Hi everyone, and welcome back to Airway First, the podcast from the Children's Airway First
Foundation. I'm your host, Rebecca St. James. My guests today are Dr. Joanne Engelby and
Dr. Eva Stack. Dr. Engelby started out in Children's and Community Dentistry and then
moved on to working in general practice where she's been for the past 30 years. She has an active
interest in the treatment of snoring and sleep apnea and is on the board of British Society of
Dental Sleep Medicine, completed the master's class in dental sleep medicine and is a member of the
American Academy of Dental Sleep Medicine. She teaches dental sleep medicine to other dentists
and is trying to increase awareness in the UK of the importance of an unobstructive airway
for all ages. You can find out more about Dr. Engelby at sleepbettermanchester.co.uk or
Jo at parkfield-dental.co.uk. You can also read her full bio in our show notes. Hailing from
County Claire in the west of Ireland, Dr. Stack studied at University College Cork where she won
awards for her clinical work and research. Dr. Stack is a general dentist with an interest in
how function and structure come together to affect our airways sleep, breathing and facial form.
She offers myofunctional therapy alongside orthodontic treatments.
She has completed a one-year orthodontic certificate in London and is trained with the
Breed Institute in Los Angeles for treatment of tongue ties. She's an avid learner and takes
courses and attends conferences to keep up-to-date with current thinking and has a keen interest in
research having most recently been published in the British Dental Journal. She is qualified as a
myofunctional therapist and as a board member of the British Society of Dental Sleep Medicine.
She is the Breed Institute ambassador. You can find out more about Dr. Stack at foreversmile.com.uk
and onclinic.co.uk. And now let's jump into my interview with Dr. Joe Engelby and Dr. Eva Stack.
Perfect. Thank you both for joining us on the podcast today. I appreciate it so much.
My pleasure. You're welcome. Awesome. Awesome. So let's go ahead and we're just going to jump
right in just for those who really aren't familiar with dental sleep medicine. Can we talk a little
bit about what this is and how this is different from traditional dentistry? Dental sleep medicine
is a relatively new area of dental practice to us in the UK. It's the discipline concerned with the
study of oral and maxillofacial causes and consequences of sleep-related problems,
which sounds very complicated. It does. But it means we're assessing the airway, the space at the
back of the mouth for airways and to treat it if appropriate with an oral appliance. So if you
have an airway with some obstruction, it causes sleep fragmentation. And depending on its severity,
it can just be a simple snore to something more complex of complete obstruction. And the name
given to the group of airway dysfunction that we have is sleep-disordered breathing. And it's
characterized by snoring and an increased effort to get breath. So how would a patient end up in
your office? Are they referred or do you do traditional dentistry and sleep? How do they end up there?
I do both. And now we incorporate questions in our routine medical history. Do you snore?
Does it bother you? Does it bother your partner? And then we are in a perfect place because we see
patients with their medical history coming in and their comorbidities to just listen and chat and
then assess what's going on in their mouth and airway. Because there's a lot of signs we can see
that shows that they may be at increased risk of having this sleep-disordered breathing. From a
young age up to adults. And it isn't a static condition. So somebody can start with snoring
and it can progress to something further. But snoring has been considered in the past just
irritating noise. And now we are much more aware of the importance and significance to health
and development. And I would add, I know that we used to think it was cute. I did even. With
my children when they would snore, when they were asleep, oh, aren't they cute? Listen to the little
tiny snore. But it's incredibly detrimental to children as well. It really is. And snoring,
as we said, is a sign of restricted oxygen. And not many of us would like to consider our children
having restricted oxygen. No. They behave in a very different way. So for adults, you get a lot of
medical issues. And in children, you get a lot of behavioral issues. So I don't know how much
your listeners know about the physical effects of sleep apnea in an adult and the long-term effects
or whether this is just about children and where would you like us to go?
Well, we focus on children. However, one of the things that I think is an important
point concept to make sure that we hammer home to parents is why it's so critically important
to take care of this in children because of the effects that it can have in adults. So
I'd love to just kind of veer off into that for a few moments to talk about, you know,
how this can manifest in the health implications that happen in adults.
Eva, should I do this bit? You do children?
Yeah, let's do that. Okay. It can be as acute as a bad night's sleep in layman's terms,
we all feel worse. We're tired, we're groggy, we're hungry, we're irritable. But actually, the
continual lack of oxygen initiates loads of systems to go into high alert and a chain of
reactions to many body systems. A, it prevents you from going into a deeper reparative stage of
sleep. But physically, the effects of apnea really affect the sympathetic nerve system,
into this fright or flight, complete stress all through the night and repeatedly. And that can
affect every system from hypertension and cardiovascular systems to metabolic and insulin
resistance to it can affect your immunity, it can affect the rate of cancer of some sorts,
Alzheimer's, atherosclerosis, it's huge. You know, the chronic effects are the diabetics.
