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Hi everyone and welcome back to Airway First, the podcast from the Children's Airway First
Foundation.
I'm your host, Rebecca St. James.
Today's episode is a bit different than that I've invited an entire panel of luminaries
and medical professionals who are incredibly passionate about airway and sleep health to
join me.
Each one of the guests today participated in some form or fashion in the SEC sleep conference
that was held in Houston earlier this month.
The guest panel includes Dr. Dave McCarty, Dr. Bill Harrell, Dr. Rob Beese, Jayton Techjandani
and Dr. Gerald Simmons.
We're going to cover a wide range of sleep and airway related topics.
So pull up a chair and settle in and join me and today's panel and today's episode of
Airway First.
All right.
Good evening and thank everyone for joining us for a very special episode.
It's our first panel ever on the podcast.
So thanks for joining us, gentlemen.
We're happy to be here.
Thank you for inviting us.
I live here.
Absolutely.
So just so that our audience understands a little bit more, recently we were all part
of an event in my beautiful hometown of Houston, Texas that was hosted by Dr. Simmons and
the Sleep Education Consortium.
So there was a lot of information that I learned as an attendee of the event and thought this
would be really an amazing opportunity to share it with some of our parents.
So that is why we are all here this evening.
So Dr. Simmons, would you like to do a little intro about the SEC and the event?
Sure.
Great.
Well, thank you very much.
So now I'm a neurologist, sleep disorder specialist and when I first got involved in
this field in my fellowship at Stanford University back in 1991, it sort of was very mind boggling
to me that I had gone through all those years of medical school and gone through a highly
regarded residency program.
And here I was doing my fellowship.
And within the first few weeks, I learned so many things that I couldn't believe I didn't
already know because I realized how fundamental they were to overall health care.
And amongst these were things that related to breathing and just some of the basics of
obstructive breathing.
And it was just very mind boggling.
So once I finished, I was in academics, I was involved in teaching, but then I transitioned
into the private sector.
But I had this underlying desire to help continue to spread the word to other health
care professionals because I realized there's a big gap in our health care system.
Just like I realized that when I first was doing my fellowship, here I was now in private
practice and I realized that so many physicians who are already done with their medical education,
they have no method of really getting up to speed to learn what I call basic truths of
overall health care and sleep, which really you consider a nutrient, you can't live without
sleep.
And there are so many things that can destroy the quality of your sleep.
And amongst those epidemiologically or in terms of the frequency, the most frequent kinds
of problems relate to abnormal breathing during sleep.
And but I wanted to come up with a course that can be done on an annual basis to teach other
health care professionals about sleep.
And so I started this nonprofit organization back in 2004 called the Sleep Education Consortium.
And every year we have a conference to teach health care professionals about sleep.
And the perspective I had gained to a great extent because of my collaboration with Dr.
Rob Vies, who's here joining us tonight.
When I was at UCLA, I was educating and I already realized the airway is going to be
influenced by the mouth and the jaw position and we'll get into more grinding, lynching
and the significance of all that later.
But so I wanted this conference to not just be for physicians, but also for dentists.
And then I also wanted to have one of the themes about collaboration.
So this has been going on.
We just had our 20th year of doing this consortium, this annual event, and it's grown in its complexity.
It's now actually a three day event for dentists, two days for physicians.
And we take people that don't know anything, we bring them to where they know quite a bit.
They're going to learn more in those three days than they would ever have learned in
medical school because in medical school, unfortunately, medical students over four
years are learning up to maybe four hours of anything related to sleep.
That's it.
And in an airway about the same or less.
Well, yeah, that's only a fraction of the four hours.
So, so anyhow, rather than going into great detail on that now, everyone here was at the
consortium conference and I'll just quickly go and introducing other people that are here.
So I mentioned Dr. Dr. Rob Vies, who is a dentist.
He's a CEO of Space Maintainers Laboratory that makes appliances.
He's been on the faculty at USC, went to dental school there and he's been involved in dental
education for many, many years and actually got me involved in helping him put together
back in the 90s educational materials for dentists.
But so he's on the panel here.
We have Dr. Bill Harrell.
He's an orthodontist who has also involved in academics in Alabama and the university
there and he's involved actually in helping coming up with new technologies.
He was very involved with cone beam CT scans from the early development and he's on the
cusp of new trends of orthodontics and he was also a part of our faculty at the consortium.
We got Dr. Dave McCarty.
He's an internal medicine sleep specialist living in Colorado, Colorado Springs.
No, Boulder.
Boulder, Colorado.
Oh, shame on me.
But previous to that, he was actually running the sleep lab over in LSU, Louisiana.
He trained at Harvard.
He went to medical school.
Duke, extensive background.
He recently just came out with a book on sleep apnea empowered and to actually educate
healthcare professionals on this topic.
And so he's well versed in every aspect of sleep medicine.
And then we also have Jayton Chandy who's actually a sleep technologist who work, he's
at the basic ground level, taking care of patients at night.
I mean, he's beyond that now.
But that's where he started.
