewing itself resting postures, which, in turn, distorts the developing

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Overview Articles

jaw shape, whereas correct adult swallowing results in the 20%–25% of children under 5 suffer blockage of the nasal
necessary physiological posture held by negative pressure airway in early life (Jesenak et al. 2011). A stuffy nose auto-
and that can be maintained during sleep when maximum matically leads to mouth breathing and reverse swallowing,
growth occurs. altering the shape of the jaws and face during development
Hunter-gatherers usually did not gorge on massive soft (Jefferson 2010). Aberrant breathing and swallowing as a
meals or on calorie-laden, nutrition-free liquids, like soft consequence of infection (bacterial or viral), gastroesopha-
drinks. We suspect cultural traditions of thorough mastica- geal reflux, adenoid hypertrophy (Niu et al. 2018), smoke
tion, deliberate complete swallows, and pauses developed (Bugova et al. 2018), asthma (Nava et al. 2007) and allergens
in circumstances where food was not normally superabun- (Jesenak et al. 2011, Marseglia et al. 2011, Niu et al. 2018) in
dant (“chew your food thirty times, kids”). A connection early childhood affect adult jaw structure. The prevalence
of muscle use and mouth breathing to jaw development of pollution-emitting motor vehicles has also contributed to
(Surtel et al. 2015) has been shown by animal experiments. It the worldwide increase in the frequency of allergic rhinitis
appears that a transition to softer diets disrupts the signaling (Janssen et al. 2003) and mouth breathing, as have changes
system that determines appropriate orofacial structure. The to more processed and readily available foods in the human
negative impact on jaw development of that transition has diet (Hoff et al. 2005, De Batlle et al. 2008).
been demonstrated in people and other mammals (Beecher Another possible contributor to the epidemic is pre-
and Corruccini 1981, Hinton 1993, Lieberman DE et al. mature spoon (utensil) feeding before a child’s normal
2004, Pirttiniemi et al. 2004, Bonin et al. 2007, Kingsmill developmental system is ready for transition to adult swal-
et al. 2010). Nonhuman animals that had their oral pos- lowing. Spoons, forks, and chopsticks may not be iPhones,
ture disrupted by nose blockage or a dietary manipulation but they are technology and are being used to change the
(Harvold 1968, Lieberman DE et al. 2004) showed changes way children are raised (Brace 1986). In most industrialized
in their jaws analogous to what is happening to children in societies, spoon feeding starts at around 6 months. Weaning
industrialized societies today (Grippaudo et al. 2016, Kahn is critical to transition from the immature or baby swallow
and Ehrlich 2018). Furthermore, studies of jaw size in rela- to the adult swallow, and the method of food delivery is
tion to toughness and abundance of food and clinical stud- important in swallowing (Aytekin et al. 2014, Hernandez
ies in which treatment focused on muscle exercise and oral et al. 2019). The practice of force feeding children with
posture (how the jaws are held when not functioning) alters spoons before they are ready likely disrupts the normal
development of the maxilla and mandible (Wong 2018) sup- sequence of development. The only way to eat from a spoon
port the environmental explanation of the jaw epidemic. is to slurp from it. Spoon feeding too early does not lead to
It seems that swallowing properly and chewing thor- the proper transition to mature swallowing; it teaches a child
oughly, which are helpful in keeping the resting tongue and to suck and swallow. This is not an infantile or adult swal-
jaws in correct posture, prevented hunter-gatherers from low; instead, it is an aberration. This is why most of the food
developing long-face syndrome (Buschang et al. 2013). The ends up on the face when spoon feeding a 6-month-old. It
spread of that syndrome may have started early in industrial- seems likely that spoon feeding became common during
ization with reduction of duration of breastfeeding (Amaral industrialization, when mothers had to hurry and get back
et al. 2017) and weaning to liquid or near-liquid baby foods. to work and spoon feeding was quick and easy. Even societ-
There is evidence that extended breastfeeding reduces the ies that traditionally use chopsticks start children on spoons
chances of children having some types of malocclusion (Visser 2015).
(Peres et al. 2015, Boronat-Catalá et al. 2017, Doğramacı What other factors might change the way people hold
et al. 2017) or suffering obstructive sleep apnea. This sug- their tongues and jaws at rest? The main time our jaws are
gests that the early complex muscle use associated with at rest is when we are sleeping. If the posture hypothesis
breast (as opposed to bottle) feeding may be one factor in is right, function (exercise) will change the shape of the
achieving the muscle tone (Huang and Guilleminault 2013) jaw, but only posture will allow for coordinated growth. In
and pressures that are critical to proper oral posture and theory, a child can have balanced growth with weak muscles
development of the maxilla and mandible. if it sleeps with its mouth fully closed. It can have strong
It was not until agriculture and then, especially, indus- muscles and also an undersized jaw if it does lots of hard
trialized food processing created the environment in which chewing and breastfeeds for years (function) and if it does
correct oral posture was often compromised that many not sleep with its mouth fully closed. So a key change in the
human jaws underwent rapid shrinkage (Goose and Parry environment of a world settling down to practice agriculture
1974, Frake and Goose 1977, Kaifu 1997, Rock et al. 2006, and then industrializing may have been how people sleep,
Rose and Roblee 2009). Agriculture and industrialization very differently from the way our primate relatives and
encouraged a more sedentary lifestyle, moving indoors, hunter-gatherers slept—mostly on the ground (not in beds),
where ventilation rates are low and allergens are concen- on their sides, and without pillows. That had many postural
trated (Bornehag et al. 2005). Subsequent sending offspring advantages, including encouraging keeping the mouth shut
to viral sinks, such as daycare centers, and other fac- (Tetley 2000). This hypothesis surely deserves more inves-
tors in civilization resulted in developed countries having tigation, because human sleep patterns are unique among