There's so many more diabetics who have apnea, in fact, most of them, two thirds, I think it is,
have some form of apnea. So, really, it's a huge implication and a lot of days are lost,
monetary, work wise, health wise. And that's only to the person who's snoring. The person next to them
is pretty disturbed a lot of the time and it can run. Right. It can impact them. And it's two of the
things you mentioned, well, I mean, there's several, but two in particular, I think are not ones that,
as laymen, we would automatically go to and think, oh, sleep apnea can lead to this,
cancer and Alzheimer's. So, those are recent things that have just come out that,
really, that completed stress, complete stress reaction of your sympathetic nervous system
can affect so many things. And the immunity and the inflammatory response and everything
is put into this stressful, increased high alert state. And they've been shown to be linked to both
of those. Wow. And another one I'd add is the rates of sleep sort of breathing in pregnancy are
highly, are often increased, you know, a little bit more weight carried, a lot more stress in the body.
And also some lack of, you know, less good quality sleep in general, because of discomfort.
And the effects on babies is quite interesting in moms who have sleep sort of breathing. So,
it tends to be a cycle that will then continue. So, yeah, it's really quite interesting. And
I mean, it's quite early in research in that field. But certainly, there are ways of kind of,
there are some case reports at the moment of treatment for women who develop sleep apnea during
pregnancy and treating it. And, you know, I think that's a really, really important piece, because
if mom isn't breathing well, reduce oxygen to baby, and the effects potentially on, you know,
the development of baby is really interesting. And I think that's a piece that we will be visiting
in the future. I think, hopefully, you know, it'll be a case that, you know, all women who are
pregnant at a certain point would have a sleep test, because I think it's a relevant piece to the
next generation being healthier.
I think it's hugely relevant. And it's not something that we talk about much at all,
which is sad. And you go through all of these pregnancy classes and they teach you all these
things, but at no point does anybody say, hey, how are you sleeping?
I think in general, the link of different health issues isn't always related. I'm only talking
about from Britain, that medic, it's come new that the link of different symptoms, such as
hypertension and acid reflux and tiredness and headaches and all things like that could be
suggestive of an increased risk of apnea. You know, the medics haven't been taught that we
as dentists are just too much about that. And it's really important.
It's hugely relevant. That's part of why we're here. And I think I say it on every podcast.
To parents as well as medical professionals, you don't know what you don't know. You weren't
taught we didn't learn this when we were growing up either. So we're all kind of in the same boat
trying to learn together. So that's something very important to remind ourselves.
And I probably, if you don't mind, I'm going to want to circle back because you mentioned,
it's not something we've talked about much on the podcast, pregnancy and sleep apnea
and the impact it can have not only on the mother, but on baby. I'm going to just kind of
guess, you know, some of the impacts are definitely stress related to the child.
So I'm going to just kind of guess, you know, some of the impacts are definitely
stress related to the child. So could the child develop sleep or sleep or breathing issues?
Could it cause the child to have higher blood pressure impact their development?
What kinds of things are we seeing so far?
Well, I would expect so those two biggies really would be the hypertension
and the diabetes risk. Because both of those we know physiologically are two major effects of
having apneas. So I think it would be really interesting to see where, I mean, it's not
something that I've come across in the research. It's just a few colleagues have done kind of case
reports on pregnant women. But I think it would be really interesting to see because we know that
if you're having desaturations that your body becomes more stressed, we know that that stress
is going to raise the cortisol. We know that cortisol is going to wreak havoc with the blood
sugars. So, you know, absolutely there are women who develop gestational diabetes who have,
you know, who are just having all the Coca-Cola, but there are plenty that aren't. And,
you know, if you were to look at them from an oral and functional perspective, I think it would
be interesting to see how they're breathing. There's a beautiful study that someone ought to do.
Perhaps myself and Joe will body together at some stage. And these are things that
we're, I guess we're just not considering right now. And then the other one is we know that if we
have the more apnea you have, the more likelihood you have of hypertension. And we know that hypertension
in pregnancy can cause preeclampsia, which can cause early birth. You know, a lot of the kids
in NICU will be because of preeclampsia mums. And, you know, we have to consider why absolutely
the pressure of pregnancy is going to possibly increase the blood pressure. But is it an apnea
issue? You know, I don't think it's been linked yet, but or confirmed in research. But there's a good
hypothesis there, I feel. A huge, absolutely. So in general, so go ahead. Those people with apnea have
five times as likely to have drug resistant hypertension and double the rate of someone
having diabetes, stroke, and congestive heart failure of those without
disordered breathing. Now, those are two facts I come back to each time and think,
God, why aren't we more aware of this? Because those two statements are huge.
Yes, yes, they are. They really are. Five times. So one of the things I have found over the course
of doing this and speaking with other medical professionals is there was something, some kind
of catalyst that transitioned you into sleep and airway. You know, doesn't seem like anybody,
most people came out of medical school with this focus. So what was it for each of you?
With mine, mine was the fact that I've been with my husband now for 35 years,
and I used to just beg him to let me get, please, just give me 10 minutes, I'll be asleep.
