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DARWINIAN

DENTISTRY
By Kevin L. Boyd, M.Sc., DDS

PART 2:

Early Childhood Nutrition, Dentofacial Development and Chronic Disease

A

s was discussed in Darwinian Dentistry part 1: An Evolutionary Perspective on the Etiology of Malocclusion1, the concept of a genome-environment mismatch is one explanation for the high rates of systemic diseases of civilization (DC’s) now seen in industrialized populations that were seldom, if ever, present in ancestral populations. Evidence from various academic disciplines suggests a correlation between risk for chronic systemic DC’s like type 2 diabetes, obstructive sleep apnea and cardiovascular disease, and changed dietary practices associated with industrialization. The mismatch hypothesis can also help explain the relatively recent increasing prevalences of certain chronic DC’s of oral origin; dental caries, periodontal disease and malocclusion are oral infirmities that have plagued mankind since the advent of agriculture some 10-12,000 years ago, but have only begun increasing in frequency over the past 250-300 years, and mainly in cultures consuming an industrial-type diet. Human fossil and pre-Industrial skeletal evidence suggest that the relatively recent secular trend in increasing worldwide prevalence of human malocclusion seems to closely coincide with changed dietary practices since the Industrial Revolution of the late 18th-mid/late 19th centuries. 28 March/April 2012 JAOS

(AMH’s) first appear in the fossil record some 200,000+ years ago; the pattern is remarkably consistent. Furthermore, many present-day cultures who remain unexposed to typically Western diets, including extant foraging and hunter-gatherer peoples like Australian Aborigines2 and !Kung bushmen3, also nurse and wean their young, typically with firm-textured and fibrous complimentary foods, according to an ancestral-type*, vs. moderntype** pattern of IECF behaviors. After the Agricultural Revolution spread out of the Fertile Crescent in roughly the 9th/8th-century BCE, the persistant threat of starvation was gradually lessened as people throughout the world gradually gained more control over their feeding environment. Over the next several millennia humans also learned to domesticate animals as an additional food source. Advances in agriculture and Fig. 1 animal husbandry gave way to better food supplies, increased population growth and eventually of hunger and starvation was a harsh reality of everyday pre-historic led to the invention of the mechanized factories and industry that existance; and breastmilk was the only source of infant nutrition for at ultimately began to flourish in mid/late 18th-century England, least their first 6 months of life. To North America and Western Europe. precisely determine at what age a child would have been completely *ancestral-type IECF- typically characterized by exclusive breastfeeding for approximately weaned from a mother’s milk, fossil 4-8 months, followed by a weaning period studies designed to detect isotopic with firm-textured complementary foods continuing well into the 3rd year of life. markers in teeth and bones have consistently verified that through**modern-type IECF- typically characterout human history nearly all babies ized by 4-6 months of exclusive bottlefeeding with commercial infant formucontinued to (non-exclusively) las and artificial nipples, followed by a breastfeed for well into their 3rd weaning period with soft pureed and year of life since long before overly-processed commercial baby foods well into the 2nd year of life. anatomically modern humans

Infant and Early-Childhood Feeding (IECF): Then and Now It is well established by anthropologists that modern human and archaic human mothers have been breastfeeding their offspring for thousands of generations. Throughout their evolutionary history food had commonly been relatively scarce for our human and prehuman ancestors and the possibility

Then: The Long 19th-Century Women, Infants and Children With the coming of the Industrial Age, many women began to leave their traditional agrarian and cottage industry domestic lifestyles for work in textile mills and as domestic workers for middle- and upper-class urban families. The historical era commonly referred to as the Long 19th-Century (1750-1914)4 is used to describe this period that featured both the emergence of the Industrial Revolution and the consequential Rise of the West. The Long 19th-Century not only brought sweeping changes in agriculture and manufacturing technology, but also ushered in improved transportation and natural resource management that would all eventually, as did the much earlier Agricultural Revolution, spread to the rest of the world. The transition from a manual labor to the new machinebased manufacturing economy seen during this era eventually led to mass migration of human populations from agrarian life to cities; increased income opportunities and general improvements in overall standards of living also contributed to the explosive post-Industrial population growth. Affordable and easily accessible highly-processed and caloricallydense foods also contributed to increased standard of living and population density. The traditional roles of women and children were drastically changed by the Long 19th-Century. Prior to the Industrial Revolution, the primary role of children raised in agrarian settings had been as active participants in familial efforts geared towards sustenance. When urbanized industry became the prevailing way of life, young children were expected to work, usually malnourished, long hours in factories under deplorable conditions. For many European and North American women of the Long 19th-Century, their traditional role in farmhouse and/or domestic cottage industry settings, which was generally conducive to ancestral-type child rearing and IECF practices within the home (Fig. 1), was often exchanged for greater income opportunities away from their homes and children. One of the biggest tradeoffs for women