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Table 1. Changes in the orofacial-respiratory environment induced by agricultural revolution and industrialization,
with possible impacts on oral posture and jaw development and health.
Hunter-gatherer societies (physical development focus) Industrialized societies (intellectual development focus)
Long breast feeding, specialized muscle use Insufficient nursing to develop posture or to hold muscle tone
No bottle feeding, normal physiological delivery Strong milk flow in bottle feeding, spoon feeding disrupts normal
swallowing, Pacifiers and bottle nipple changing tongue posture
Wean to adult diet, baby learns what and how to eat Baby food, pap, spoon feeding disrupts self-learning
“Chewy” diet, and proper swallow, encourages salivation (PH, cleaning, Increasingly liquid diet, bypasses positive nutritional and developmental
remineralization, first digestion, etc.) effects from vigorous chewing, salivation
Sparse populations, less viral transmission, fewer stuffy noses Dense populations, more nasal blockage, lead to hanging mouth open
at rest
Much time spent outside, less allergen exposure Little time spent outside more exposure to concentrated allergens
Sleeping on the ground, head not pillowed Sleeping on a mat or bed, head pillowed
Sleep relatively exposed to predators or enemies, snoring selected Sleep securely indoors, snoring less lethal
againsta
Body, nasal breathing and general posture maintained Body, nasal breathing and general posture often ignored
Active outdoor living, mouth closed, predominantly nose breathers, Couch potato, cell phone addict, teeth kept mostly apart at rest, nose
tongue plastered on palate and teeth lightly together at resta frequently blocked, mouth often hung open, tongue held low partially
resting over teeth kept apart
Note: Environmental changes possibly influencing jaw development in modern societies. Italic text represents the correct posture to provide an
environment for normal jaw development. aSpeculative.