And it was everything was fine until one night I woke up and I was a good sleeper and I didn't
used to wake and I heard this foghorn next to me. And I thought, I'm going to kill you if you don't
stop snoring. And then he stopped snoring. And for one little moment I thought, oh, I'm powerful,
I've just killed him. Oh my God, I'm evil. And then he started to snort and gasp and breathe again.
And it's terrifying to lie next to somebody and breathe. And I actually woke him the next morning
and he's a medic and said, are you aware this is what happened? I even quite horribly recorded him
to say, this is what you sounded like. And this is about 15 years ago. And then I started to look
into it and I made him a little prototype of some impression material in his mouth and that used to
fall out. And now we have gone to bespoke beautiful appliances. And now beforehand the guy's on the
ski trip. Nobody wanted to share a room with him. They said, nice guy when you're awake, but when
you're asleep, it's hideous. And the guy who drew the short straw this year, he hasn't been for a
few years, signed him off as absolute delight. No, not whatsoever. So, you know, when we can get great
treatment outcomes. But that's what lit my fire. And now it's fantastic to make people feel better
to improve the quality of our patient's life. And you see people come back with their mojo and you're
reducing their risks of significant disease. So even if you catch it later in life, you can have
an impact on their overall health span. You can it's been shown that you can slow down the rates of
things. It depends what we're talking about. And I'm not sure how much studies have been in. A lot
of more studies have been done about CPAP and the reduction in risks. And now as we're introduced,
our oral appliances, we hope they're the same effects. But again, there's another study.
Yeah. Oh, wow. And what about you, Dr. Stack?
So when I was, oh dear, have I lost you guys? No, no, we're here.
So when I was at university, my final year case was, was my father. And I, you know, took him from,
you know, a mouth that hadn't been worked on in a long time. And I saw him like 20 times.
And we fixed him right up good o and I got my honorary degree and all was well. And
four years later, my dad passed away very suddenly. And it just puzzled me as to what
on earth was going on, which made me, you know, think about all of the potential symptoms that
really put me down on a rabbit hole. I was really keen to work out why my dad just was there one
minute and not anymore. So then I kind of looked at all the images and pictures I had of his mouth
and realized that he constantly mouth breathed. He had a narrow palate. He had worn teeth. He had a
high malin patty. He would wake up several times during the night. It's just the checklist.
The checklist. Yeah. And that obviously is very personal and hard, but I would not want that to
happen to anybody else's father. And that is why I am so passionate about trying to make change
and trying to influence some difference because yeah, lives can be shortened and that causes
pain all around. And if it's not necessarily shortened, you know, you can live with a lot of
comorbidities that are unpleasant and just give you less life quality. And, you know, we
are very quick to look at pharmacological treatments for different conditions, but,
you know, fundamentally you sleep well, you eat well, you move well, you breathe well.
You know, those pillars are going to lead to a better life. And it's amazing to have,
yeah, within my own profession to have the ability to make a change. So that is why I like
working in this area, which is, yeah, that's it. And that's something that I do find that anyone
that has done the research, first of all, there's something that gets them here. They don't just
stumble upon it usually. There's something and there's this passion once you see it, once you
understand it and you realize, as you said, it's not just how it would impact your health span,
it's your quality of life. And it's something so simple. I mean, it's relatively simple by comparison
to, you know, having to live with diabetes or Alzheimer's or some of these other things that
will come down the road because of it. It's so simple. So I saw something, I'm not sure how
recently you posted this, but there was a link between snoring and mental health.
And I really want to talk about this because the US Surgeon General has indicated this is
one of his big initiatives is mental health, specifically in children. And more studies
have come out that, you know, mouth breathing and sleep apnea, they're impacting
children and their mental well-being, depression and anxiety, which is off the charts in the US,
as well as globally, but specifically here. So can we talk a little bit about how sleep apnea
does impact children and their mental health? So snoring is the sound made when the tissues
have a restricted airway. And there's from a little bit, there's a spectrum from a little bit
of resistance to more until there's a complete blockage that can happen multiple times a night.
And as we've said that multiple times a night puts your body into stress and your whole body's in this
active stress situation physically and mentally. And adults with sleep apnea often suffer from
daytime sleepiness and long-term cardiovascular effects and diabetes. And the kids whilst they
might be storing that for later are much more likely to have behavioral problems, cognitive
problems, development and growth. They have poor memory and concentration, they have behavior which
mimics ADHD and in some studies they've shown that there is an increased incidence of ADHD with mild
and moderate. And it says that about one to five percent of children have obstructive sleep apnea
and it's commonly under diagnosed. And it's, you know, kids can play up, we all know that we're
perhaps not as patient when we've had a bad night's sleep. But if that's chronic, then we become less
alert, less cognitively able, we're less able to learn with our mood alertness and performance.
And we often have more rebelliousness, hyperactivity, impulsiveness, we have difficulty
controlling emotions. And most teams anyway are just learning or kids are learning to control
the emotions, they don't need the extra hassle of reduced oxygen brings. There's interesting
studies shown that after often children have problems because of large adenoids or tonsils.