His introduction to sleep was functioning as a sleep technician and then also getting
an engineering degree and taking his knowledge of engineering and applying it to being a
sleep technologist.
He's a great educator.
He's helped many, many technologists get their training and become certified.
And he's actually currently the vice president of the Texas Society of Sleep Professionals.
So he's a very knowledgeable person and involved in many different aspects of sleep medicine
as well.
So we're all here.
We had a much larger faculty conference.
Yeah.
Like 17 people.
Is that 17?
I think it was close.
I think faculty members total.
But we have the subset here that I think can handle pretty much most of the questions that
would come up regarding the conference.
And thank you for having us here.
And Rebecca, bets in your hands.
Awesome.
Well, thank you very much.
And I'll just say that parents had so many questions and I was fortunate enough to attend
all three days and even got to bounce around some of the hands-on events, which was really
cool.
So what I did was for parents that are interested, I'll make sure there's links to everything
so you can go to everybody's website.
You can see their LinkedIn.
Many of these gentlemen have been on the show already, so you'll be able to see their podcast.
But you can check out the conference.
You can see that just so much information was covered.
And I just kind of handpicked a few pieces that relate to things that our parents have
asked about before.
So we're going to start with the fact that at the conference we did talk about children
and adults, but today we're really just going to focus on kids.
So I want to start with, let's first define sleep-roxism in TMJ.
I think parents kind of have a basic understanding of that, but let's go ahead and level set
with that.
And then how does it present in children?
I can start.
Absolutely.
So looking at it from the parent's point of view, I think one of the things that I hear
all the time as a practicing dentist is a mom or dad coming in, usually a mom, saying,
I hear my child grinding their teeth at night.
Is that normal?
This is a good news, bad news question, because the bad news is most of my peers, unfortunately,
will say to that parent, well, let me look.
And they open the patient's mouth and they look in there and they may see a little bit
of wear on those baby teeth, children's teeth, or in the mixed dentition, they may see a
little bit of wear.
And particularly when they still have their baby teeth, their primary dentition, and they'll
look at the parent and they'll go, well, don't worry, that's normal.
And let me assure you that there's absolutely nothing normal about that.
So there's the idea of what's normal, like the normal variation is normal, healthy is
the question.
It's the fact that it's common.
Yeah, common is common.
And widespread doesn't make it healthy, right?
Exactly.
Yeah.
Exactly.
To your point, Dave, is it's very common.
And the other part that's common is the unfortunate response by dentists who aren't just aren't
aware of that.
And this is why we're here to try to educate the parent.
One of the things I'd like to see accomplished today is that if we can give you parents a
little bit of knowledge, it's going to spur you on to further ask the dentist and point
some of those dentists in the right direction to help them.
I mean, I want the parents to help the dentists and any other primary care physician to then
help them.
I mean, this education has to go all the way.
So the first thing that you need to know is it may be common, but it's not particularly
healthy.
And the only other thing that I want to say right away is one of the things that dentists
will do right away in my process of trying to educate you parents there is they'll say,
one of two things, well, we'll watch it.
One of the things I hate the most because I'm going to watch you get ill.
I'm going to watch your problem get worse.
God, I hate that.
And then the second thing is, well, let me make you an appliance that will give you a
bite plane, something that will stop the teeth from being ground away.
And that's what they know.
And not only you mean you're talking like a night guard.
I'm talking more like what would be a retainer, Holly type retainer that has a biting surface
in the front teeth.
So it separates the back teeth.
And when they close on the front teeth, they can't grind their teeth.
They're hitting the bite plane.
And that's a common thing that dentists will do because that's what they know.
But the focus is on protecting the teeth, not in figuring out why the teeth are wearing
away, right?
Well, they don't even know.
And let's just...
They don't even know that it's a sign and symptom of an airway problem.
And I'll let Jerry go from there.
Well, so let's just expand the definition now.
So grinding.
So what is Bruxism?
So Bruxism actually is no longer considered just the grinding, but also the clenching.
So if you're clenching your teeth at night, it's also considered Bruxism, sleep Bruxism.
Now once that child has that kind of an appliance, they may be protecting their teeth and they
may not be moving back and forth, but they're clenching into that appliance.
And they're building up all those musculature here.
And their joint may be protected because they've opened up the space.
So there's not going to be as much pressure right on the joint itself, but there's still
a tendency to be clenching.
Now when a child's clenching or grinding, what are they doing?
They're keeping their jaw forward because when they relax, the jaw may be falling back.
And that's the problem is that the airway is prone to obstruction.
And so the clenching or the grinding becomes a protective mechanism to help keep the airway
open.
So it's an abnormal phenomenon that's occurring as a reflex to protect the airway.
You know, it helps to sort of point out that this is a symptom of a larger problem.
This is the body's attempt to compensate for a stressor on the system.
And so just by protecting the teeth, we're not solving the problem yet.
The stressor is still there, in other words.
And I think that's the point is that the grinding of the teeth is just a sign of an internal
problem that still needs to be solved.
So you're saying this and so what proof do we have?