primates and are thought to have been critical to the devel- change in facial development and a reduction of jaw size;
opment of human beings’ extraordinary cognitive abilities the development of speech; and postagriculture changes in
(Nunn et al. 2016). An interesting issue is the different living environment. See table 1.
perceptions of nighttime safety between hunter-gatherers
and sedentary peoples (Musharbash 2013) and their possible “Genetic” causation
impacts on sleep quality and, therefore, on jaw development. The overall failure of the dental community to understand
Sadly, we lack the data to say how blame should be appor- the jaw epidemic is partly because “most of the theories
tioned for the epidemic among the factors discussed above accept genetic changes as the main or underlying cause”
and listed in table 1. But environmentally instigated bad (Knösel et al. 2016). This persistent error can be seen in
oral posture, we emphasize, appears to disrupt the muscu- this quote on malocclusion in the respected WebMD (www.
lar–postural guidance of facial development, leading to the webmd.com/oral-health/guide/crooked-teeth-misaligned-
jaw epidemic as first agriculture (Katz et al. 2017) and sed- bites#1): “Most often crooked teeth, overbites, and under-
entariness and then industrialization spread over the world. bites are inherited traits just as the color of your eyes or size
Eating, not surprisingly, has a great impact on jaw form, as of your hands.”
has been long recognized (Ferris 1909). The effect of loading The US-government-approved MedlinePlus chimes in
bone with heavier mastication appears directly to affect the with roughly the same view (https: //medlineplus.gov/ency/
density and size of the structures (Lieberman DE et al. 2004, article/001058.htm): “Malocclusion is most often hereditary.
Zink and Lieberman 2016). “Both human and animal stud- This means it is passed down through families.”
ies have reported the effect of food consistency on orofacial Orthodontics is a big and successful business, and, in an
development, suggesting that a diet with harder textures era of genetic determinism, it is convenient to blame maloc-
enhances bone and muscle growth, which could indirectly clusion on genetics, avoiding the complexities of prevention.
lead to better mastication efficiency and potentially reduce As a result, orthodontic techniques tend toward symptom
the need for orthodontic treatment” (Le Révérend et al. management with temporary relief of aesthetic concerns—
2014). However, without considering the effect of posture, teeth straightening for teenagers, with lifelong management
it is difficult to determine the influence of chewing on the strategies (retainers) usually required for permanent success
form and balance between the jaws (Kaifu 1997). (Little 1999).
In summary, here are hypothetical evolutionary and Some scholars, although they accept all or some of our
then environmental steps to explain the origins of the jaw narrative, still assert that part of the problem must be
epidemic: a shift from sleeping in chimp-like tree nests genetic or hereditary. They apparently do not realize that,
to ground sleeping and a change of sleep posture; mouth because every attribute of all living organisms must to some
breathing for endurance running when hunting on the degree be traceable to their DNA (or RNA), the statement is
savanna; a switch to a hunter diet, with reduced chewing nonsensical. Nonetheless, some scientists continue to push
and altered swallowing; smoke-induced respiratory distress partial blame for the epidemic toward genetic evolution
from the use of fire; a change in mouth resting posture; a (Punjabi 2008) while ignoring the etiology of jaw shrinkage

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Box 1. Some genetic detail.

Recent attempts to find genetic contributions to craniofacial phenotypes have also used GWAS. For example, an analysis of 2329
people of European ancestry using more than 9 million single nucleotide polymorphisms (SNPs) found that 1821 SNPs across 15
genetic loci were associated with quantitatively defined aspects of facial shape (Claes et al. 2018). They found that most of these genes
were active in CNCCs, a group of embryonic cells that arise at 3–6 weeks of gestation and are important in formation of the facial
plan. Many of the SNPs involved were regulatory variants. It is not unreasonable that such regulatory elements can be profoundly
affected by environmental conditions during development. The type of chewing or breathing could well constitute environmental
effects on CNCCs that may contribute to phenotypes of the jaw (Askary et al. 2017). It is still the case, however, that the sample sizes
of genetic studies of jaw morphology are underpowered relative to corresponding GWAS of such phenotypes as height and body mass
index, where sample sizes of half a million are now routine. Genetic studies of malocclusion etiology have identified 4 deleterious
mutations in genes, DUSP6, ARHGAP21, FGF23, and ADAMTS1 in familial class III cases. (Weaver et al. 2017). Although some of
these variants may have large impacts on class III phenotypic expression, their low frequency (less than 1%) makes them unlikely
to explain most class III malocclusions that can be as high as 18% of malocclusion in Chinese population for example (Hardy et al.
2012). This research also may seem to some to confirm the theory that the basic cause of widespread malocclusion lies in “genetic
etiology” when, in fact, it cannot. To the contrary it is becoming increasingly clear from studies of height, mental illness, body mass
index and most other complex human traits (likely including jaw configuration) that the heritable component is due to hundreds or
thousands of genes each with very small effect. That militates against a sudden, near global, genetic change causing a rapid shrinkage
of human mandibles and maxillae.