And they've shown that in some, then there is a significant positive impact on behavioral problems
such as inattention, hyperactivity, oppositional defiance and conduct disorder after adenadontis
electomy. I find that a lot of teeth around. And the mean scores of ADHD and all the behavior issues
decrease significantly after the surgery to the extent that the parents weren't bothered about
the behavior. Now, I don't think it ever goes back down to the baseline group. And you do have a
high risk of it recurring, particularly if you've got higher AHI or you've got high-och palette or
a Malanpati score of two to four, that's the rating we give to the space and have a crowded or
referents at the back. There's more risk if they're male or over seven, if they've got allergic
rhinitis or asthma or if they're of African American race. So there are factors that do
affect it, but on the whole, there was a significant increase in behavior.
You mentioned something that, if you can speak to it, males over seven. So why are they different?
Not quite sure. It could be that males have a longer soft palate. I'm not sure, Ithara, you sure?
Well, I guess the cranium would have pretty much developed at that point.
So I'm not sure, but I'm just thinking on a, so if the soft tissues haven't caught up with the
heart tissues, then potentially that's why, because at that age, we're pretty much
facially developed. There's 80% of our efficient developments done by age six, so there could be
that too, but I'm not entirely sure. I'm not sure either. I don't know whether you're starting from a
different place, either. Yeah, yeah, just curious. Another, this one point that I think is quite
mind-blowing as well. The brain constitutes only 2% of the whole body, but it uses up to 20% of the
total metabolic oxygen. And it's thought the conditions that reduce the metabolic oxygen affect
the brain and cause cognitive and neurobehavioral impairments. Right now, we have seen that,
that it can decrease a child's IQ up to 10 points, which is staggering.
It really, oh, that's a huge number.
It's an extra thing to throw up a child who's learning how to regulate emotions and their
weight. Anyway, it's an extra thing that we can do something about. And there's some things we
can't do about, but that is something we could. So we've talked before about the Malan Patty score,
and I'll make sure to put, for those who haven't seen, I have a visual that really shows the four.
So they'll have a perspective of what we're talking about. How do you know, though, that just removing
the tonsils, for example, would be enough? Or do you even have to go that route if you can look at
a child's mouth and say, oh, they have no room? Where do you start? It's a few things. I've got a
is of a child's adenoid face. Okay, see that with an elongated face, and you have Venus pooling,
and it looks a sort of different sort of face there. Often where they've got a narrower,
they've got a high-volted palette, narrow jaw, narrow face, and often their head is, if I show
that, is forward. Their posture is ever head forward as they're trying to get more airway. So
sometimes you see a child as they walk in. I think we might have lost Eva. I see that.
I'll watch for her to pop back in. Okay. And so a child can often have dark
bags under their eyes, and then open the mouth, and you see quite often worn teeth,
because worn teeth and Bruxism is often now thought to be a sign more related to some sleep
disordered breathing. Which is grinding your teeth, correct? Yeah. Okay. So you often see that, and then
the jaw, top jaw, typically we want it to sit outside the bottom jaw, and in a lot of these
cases, you've got a mismatch, and everything's very narrow, and there's nowhere for the tongue to go,
except backwards. When a child then lies down, the tongue goes back, they've already, if you open
their mouth, you can sometimes see the tonsils kissing, and it's called kissing. As they're
meeting at the back, and the tonsils are the tissue at the back of the mouth, and the adenoids are
the tissue at the back of the nose. And if you've got that inflamed tissue at the back of the nose
and the throat, then you are hampering that child's ability to breathe. So you could start there as
you're trying to bring the jaw forward and make some of the other adjustments just for the immediate
relief? Well, I think at that point, I would ask someone, do they snore? Have you been to
C&E&T opinion? Before I started playing, I would at that point refer on, I think it's
appropriate that if there's a significant other problem, we try and get that long term.
And some children grow out of some of the adenoid chronic things and don't need surgery.
Okay, that's interesting, because this is now the second time I've heard this mentioned.
And how do you know when to do it, when not to do it? Because I've also heard something very similar
about a tongue tie, which I was under the impression you always take those out, but apparently,
you don't always treat those.
You're listening to Airway First with today's guests, Dr. Joe Engelby and Dr. Eva Stack.
You can find out more about the Children's Airway First Foundation and our mission to fix
Before Six on our website at childrensairwayfirst.org. The CAF website offers tons of great resources
both for parents and medical professionals. In our Parents Portal and Clinicians Corner,
you can find educational and informational content, including videos, blogs, our recommended
reading list, comprehensive medical research, podcasts, events, parent support, and educational
opportunities. Parents are also encouraged to join the Airway Huddle, our Facebook support group,
which was created for parents of children with airway and sleep-related issues.
You can access the Airway Huddle support group at facebook.com backslashgroups backslash airway
huddle. Are you a medical professional or parent that is interested in being a guest on the show?
