A Call to Evidence: How We Build the Future Together

By Ellen Stothard, PhD
Chief Science Officer, Rebis Health
Co-Creator, Empowered Sleep Apnea project

5 June 2025

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A Call and a Calling

It is time to operationalize our experiences to shape the future of Evidence-Based Medicine in the field of SLEEP.

David Sackett, father of EBM, taught us that best evidence must always be held in concert with clinical expertise and patient values.[1] He also warned us of the misuse of "evidence" to defend inertia.[1]

As Carl Sagan famously said, absence of evidence is not evidence of absence.[2}

Time marches on and the development of new techniques brings new and greater insight. Science is not static. The time for open and systematized data collaboration is here.

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From Pilot to Drivers Seat

In research, the exploration of a hypothesis often starts with a pilot study. A pilot study is often a smaller, controlled investigation that balances risk, benefit, cost and value to assess whether there may be a signal worth pursuing. It is my view that the field of Airway Medicine (the confluence of Airway Focused Dentistry and Sleep Medicine) has gathered enough signal from isolated success stories to begin to pursue publishable patterns.

I propose the solution lies in a combination of strategies:

• A central data repository

• Shared validated and experimental outcome metrics

• Both population health (big, real-world data) and case-control (smaller, standardized data) comparing expansive and retractive orthodontia approaches

• Long term (>5 year) follow-ups with real world evidence of clinical importance

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The Future is Already Here

We have among us pioneers in this—clinicians and researchers who are already doing the work of treating, testing, tracking, and assessing care quality and outcomes throughout a variety of treatments in airway-focused, expansive orthodontia. Names like Ben Miraglia[3,4], Audrey Yoon[5], Stanley Liu[6], and Kevin Boyd[7] appear repeatedly in presentations and documentation of the field's evolution. Their collective efforts have demonstrated a signal—a meaningful indication that expansive strategies not only improve alignment but reshape lives.

Rather than working in silos, what if we pooled that signal? What if we collaborated to systematize outcome measures and developed shared cohort descriptors? For instance:

Imagine three cohorts:

• Early intervention (<6 years)

• Middle (6–10 years)

• Late (>10 years)

And then imagine tracking the following across those cohorts:

• Rate of third molar extraction

• Objective measures of craniofacial growth

• Longitudinal physiological sleep metrics (e.g., HSAT AHI)

• Longitudinal physiological airway metrics (e.g., Cone Beam CT, Nasal Rhinomanometry)

• Quality of life, fatigue scores, and/or comorbitidity burden over time (e.g.: GERD, hypertension, TMJ dysfunction, headaches, mood disorders, ADHD)

Many of these outcomes already reside in databases across our clinics. That means this isn’t just possible. If we work together, we could begin looking at these signals, systematically, now.

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Following the Physiology

In the world of Airway-Focused Dentistry, it is accepted that mouth breathing in children has been shown to alter craniofacial development and increase the risk of malocclusion.[8] It is not a harmless habit, but a physiological signal of dysregulation.

Thus, we turn our focus to promoting nasal breathing, which supports better autonomic balance, increasing parasympathetic tone and reducing diastolic blood pressure.[9]

Further, as we look outside our field, we find the work of anthropologist Robert Corruccini—particularly his comparative studies of craniofacial structure in industrialized and pre-industrialized populations—which demonstrated more than two decades ago that malocclusion is not primarily genetic in origin, but epigenetic.[10] It emerges from how we breathe, chew, and swallow as we develop. This places airway obstruction and mouth breathing not as secondary disorders but as primary effectors of development.

These are not minor findings. These are strong signals, and they must be followed.

We have begun to see a number of such individual signals—Miraglia's case studies, Yoon and Liu's interdisciplinary frameworks, Boyd's evolutionary oral medicine advocacy—which deserve to be pooled, tracked, and measured across cohorts.

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The Role of Rebis

At Rebis, we are building systems that focus in on the complexity of human physiology and  demystify it for real-world use. But we cannot do it alone. We want to build a community of clinicians across demographics and geography willing to document and disseminate. We need data scientists who understand nuance and physiology. And we need leaders in airway-focused care who are willing to open their books for the good of the future.

Together, we can create the path that future generations deserve to walk. One with room to breathe, to grow, and to sleep in peace.

Let's show the world what true science looks like when it walks hand-in-hand with integrity.

In his essay yesterday, my Empowered Sleep Apnea partner Dave McCarty asked somebody to fetch him a flashlight.

My answer is that this is what science is for. For illumination.

Let there be light!

Ellen Stothard PhD
Chief Science Officer, Rebis Health

Longmont Colorado

5 June 2025

References

1.         Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996;312(7023):71–72.

2.        Sagan C. The Demon-Haunted World: Science as a Candle in the Dark. New York: Random House; 1995.

3.        Miraglia B. An Invisalign finish to an early Class II correction with myofunctional appliance therapy. J Am Acad Cosmet Orthod. 2013;8–13.

4.        Miraglia B. See the whole picture, treat what you know: a case report. Dent Sleep Pract. 2021;10(4):34–36.

5.        Yoon A, Gozal D, Kushida C, et al. A roadmap of craniofacial growth modification for children with sleep-disordered breathing: A multidisciplinary proposal. Sleep. 2023;46(8):zsad095.

6.        Liu SYC, Huon LK, Iwasaki T, et al. Efficacy of maxillomandibular advancement examined with drug-induced sleep endoscopy and computational fluid dynamics airflow modeling. Otolaryngol Head Neck Surg. 2016;154(1):189–195.

7.        Boyd KL. Sleep disorders in pediatric dentistry. In: Sleep Medicine for Dentists: An Evidence-Based Overview. 2nd ed. Quintessence Publishing; 2020.

8.        Zhao Z, Zheng L, Huang X, et al. Effects of mouth breathing on facial skeletal development in children: a systematic review and meta-analysis. BMC Oral Health. 2021;21:108.

9.        Watso JC, Cuba JN, Boutwell SL, et al. Acute nasal breathing lowers diastolic blood pressure and increases parasympathetic contributions to heart rate variability in young adults. Am J Physiol Regul Integr Comp Physiol. 2023;325(6):R797–R808.

10. Corruccini RS. How Anthropology Informs the Orthodontic Diagnosis of Malocclusion’s Causes. Lewiston, NY: Edwin Mellen Press; 1999.