and distortion (Powell 2009). The success of some clini- Suffice it to say that if there were selection pressures
cal techniques to normalize jaw growth in young children against big jaws, the limited number of generations (as few
(Kahn and Wong 2016, Kahn and Ehrlich 2018, Wong 2018) as 15) in which shrinkage has been observed in population
and abundant evidence that jaw shrinkage is a factor in both samples (Luther 1993, Larsen 1995, 2006) would not be long
obstructive sleep apnea and the advancement of maxilla enough for a genetic–evolutionary explanation. Anecdotally,
and mandible are key treatments, in addition to other surgi- shrinkage has been observed in one generation (Waugh
cal techniques (Sunitha and Kumar 2010, Olszewska et al. 1937) or within a single individual (see figures 1 and 2).
2012). This further makes clear the largely environmental There is also discussion of the possibility that genetic drift
cause of the epidemic. is involved in jaw morphology. But drift is random changes
This confusion over etiology is a possible result of the in the frequency of structural genes in small populations—
genetic determinism (Feldman 2014) that is characteristic of hardly an explanation for a unidirectional global trend in
much of popular science. For instance, recent genome-wide populations of millions exposed to similar environmental
association studies (GWAS) studies aimed at orofacial issues changes.
have been focused on possible genetic factors involved in
the variation in the eruption of third molars (wisdom teeth). Treatment of individuals
But they in no way suggest that selection and widespread Prevention is the ideal solution for parents of children with
genomic evolution explain the rarity of impacted third molars jaw development problems. The best course is probably to
in hunter-gatherers compared with their common occurrence seek help from an orthodontist or other practitioner who
in settled or industrialized human populations (Sullivan works with the postural factors and have her help them to
et al. 2016, Crittenden et al. 2017, Vukelic et al. 2017; see change their child’s jaw resting posture. The aim is to redirect
also box 1). Similar problems occur when “racial” differ- the trend in growth from the age of 3 or 4 so the jaws remain
ences in the occurrence of jaw-related disease are discussed. balanced by fostering a correct swallowing or resting environ-
For instance, Weinstock and colleagues (2014) found that ment. To date, there are almost no treatment approaches that
African-American children were about 20% more susceptible aim for the prevention of jaw development problems. There
to pediatric obstructive sleep apnea than children of other are no definitive evidence-based interceptive approaches. No
ethnic groups. But, unhappily, possible key environmental early intervention approaches have been proven to change
variables such as allergen concentrations at home or the length skeletal growth patterns to any clinically significant degree.
of nursing were ignored, as were different head shapes in dif- The focus on functional appliances (devices that attempt to
ferent human groups that could make some more susceptible change the shape of the mandible) and the correction of dys-
to the impacts of environmental change. In short, despite the function have not been successful means to correct skeletal
great attention paid to a possible genetic evolutionary cause of malocclusion. Schulz and colleagues (2005) and Siara-Olds
the jaw epidemic, precious little evidence of genomic change and colleagues (2010) revealed that these methodologies
being a significant factor has been uncovered (e.g., Cruz et al. provided a predominance of only dentoalveolar changes
2008, Xue et al. 2010, Mossey 2014a, 2014b, Moreno Uribe (altering the parts of the maxilla and mandible that evolved
and Miller 2015, Patel and Ifzah 2016). to hold teeth), whereas Tulloch and colleagues (1998, 2004),

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Figure 1. Indian Grandfather born in village who had come to England as a young man with his children. Son in center.
Grandchild (right) was born in industrialized society. You can see a progressive reduction in the forward dentofacial
growth in the three generations. Photographs: John Mew.

Figure 2. Allergy can block a young person’s nostrils as thoroughly as plastic plugs can block those of a rhesus monkey.
Look at the consequences in the present figure for an attractive youth (left) getting a gerbil for a pet. He was allergic to the
gerbil, and the resulting nasal congestion and mouth breathing redirected the growth of his jaw with sad results (center
and right). Photographs: John Mew.

Flores-Mir and Major (2006a, 2006b), O’Brien and colleagues However, almost none is not the same as none. Sankey
(2009), and Batista and colleagues (2018) have confirmed the and colleagues (2000) and Mew (2004, 2015a, 2015b)
elusiveness of any form of definitive methods for modifica- showed treatment effects of clinically significant growth
tion of the basal bone. direction changes of basal bone.