Then shoot us a note via the contacts page on our website, or send us an email directly at
info at childrensairwayfirst.org. As a reminder, this podcast and the opinions expressed here
are not a medical diagnosis. If you suspect your child might have an airway issue, contact your
pediatric airway dentist or pediatrician. And now let's jump back into my interview with today's
guest, Dr. Jo Ingleby and Dr. Ifa Stack.
I'll leave Ifa to talk tongue-tied, but with the adenoids, I don't know when you need any
endiculants. Okay, got it. Got it. With regard to the adenotant, adenotant left me. Obviously,
if we don't need to put a true surgery, that's better. But if the tissues are chronically damaged
or chronically inflamed to the point that they're not going to come down, then, you know,
I think it becomes a no-brainer if it reduces the breathing space. But children do grow out of
tonsils and adenoids. They do tend to get smaller from the age of six. And also, the other thing is,
you know, if there's allergies and there's a change to that exposure, then that can reduce
the size of the tonsils. And the other thing is there has been the UN study, which I'm sure
you've all come across before, where expansion of the palate has led to reduce tonsil size, but
it's still so new. And it will take time for this to filter through to dentist, doctors,
midwives, everybody, because it should be a multidisciplinary approach as well. But with
increased awareness, hopefully parents become more aware, dentists become more aware, and we can all,
there are, in Britain, hopefully there will be more myofunctional therapists to help. And,
you know, we can start treating these patients in a conservative, prevented way.
Right. So we're getting to the root instead of let's just keep putting band-aids on it,
and let's just give them medication and understood. So you mentioned myofunctional therapy,
which was an excellent segue for my next question. So, Dr. Sack, let's talk a little bit about how
myofunctional therapy plays into sleep hygiene, as well as sleep apnea treatment.
Okay. So I would separate sleep hygiene and sleep apnea treatment. So sleep hygiene is
things that we can all be doing to improve our sleep architecture. So, you know, the amount of
deep sleep we're going to get, etc. So that's to do with, you know, how we live our lives on a day
to day basis. So how, you know, how we're eating, how far away from our, our night we're asleep,
we're eating, how far away from our night sleep we're eating, you know, how well hydrated we are.
And, you know, what we've done in the hour or two before bed, light exposure, first morning
night exposure, sunset exposure, you know, our melatonin levels, you know, it's pretty easy
to get it right if you follow the, if you follow what we're supposed to do. And if you have a really
easy life that means that you can just go and look at the sunrise and go look at the sunset and
take on your ear outside and not be exposed to toxins and, you know, eat all organic food and,
you know, have, you know, not have conversations at late at night on computers and all those things.
So, the two people in the world that can do that. So for the rest of us, right?
I should have my blue blocking like goggles on that would be really impressive.
Just with my lips are good. But yeah, so, so all those sorts of things would kind of fall under
sleep hygiene. And then, you know, stress relief, breath work, all those, you know,
we're looking at myofunctional therapy, we're looking more at actual targeted exercises to
treat the hormonal dysfunctions that we present with. So whether that is weak lip support,
causing, you know, mouth breathing, whether it's a tongue, that is a bit floppy, whether it's a tongue
that quite doesn't fit into the roof of our mouth, whether it's a tongue tie, whether we have, you
know, TMJ problems because of poor chewing, you know, whether we can chew at all, a host of issues.
And those are structural and functional issues that need therapeutic support rather than
being a case of, well, you know, because we could have amazing myofunctional support, but if you
decide to drink three bottles of wine before you go to bed, it doesn't make any difference.
It's not going to be good. Or similar, if a kid has, you know, lots of skittlings before bed,
you know, so it's managing two different things. But it's for, you know, for families, it's very
much on mom and dad or mom or dad or parents, whatever that looks like to manage both hygiene
and both and all the therapies and whatever else comes with that.
And together. So for parents that are, and we've got a few things on our website, which I'll make
sure we include a link to hear about what good sleep hygiene looks like. But for parents that are
just becoming aware and overwhelmed, which is what we find a lot when parents, you know, find out
what's going on, what are a few things they could start with, you know, that would be pretty impactful
when it comes to sleep hygiene, just, you know, with a younger child, what are some things they could
start with initially?
Screen time is a big one.
Overall or just before bed?
Overall.
Overall, we weren't designed as humans to be in front of screens. So, you know, that's a given.
But certainly later on the evening, certainly the less green time, the better.
You know, light exposure, having, you know, less blue light generally, you can put dimmers in your
light, you can have certain wattage on your, on your lights, lots of hydration,
you're not eating too close to bed, looking at your sugar, kind of consumption throughout the day,
breath work, if it's possible. There's some simple but take a breathing exercises that
can be done that are quite nice.
You know, trying to get the kids outside if you've got green space.
You know, it's not easy, man. It's really not easy.
No, it's not.
But, you know, at the weekends, making sure that there is outside activity, you know,
just trying to live as naturally as possible is a good way to think this is the way we should
be helping our sleep. Because, you know, we used to be able to sleep pretty well. And we now have
so many toxins all around us, along with all these toxic lights that are not good for us either.