who sought better wages away from the home was in having to give up the ability to breastfeed and traditionally wean their young beyond the stages of early infancy. Prior to the Industrial Revolution, and usually only during extenuating circumstances like maternal death during childbirth and famine, occasionally newborns had to be fed emergency foods that usually consisted of being wet-nursed and/or fed nutritionally-inferior animal milk and weaned with low-nutrient cerealbased gruels; wet-nursing usually involved the employment of a lactating woman other than the child’s own biological mother. Seemingly superior to other forms of artificial feeding, wet nursing is considered a somewhat inferior substitute as wet nurses did not usually feed children according to an ancestral-type pattern (i.e., ‘on-demand’ and in to the 3rd year of life). As the Industrial Revolution encouraged the employment of women away from their homes and hearths, the newly available highlyprocessed, calorie-rich and inexpensive soft starchy foods were often viewed as a modern miracle. By the middle to end of the 19th-century the trend away from traditional ancestral-type IECF practices was accompanied and gradually replaced by a trend towards feeding babies according to a modern-type IECF regimen that primarily consisted of manufactured animal milk-substitute formulas, newly invented artificial rubber nipples5 and highly-processed soft-textured gruels. These new commercial baby food products were also often aggressively marketed, not so much as emergency food alternatives for certain babies who couldn’t be traditionally fed according to an ancestral-type IECF regimen, but more often as superior sources of nutrition for all babies; the earliest commercial infant formulas were also marketed as being ideal for individuals of all ages who suffered from chewing disabilities (Fig. 2). Artificial methods of IECF is by no means a recent development in human history. Archaeological sites in the Nile Delta have contained specimens of wooden baby bottles,

Fig. 2

and references to artificial feeding are seen in ancient Roman literature and also in the Old Testament. Now: Infant Nutrition… ...Breast is Best? While formula-feeding can be useful and beneficial in terms of convenience and under certain extenuating circumstances that might preclude breastfeeding, scientific evidence is overwhelming regarding the health advantages of breastmilk in comparison to feeding babies with artificial formulas. According to the World Health Organization (Appendix 1):
Breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants; it is also an integral part of the reproductive process with important implications for the health of mothers. As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond. Exclusive breastfeeding from birth is possible except for a few medical conditions, and unrestricted exclusive breastfeeding results in ample milk production. Even though it is a natural act, breastfeeding is also a learned behavior. Virtually all mothers can breastfeed provided they have accurate information, and support within their families and communities and from the health care system. They should also have access to skilled practical help from, for example, trained health workers, lay and peer counselors, and certified lactation consultants, who can help to build mothers’ confidence, improve feeding technique, and prevent or resolve breastfeeding problems.

When discussing issues related to modes of infant feeding and potential health outcomes, it is important to be mindful that there are primarily two

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Fig. 3

Fig. 4

different components to consider: 1.) the chemical composition of artificial formulas when compared to chemical composition of breastmilk as the ideal standard; and 2.) the mechanical mode of delivery of infant formulas and/or pumped breastmilk from artificially nippled-bottles, in comparison to the ideal standard of breastmilk directly suckled from the breast. And when discussing infant feeding with regard to potential health risks vs. potential health advantages, it is also important to consider that it may be difficult to determine whether a particular health outcome is directly related to a specific mode of infant feeding; for example, prolonged bottle-feeding has been shown to positively correlate with recurrent ear infections6, but does this necessarily imply that breastfeeding is somehow inherently protective against developing recurrent ear infections? Breastfeeding is indeed associated with reduced risk for many diseases in infants and mothers; in contrast, the following deleterious systemic health issues have been positively linked to prolonged formula feeding: acute otitis media, nonspecific gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, asthma (young children), obesity, type 1 and 2 diabetes, child30 March/April 2012 JAOS

hood leukemia, sudden infant death syndrome (SIDS), and necrotizing enterocolitis. (Appendix 2). In addition to the well-recognized nutritional, immunological and psychological benefits, breastfeeding also promotes adequate development of the dental and oral myofunctional structures7. Two primary oral health issues associated with mode of infant feeding include risk for dental caries and/or malocclusion. When compared to formula-feeding, due to the presence in breastmilk of cariesinhibiting lactoferrin, combined with the fact that lactose (the only sugar in breastmilk), is not an optimal energy substrate for Mutans streptoccus, breastfeeding seems to be highly protective against the development of early childhood caries (ECC). In terms of malocclusion, when compared to bottle-fed (with human or commercial formula) children, breastfeeding has been shown to be protective against development of anterior open-bite8 and posterior cross-bite9 in the primary dentition. Wolff’s Law and Moss’ Functional Matrix Wolff's Law, which was established in the late 19th-century, essentially states that a bone’s form will follow