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Figure 3. Treating children with baby dentition can help

develop the jaws and improve their breathing. Note high palate
on the top left (upper jaw before) and top right much flatter
(after) forwardontic expansion and postural treatment. In
the lower left (lower jaw before) and right (after), note there is
much more space for the tongue after 3 months of treatment.
Photographs: Sandra Kahn and María Jóse Muñoz.

Addressing oral posture is the common thread for each

of these studies and a sound reason to direct attention and
funding to testing and developing postural approaches
(rather than the historical and current attention to func-
tional approaches) for the correction of malocclusion and
sleep disordered breathing.
But as we have said, for patients already suffering the
stress that accompanies this epidemic through sleep disrup-
tion (of which the worst is obstructive sleep apnea), symp-
tomatic treatments include oral appliances, the use of CPAP
(continuous positive airway pressure) machines, and surgery
(Liu et al. 2016, 2019).
As the role of poor oral posture as a cultural–etiological
factor for malocclusion and sleep disordered breathing, is
confirmed, programs such as Forwardontics and GOPex
(short for good oral posture exercise; Ehrlich and Levin 2005)
specifically designed to restore norms (such as table man-
ners and linguistic patterns; MacLarnon and Hewitt 1999)
that provide a natural oral environment and cure or signifi-
cantly improve aberrant swallowing and other ailments can
be employed in treatment of individuals (Ehrlich and Levin
2005, Ehrlich 2009). Figure 4. Profiles of children being treated by postural
These protocols encourage closed mouth resting posture by techniques. Left before, right after. Note on the bottom
creating a new jaw architecture (expansion) as well as the cor- left child, holding chin high to keep airway open, on right
rect breathing and, especially, swallowing patterns. The exercises normal posture, wide smile and gaps between baby teeth
focus on changing the start and end of the swallowing routine visible. Photographs: Simon Wong.
to produce the proper pressures during long rest periods. This
should accompany the array of therapies being implemented to (Born et al. 1999). Consonant with that, obstructive sleep
address the symptoms of the jaw epidemic. The results of treat- apnea is fairly consistently associated with increased tone
ment and posture training can be seen in figures 3 and 4. of the sympathetic nervous system (SNS; arising from
Poor sleep quantity or quality is stressful, and indices of increased stimulation of the SNS or decreased renal clear-
activation of the physiological stress response can be induced ance of circulating catecholamines), and well as activation of
by truncated sleep, disrupted sleep, and even the anticipation the adrenocortical axis (for a review, see Meerlo et al. 2008,
when going to sleep that it would be unpredictably disrupted Bisogni et al. 2016). Moreover, the bulk of studies show that