Right. And as a mother of at least one that's still in school, that has everything on an iPad,
back in my day, we had the backpack with all the books. And the worst we had to worry about was
throwing out a shoulder or a rubber, something with a heavy backpack. I'll take that. But to see
a child that has no books and they're constantly on their iPad, everything is on the iPad, the book
is on there, the homework is on there, the lectures are on there. You know, it's one of those I would
just like to rally that please bring back the books. That's all I'm saying. I think to have a
time that stops that and then a transition of relaxation before a regular bedtime is at least
something you can do. If we could all get much more fresh air and all go back to whatever. But
that is unlikely to happen when all your work is on your iPad. Exactly. It is. Right. And my
heart goes out to the kids that were like me, they were doing homework late into the night,
especially the teenagers. You have after school events, you have band, you have cheerleading,
whatever. And you have a job and then you come home and you're with your family.
And then you're doing homework late into the night. We're just basically handing these
children health issues. Yeah. And it's not just children. It's throughout. I have a five-month-old
baby. He's not really exposed to screens just yet, but that's going to come. And it's really
interesting because I'm currently working through sleep learning and the pattern that
we're that's known to work would be, you know, feed, then feed in a kitchen in the kitchen
so that they get used to eating their last meal in the kitchen, then take them up to the bath,
have a nice relaxing bath, then do a baby massage, then have a read of a book, then say your prayers
and go to sleep. And, you know, actually, that's a pretty good way for it. No, but it's a pretty
good way for us all to be living this night. It is. It is. We've been out for a walk, you know,
and all of those things are setting him up to have a good night. Well, I hope to have a good
night. But, you know, we know that those are things that are going to improve sleep architecture. But,
you know, it's and that's how we used to live like not that long ago. Like when I was at university,
which I qualified 10 years ago, I wasn't really in the library late at night with a laptop. I
was there with books, like in highlighters, you know, I think, you know, in a very short period
of time, everything is online, you know, I'm any online, any postgrad programs I'm doing now, it's
all on the computer, you know, even more and more and more. And I would expect you probably for you,
in your career, you probably would have gone from never using a computer to now spending about 50%
of your time on a computer right now. I think we all have to be aware, though, that it wouldn't
be practical to say to everybody, you can't use your iPad, your child who is all the time on.
We just have to have limited as much as we can get out there and get as much natural bits we can do
going on. Give us a time period of, as Eva says, some gap between whatever we do and sleep. Can't
it's not just a light switch you can turn off, and then suddenly have no effect. No, no, and your
mind needs to wind down. Yep. And I also think just to add to this on the personal side,
from doing these podcasts, I've caught my own behaviors, you know, I was 30 years ago because
I'm old. In college, I was that child that was at the library late at night working, but it was
with books. So I'm used to being up late and reading before bed, but life happened and technology
happened and children. And at some point, I got into this horrible habit of, well, let me just
unwind by playing some games on my phone until I fall asleep. So, you know, even I have had to
backpedal my behavior and I'm finding, you know, this is, as parents, this is something I think we
can do. We're showing our children what to do. So put that phone down, don't pick it up, have a book,
you know, maybe sit outside with a cup of tea and talk to your spouse before you go to bed and
or something just change. And some of it is some of us are natural larks and some of us are natural
owls. And we do have to acknowledge that as well. But I mean, a lot of teenagers would like to start
their day later on. That's other programmed. Yeah, I wasn't, but apparently other children are.
So, but it's about actually just acknowledging what's going on. And if you cannot, if you are
struggling with your sleep or your child is then to actually look at what's going on and seeing
what can you do to help and make it a more natural or a more regulated, you know, what's going to
increase the likelihood of you having a better night's sleep. Yeah. Yeah. And I know we've touched
on this a little bit, but just to kind of package it up in a nice little way for parents. What are
some home things we can do to help our children with? Not just sleep, but maybe sleep apnea or
what kind of exercises or things should we be doing as they're coming up? I know that baby lead
weaning is something that is now being talked about because we're giving our children all these
soft foods and we're all guilty of it. So, letting them chew is good for them. It's going to
strengthen the jaw. It's going to help bring it forward. What are some other things that we as
parents could be doing to help our children? Encourage nasal breathing would be one of the
ones I'd say as much as you can. Make it a game. Check that they can.
Yeah. Take them to someone who can help them. Yeah. I mean, from birth, like,
breastfeeding if possible and if desired, and if desired, then having support for feeding
because we know that tongue-tie weights are probably higher than what's, you know,
if I'm Brazilian with a 20% there is tongue-tie. So, you know, that's 20% of people who will have
issues from get go with feeding. So, breastfeeding is one and allergies is the other.