it’s function: “Remodeling of bone… occurs in response to physical stresses—or to the lack of them—in that bone is deposited in sites subjected to stress and is resorbed from sites where there is little stress. In essence, a bone's form follows its function.”10 According to Pottenger11, “In accordance with Wolff's law, the vigor of the nursing infant and the resistance of the nipple to his effort determine how strong the important muscles of mastication will be. The pull of the muscles acts on their attachments and develops the accompanying bones of the skull and mandible in proportion to the force exerted.” Complementary to Wolff’s Law is Moss’ Functional Matrix Theory (FMT) of bone growth; in the 1960’s Professor Melvin Moss, a Columbia anatomy professor, introduced his FMT12 which describes how bones are essentially grown by intercapsular pressures at ‘growth centers’ rather than grow independently (of applied force) at ‘growth sites’. The example most commonly used to illustrate the Moss FMT concept is that of how an expanding and encapsulated infant brain applies internal force against the cranial sutures/fontanelles and thus stimulates interstitial bone growth across the sutures, and in turn, will ultimately determine the final cranial vault volume. Breastfeeding Mechanism Previous thinking regarding the mechanism by which babies extract milk from their mother’s breast was primarily predicated upon the perception that a baby’s sucking would stretch the nipple to the junction of the hard and soft palate and then the tongue would massage milk expressed from the nipple during nursing (Fig. 3); it has only recently been determined through ultrasound imaging data (Appendix 3) that the actual mechanism by which babies remove milk from their mother’s breast is primarily due to a vacuum action produced by a lowering of the baby’s tongue from the roof of the mouth13. After the expressed milk is swallowed, the child then re-elevates the middle portion of the tongue firmly against the roof of the mouth with

simultaneous pushing of the mother’s nipple against the inside of the pre-maxillary/incisive suture junction (Fig. 4). This has a widening, flattening and lengthening effect on the palatal-facial sutural complex (i.e., mid-palatal, transverse-palatal and incisive sutures) (Fig. 5) that is consistent with, not only the bone growth theories of Wolff and Moss, but also with the good dentofacial development that is seen in typically ancestral fed versus non-ancestral-fed individuals (Fig.8). Given what is observed about how the expanding infant brain essentially grows the cranial vault, it seems reasonable to suggest that the initial volume of the palatal-facial sutural complex is primarily determined by the pressure of a breastfeeding baby's tongue/mother's nipple against the (still patent) mid-palatal, incisive, and to a lesser extent, transversepalatal sutures. Worth noting, the incisive suture (IS) (Fig. 6) separates the hard palate into two separate bones, a pre-maxillary section and mid/posterior section; the pre-maxillary section provides the foundation for the development of the mid-face, and interestingly, the IS disappears at about 3 years old in most children ….on about the same time that preIndustrial humans and modern day hunter-gatherers usually stop breastfeeding their babies. Sleep-Disordered Breathing, Attention Disorders and Malocclusion Malocclusion, and some orthodontic treatment options (e.g., bicuspid extraction and incisor retraction)14 is seldom discussed as a possible predisposing risk factor for later development of certain chronic systemic diseases that were likely never suffered by our ancestors. Additionally, certain orthodontic treatment strategies that are designed to encourage very early development of a child’s palate and airway, such as Biobloc-Orthotropics15 and myofunctional therapy16, are also seldom discussed, and on many occasions even disparaged, as a possible options for decreasing susceptibility to later development of chronic systemic disease.

Fig. 5

Fig. 6: Course of the incisive suture (SI) from the palatal to the facial surface of the maxilla. The incisive suture is often still evident until age 5.

One such disease that is indeed often associated with some forms of malocclusion is adult obstructive sleep apnea (OSA), a potentially lifethreatening respiratory condition. OSA is a particularly severe form of sleep disordered breathing (SDB) that is now being more frequently seen in children. Due in part to the inferior quality of orally-versus nasallyinspired environmental air (Fig. 8), pediatric OSA is often characterized by early viral infections and associated enlarged lymphadenoid tissues (tonsils, adenoids); high palates, narrow dental arches and retrognathic jaws are also associated risk factors for OSA16. In a recently published study on palatal vault changes and treatment efficiency implications in growing subjects17, the authors’ conclusions provide definitive support for decisions that are sometimes made by allied pediatric health professionals to recommend addressing malocclusion in the primary- and/or early to middlemixed dentitions when certain airway-impairment risk factors, such