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 Overview Articles

when obstructive sleep apnea is significantly countered by prevention has long been recognized, but nonetheless, the
CPAP treatment, there are decreases in circulating catechol- emphasis has remained on the symptoms rather than the
amine levels, blood pressure, and heart rate (for a review, etiology of disrupted oral posture, especially causes in early
see Bisogni et al. 2016). These findings constitute further childhood. A sign of this misplaced emphasis is the wide-
evidence of the adverse downstream health consequences of spread opinion among orthodontists that early treatment
the jaw epidemic. does not work, when their view of “early” is starting around
7 years old—about at the end of a key growth period of the
Societal response human face (Scott 1954).
Problems such as the impact of premature spoon feeding “As the technology of tooth movement has improved, the
on jaw development would best be dealt with by trying to smaller has been the interest in the developmental aspects
change social norms. Feeding practices need to change. of the malocclusions” (Varrela and Alanen 1995). Indeed,
Utensil use needs to be timed with proper development. Varrela and dental anthropologist Robert Corruccini (1984)
Spoons and pureed baby food, should not be used at 6 correctly stated, “From the clinical point of view the most
months when the child’s first teeth are erupting but delayed important element of the new perspective is that most
to 12–18 months, when its molars come in. That time also of the malocclusions orthodontists are treating today are
coincides with the beginning of speech. It should become environmentally induced and, at least in theory, prevent-
the norm to respect that timeline, and the dental commu- able. Prevention can therefore be considered as a potential
nity should be at the frontlines of promoting it. Other social alternative for active treatment.” In practice, the only “pre-
strategies that could help reduce the impact of the jaw epi- vention” done (functional orthopedics; Fränkel and Fränkel
demic would be to train health professionals to reemphasize 1983) is to use appliances in attempts to correct jaw shrink-
posture and table manners, encourage children not to talk age in 7–8-year-old children, when we believe it is already
while they are eating—mealtime discussions should be an too late. We, in contrast, suggest guiding jaw growth in
important source of education. But only encourage discus- children as young as 2 years old,
sion after they are 6 years old and in an appropriate place. It’s Now is surely the time for a broad revision of dental
been done in the past; perhaps it could be done in the future. and orthodontic training. The orthodontic profession is in
Promoting good eating and speaking manners may be trouble. As orthodontist Bill Hang quoted, “Smile Direct
a social animal’s antidote to bad jaw growth and develop- within 5 years will do more orthodontics than all the ortho-
ment. But as clinical studies show, that requires discipline dontists in the United States combined.… Every practice
to counter the social pressures of industrial society. Sadly, will be devastated (https://vimeo.com/295502729).” Smile
the cure may continue to elude society if people continue to Direct Club is a commercial enterprise that, using techniques
ignore adult responsibility in this and related areas (Kahn developed by Align Technology for straightening teeth with a
and Wong 2016, Lustig 2017). Until such extensive social series of plastic disposable devices, straightens teeth with no
change can be entrained, there is a possible chain of action direct contact with a dental professional involved (https://
for both the avoidance of jaw shrinkage as well as mitiga- bit.ly/2BPKKzH). One danger of this is that just moving
tion of the consequences when it has occurred. Sadly, the teeth around and then necessarily holding them in place
latter may involve surgical correction of poorly developed with a plastic or wire retainer may not solve problems of
skeletal structures. Permanent solutions invariably neces- airway restriction that a forwardontist (an orthodontist with
sitate the modification or elimination of the habits, postural enhanced training when needed) could correct. Indeed, they
and functional, that resulted in less than optimal size and may disguise the malocclusion symptoms of the much more
configuration for orofacial structures. The jaws, tongue, all serious consequences of jaw shrinkage that, as we’ve noted,
the 32 adult teeth, including the third (wisdom) molars, and include heart attacks, malignancies, learning difficulties,
the airway develop in coordination and need to be treated dementia, and death on the highway or in hospitals.
as an integrated complex (as in a sense, should the entire During a pandemic, less active treatments, changing
body, including the mind) if modern environments are to be habits early, and the use of remote online consultations
prevented from causing serious noncommunicable diseases. will lower the risks to families and healthcare personal.
Early intervention (starting, ideally, in infancy) with targeted This involves using removable appliances and minimizing
growth programs has was shown in limited clinical trials that personal contact and aerosol production to help to prevent
jaw shrinkage can be avoided (Wong 2018). contamination within the orthodontic settings. Prioritizing
This brings us to a social–institutional question: How do treatments that retrain nasal breathing and resting with
we increase the supply or availability of orthodontists and mouth fully closed will very likely enhance the antiviral
other practitioners who fully understand the jaw epidemic? response against SARS-CoV-2 by engaging the filtering
Orthodontic professionals are the clinical facial growth effect of the nose and by increasing antiviral NO levels in the
experts, basing their practical techniques on the ideas of airways (Martel et al. 2020).
pioneers such as Angle (1907), Moss (1997), and Enlow One of the basic educational problems the jaw epidemic
and Hans (1996). The need to move orthodontics from highlights is the lack of training in evolutionary theory, not
symptomatic treatment of misaligned jaws and teeth to just in medical schools but in elementary, secondary school,

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Overview Articles

and college education. Not only does this lead to absurdities malocclusion) in children and adolescents. Cochrane Database of
such as that crooked teeth are caused by genetics and the Systematic Reviews 3 (CD003452).
Beecher RM, Corruccini RS. 1981. Effects of dietary consistency on cra-
resultant expense and suffering but, more dramatically, in niofacial and occlusal development in the rat. Angle Orthodontist 51:
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