You know, looking at diet and what diet interventions may cause, may cause any kind of reflux
and then encouraging, even with the babas, encouraging nasal breathing through oral
motor exercises, which would be done with a physio or OT, speech and language service,
or an ABCLC or a tongue-tie provider or an easy above together or an osteo. But there's
numerous people that would be involved in that team. And then once they get, as you described,
once they start to wean harder foods ideally and if possible continued breastfeeding.
Because that deep latch, our ancestors would have breastfed till about the age of four.
And we know that that was related to having a wider palate. And that's something that obviously is
incredibly demanding on the whole family, particularly your mum. So, you know, the way,
the real, how realistic that is, is questionable in our modern times. But it's certainly baby
leg weaning and really, really looking at reducing allergens, where, you know, whether it's just
dairy, whether it's a dander from animals, you know, anything that might potentially
increase any inflammation in the, in the, in the airways is something to be reduced, looking at,
maybe increasing filtration for the air, reducing air conditioning. Again, making sure that you're
trying to live in an environment that's less toxic. I mean, so much of this stuff is so high
and mighty, you know, it really, really is. Because, you know, we really have damaged our
environment significantly and our way of living in a natural, in a natural way. But, you know,
again, just going back to trying to live as, as primitively as possible. And then, you know, when,
when, when I was getting into kind of three, I would say would be, I mean, I don't tend to
work very well with three year olds, but certainly kind of four or five, you're starting to get a
little bit of cooperation. And then doing some, some or more exercises. And there are some amazing
myofunctional therapists, I think Barbara Green, she's amazing. She does the most incredible work
with like 18 month olds. And they're doing all of this fabulous myofunctional therapy work and
really doing great. But for me, like you're thinking you're going to get cooperation
or sometimes three plus, yeah, sometimes far higher. And sometimes you got a really
cooperative three year old. And I think it's a total lucky dip. I don't think it's,
I'm sure there's a bit of parenting involved. But I think sometimes it's a lucky dip. So you just
don't know what you're going to get. But yes, doing basic exercises, doing breathwork, you know,
yeah, doing different games to promote nasal breathing, something like putting a lollipop stick
between the lips and holding that for three minutes, so that they're breathing through the nose.
You know, they're not holding that lollipop stick with their teeth. And if they can't, if you can't
breathe through your nose for three minutes, that's a direct referral to an ENT. If you
can breathe through your nose for three minutes, you can breathe through your nose for your whole
life. There's a really fabulous book by Patrick McKeown. Close your mouth
and save your life or is it just change your life and change your life. Yeah, a small little book.
And that's a really, really cool little book that you can, you know, it's a pretty simple,
simply illustrated book. So, you know, easy enough to start with, with young ones,
but they've got to be compliant. They've got to want to be there, you know, and, you know,
and every kid hits that at a different point. Obviously, and unfortunately, or maybe not so
obviously, but it's the kids that often need that help the most, that are least interested in
partaking in that. And that's just an unfortunate reality of how things are right now. And
just really difficult for parents who find themselves in that situation. Because the last
thing you want to do is force a child in doesn't want to do something to do something because it's
just for every reaction you got an equal and opposite for every action you got equal and
opposite reaction, right? So it's just trying to meet the method level. And then upwards from seven,
I think my functional therapy is pretty, pretty standard. You can do early intervention orthodontics,
you know, depending on the, again, the patient and the skill of the practitioner, you can start
that from kind of two or three sometimes. I mean, I'm not, I'm not treating that young. I kind of
four or five would be where I would be like, okay, we can, we can look at doing some, you know,
our past development, if that's, if that's seemingly necessary. And then, yeah, from kind of
70s, you've got your window of growth for early orthopedic appliances. And a lot of the facial
growth is done around puberty. So, I mean, the job will so will still grow. The job and the female
stops to grow at 18. No, no, Joe, correct me. Is it the girls are 18, the boy, the 21? Yeah, that's
what it is. So this continued job growth until that point. So, you know, you can manipulate growth
all the way up until that stage with appliances. And at any point, I think my functional therapy is
helpful. The thing about my functional therapy is you must be tough. If you work out really hard
and you get great strength, and then you just let it all, you know, weaken again, and it will
probably go back to you. Yeah, absolutely. And unfortunately, this is why my functional therapy
doesn't get maybe the respect that it deserves, because it's a constant effort. But similarly,
you know, going to the gym is a constant. If you, you know, if you work out every day for
six months, and then you just don't, you'll look great for a little while, and then it'll
weaken a little bit. So, yeah. But I mean, if you, so the goals of my functional therapy is to
integrate patterns, and normal muscular patterning, so that you know how to use,
you know how to use muscles in the correct way, and you learn to integrate those, but
you need to give up the work. Right, right. And then later, as adults, you've got all
appliances, which Joe's been talking about. So I'm going to put you both on the spot, and this is
strictly just opinion. But from this side of the pond, it appears as though your side is a little
ahead of this train, this change that we're seeing as far as airway and sleep and the impacts that
it's having and putting together these diverse teams. So it's not, you know, over here, everything
is very siloed, pediatricians and dentists, everybody siloed, but it appears that there seems
to be a little more cohesion, and you might be a few steps ahead at the moment. So what's driving
this? I'm not sure that's totally the case. Okay. Yeah, I would say the same. That's what it looks
like. Okay. I think the nice guidelines change, and that's the National Institute of Clinical
Excellence. And that's a body that assesses current practice action plans, and it evaluates the
outcomes on results and the benefits are cost wise and to the patient and everything. And they
changed in August 21. And they acknowledged oral appliance therapy as an alternative treatment for
mild to moderate sleep apnea, if they choose not to have CPAP, or if they cannot tolerate CPAP.