as a narrow/V-shaped dental arch and/or a deeply vaulted palate, might be present. According to a 2007 report published in the journal Pediatrics17, childhood SDB can have an adverse impact on cognitive development, behavior, quality of life, and use of health care resources. In response to a recent New York Times article18 about an alarming national shortage of ADHD medications, Bronx otolaryngologist and sleep medicine specialist Dr. Steven Park commented (Appendix 4), “There’s no doubt that ADHD medications can be lifesaving for millions of Americans, but there’s another dimension to this issue that’s being ignored by the mainstream media and the general public, despite growing evidence in published studies. It’s a general consensus in sleep medicine that sleep deprived adults get drowsy, whereas children become fidgety and hyperactive. Not only are todays’ children sleep deprived (homework, TV, etc.), many are not able to breathe properly at night, due to narrowed airways.” Dr. Park goes on to say, “in a study published in

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Fig. 7

High and narrow palatal vault and V-shaped archcommon in Western-exposed children.

Shallow/flat and broad palatal vault and U-shaped arch of a pre-Industrial (16th-century) child.

Fig. 8: During nasal respiration the paranasal sinus complex has 4 main functions: 1.) filtering of large particulate matter (e.g., dust mites, fungi, bacteria, industrial pollutants); 2.) warming of inspired environmental air to body temperature; 3.) humidification of drier environmental air; and 4.) release of nitric oxide (N-O); N-O is a powerful anti-microbial, anti-oxidant and smooth muscle relaxant which acts to facilitate diffusion of oxygen from the alveoli to the bloodstream and also decrease vascular resistance.

Pediatrics in 2006, 28% of children scheduled for tonsillectomy were found to have undiagnosed ADHD, compared to 7% in controls. After tonsillectomy, 50% of the ADHD group were cured. Another study showed that children with ADHD are more likely to snore, and that about 25% of children with ADHD could be treated effectively by treating their sleep apnea. Notice all the typical findings in a child with sleep-breathing problems that are also found with ADHD: inability to sleep supine, snoring, nasal congestion, mouth-breathing, snoring parents, unrefreshing sleep, frequent urination, inability to focus or concentrate, history of needing braces, and bottle-feeding. You don’t have to be obese or snore to have sleep apnea. It’s clear that in some children with ADHD, stimulants like Ritalin or Adderall work because they’re sleepy. My feeling is that all 32 March/April 2012 JAOS

children with ADHD should be screened for obstructive sleep apnea.“ Future Considerations Chronic diseases of civilization that result from a genome-environment maladaptedness were likely seldom experienced by our pre-Paleolithic ancestors and only began to appear significantly in humans following the Industrial Revolution of the middle 18th to late 19th centuries. Similar to what is now understood with regards to adult immuno-competence development through having been exposed to adequate antigen-exposure challenge in early childhood (i.e., Hygiene Hypothesis)20, early growth of the infant and early childhood palatal-facial sutural complex is likely responsive to tongue and masticatory challenges in much the same manner as the developing neurocranium’s sutural-fontanelle complex is responsive to the challenges imposed of the

expanding brain. In accordance with Wolff’s Law and Moss’s Functional Matrix theory, it seems reasonable to suggest that an ancestral-type IECF regimen would be conducive to optimal palatal-facial development. Optimally growing palates and open nasal airways can confer resistance to later SDB/OSA in children. Encouraging mothers to breastfeed and wean their infants with minimally-processed complementary foods whenever possible, can only be seen as a good thing from an oral-systemic health perspective. Regardless of how risk factors for SDB/OSA are acquired, very early non-surgical/non-invasive efforts to decrease nasal airway resistance, including early palatal expansion and/or other efforts aimed at improving tongue posture (e.g., myofunctional therapy and/or Biobloc-Orthtropic treatment), should also be considered. Whether of systemic or oral origin, chronic diseases of civilization (DC’s) all seem to follow a predictable pattern of progression: first, if a susceptible individual is identified early, DC’s can often be prevented; second, if signs and symptoms are not too advanced, DC’s can often be successfully reversed and/or treated; and third, if not prevented, reversed and/or appropriately treated, systemic and/or oral DC’s can seriously threaten well-being and survival. Increasing U.S. prevalences of diagnosed, and likely many more undiagnosed, cases of pediatric SDB and OSA, should serve as a call to action for all pediatric health professionals to screen their patients for SDB/OSA risk factors….especially when those patients are growing children. Orofacial myologists, pediatricians, sleepmedicine specialists, lactation consultants, otolaryngologists and dentists, need to work together in collective efforts to compile solid evidence in support of how an inter-disciplinary approach to treatment can vastly improve pediatric nasal airway competence, and thus, facial and somatic growth potential and overall (lifelong) systemic health.
Editor’s Note: Article references are available upon request or for download in the digital version at www.orthodontics.com.