Now, we all know that CPAP is great if a patient wears it. And there's many things that make it
that the compliance or success aren't as good. And the other options are oral appliance therapy.
And it works. And since that has come in, we have now been trying to get that as part of
integrated into a treatment option in our health service. And that has been a long process. And
we're also trying to now contact, and I think it's more on a personal level, I've contacted the ENT
specialist near me. I've contacted the sleep clinics, I get referrals, you asked me earlier,
how I got patients, and I have receiving referrals from the sleep clinics for about 10 years, because
they knew before the nice guidelines changed that if we've got a patient with this and they're not
really holding on this works great. And then when I'd sent them back for sleep tests, they'd go,
hold on, this works and they're using it. So although it is slightly less effective per time,
in some cases, because a patient tolerates it and complies much better with it, you get equal
effect for the mild and moderate. And so really, they were surprised when they did post-sleep
tests afterwards on the success, they rang me excitedly and said, but it really works. Yes,
I know. So I think it's on a personal level. And then it has to drift down with education,
and it's a lot of the medical tools of the medical publishers to say, can I put on a
webinar to just show you how these group of symptoms could be suggestive of sleep apnea?
And that, you know, there's a two year waiting list for our sleep clinics. Meanwhile, we could make
make them an appliance and see if that works, or we could do a home sleep test. And this sort of
thing, you know, let's try and work more in together. Because if we check if a patient can breathe
through their nose and if they can't, then I'd re refer back to an ENT, you know, to say, hold on,
we've got a problem, you know, let's together and try and make. And in some cases, with some adults,
when somebody's not being able to comply with CPAP, to wear an appliance with that and have adjunct
dual therapy can be extremely successful because the side effects of a CPAP of high pressure and
arophagia and that horrible feeling of full of air, you can have much lower pressures when you
open up the airway by wearing an appliance. So that's another option we've got. And so we are
trying to make this more multidisciplinary, increase awareness. Because we as dentists,
patients come to see us, we're in an ideal position, they come every six months, we have a look,
we chat, listen to them, they trust us, you know, it's that feeling of, yes, oh, God, my wife's not
let me in the bedroom. And you know, for some people, that isn't an issue. And other people are
desperate to please help me. Right. And it's, we're in a great position to see the risks,
assess them and treat them if appropriate. And it's that multidiscipline approach. That's one
of the things that we rally for. Absolutely. Because then you're treating them as a whole patient.
Absolutely. And we're looking at their whole health. And we can, we in Britain aren't allowed to
diagnose sleep apnea, but we can refer for that. We can do some home sleep testing and get that
reported by a physician or a physiologist. Yeah, we can gain information. And, and, you know, some
GPs, medical practitioners are becoming a little more aware because nobody's been taught this.
We're all sort of, thank you. And we're all fumbling all the way through. Right. Right.
Right. As fast as we can. So at the end of every episode, I always like to hand the floor back
to our guests and let y'all have the final word. It can be for our parents. It could be for other
medical professionals, but just, you know, final thoughts from each of you.
Eva?
Um, final thoughts, sorry, Joe, go first because maybe...
Okay. I would say awareness. I want more awareness. I want nasal breathing, more awareness. And
go online, rally, find, find someone who'll help you. Contact us, contact your American Academy
of Dental Sleep Medicine. There are people out there. It is the messages getting out there. We
just need to increase awareness on other medics, other specialties, and just keep showing that this
can work. And we can really improve people with a little appliance instead of a CPAP or surgery,
or, you know, we're helping them with my functional therapy. We can help them positively change their
own health risks without medication. Yep. And my thought would be, um, follow your gut instinct
if you feel as a parent that something is not right, then seek someone who will listen
to your concerns because you're probably right.
And to professionals, I would say you want to know what you know, and what we got taught at
medical and dental school, half of it's probably outdated. So we got taught anatomy and physiology
so that we could understand how the body works. And sometimes we need to
go back to that unpack presentations of what is coming to us in our practices.
Yeah. Yep. There you go. Continually learning. Yeah, absolutely. I cannot thank you both enough.
This has been illuminating and informative and just truly a pleasure. So thank you both.
Yeah. Podcasts like this do spread the word and increase awareness. So thank you. Absolutely.
Thanks again to today's guests, Dr. Joe Engelby and Dr. Eva Stack for sharing their medical insight
and each of you for listening to today's episode. If you're new to our podcast, please don't forget
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Bye.