I mean, it's easy for us to say this conceptually, it makes sense.
But how do we know what proof is there?
Well, I'll just point you to several studies that have looked at children that have enlarged
tonsils and looked at the frequency of bruxing that occurred in these studies and found that
anywhere 25, 35, 40% of those kids were bruxing at night.
Then they had their tonsils taken out.
And that opened up the obstruction.
And then the frequency of bruxing dropped down to 10%.
And so their occlusion, people say the bruxing is because of the occlusion is off because
of the alignment of the teeth are off.
But by taking out the tonsils, you're not changing the alignment to the teeth.
It's the same.
You're getting the improvement because you opened up the airway by getting rid of the
obstruction of the tonsils.
Now, getting the tonsils out is not going to resolve the problem in most of these cases
indefinitely.
It's going to help the problem.
It's going to help open up the airway.
But usually these children have other aspects of having compromised airways.
And maybe it might be several years later that they're going to demonstrate more of the problem.
But the main point to make here, though, is that opening up the airway improves the bruxism.
And we now know there's also from children that have been diagnosed with sleep apnea
that we've put on C-PAP, the mask that hooks up to a tube to a machine.
And now C-PAP is not a long-term solution.
I call it a transitional therapy.
So we use it temporarily while orthodontics can be done to open up the airway for long-term
management.
But the bruxing will stop when we put the child on the C-PAP because now they're airways protected.
So one of the things that I'm sorry, Bill, go ahead.
It's all right, because I'm going to bring you up into this, too, Rob.
You know, in dental education, and you probably were the same, Rob, we would talk about bruxism
in children, especially in the primary dentition.
Like you said, it was kind of considered, well, this is normal.
You know, the baby teeth are softer than the permanent teeth, and they just wear like that.
And again, what Jerry brought up earlier was we thought in dentistry that it was all related
to, well, the bite soft, and so they're trying to grind their teeth.
Well, that's not true.
And the problem is in the primary dentition, if you look at the wear pattern from a dentist's
standpoint, if you look at the wear pattern, it's not that much about side to side.
It's front to back because they're trying to open up the airway.
So finally, we're getting a little smarter.
But dentists are taught that the baby teeth are softer and they just wear naturally, and
it's a normal thing.
But you know, within the recently, like Jerry brought up, some of these studies have kind
of opened our mind a little bit better to the reason why.
Because these kids aren't, we think about adults doing grinding too, and we say it's
stress.
What are kids, what's their stress level, unless they're abused or something like that?
I mean, they don't really have much stress, so it's got to be from something else.
So go ahead.
Okay, thank you.
What I was going to say is just trying to leave messages for the parents, like what's
the next step for you?
So when we talk about Bruxy, it would be, number one, pay attention.
And we're always trying to figure out, we know that parents will listen for snoring
and things like that sometimes because they can actually hear them.
But I would say, pay attention to see if your child is Bruxy.
And then if they are, then you go to your dentist and you say, my child is Bruxene.
And when the dentist says to you, oh, that's normal, you then have to say, well, look here,
I've heard from these doctors that it's really not normal.
And let me show you where you can go look.
And can you refer me to someone in your area that maybe there's an MD or someone who specializes
in sleep that I can have my child evaluated because it's not normal.
And here's the thing, consumers push the curve.
You know, consume, it's what the, and as one of the things we talk about with collaborative
care is how do we push this forward?
And the one reason that I wanted to do this more than anything is I want to speak to you
parents out there, have you helped us to push it forward because it's going to only happen
when you start squawking.
So okay, so as a physician, so physician, they get, they hear about going to a conference
and they're going to say, I don't have time.
I'm so busy.
Why am I going to go to conference?
You know, I work so hard day in, day out, and I don't want to take time off to go to
some other conference for a topic that maybe I'm not all that thrilled about.
It's not within my specialty.
I just, I don't want to do it.
You know, but when the parents are saying, here's a problem and obviously you don't know
how to solve my problem with my child.
And then the physician then said, finds out that there is a conference that they can go
to to learn the answers.
Then they're going to be more motivated.
The more they're going to be challenged during the day by the patients coming to them with
a problem and then they're presented with an opportunity to get the knowledge to deal
with that problem.
That's what it's going to connect it to.
That's going to change.
It's going to, and I will say, we'll put links in the show notes, but for example, the SEC
conference and Airway Health Solutions, they both have a great video series that we can
put out that you guys can obtain.
So maybe you can't get away to go to some of these events.
There are options.
We also have an area of our website, the parents can send clinicians to all the clinicians
corner and we are building on that to make that more robust.
And it's because of people like you, it's your information we're putting there.
So there are places you can at least send them to start looking.
But I want to touch back with, with Bill for just a moment because in your podcast, one
of the things we talked about was TMJ.
And you know, we kind of made this connection and I just want to make sure that we address
it here as well for anyone that didn't hear it about Brexitism and TMJ, but more specifically,
kind of to Rob's point, you can hear them snoring.
You can't always hear these other things, but there are signs and symptoms as parents
that we can look for.
And let's define it also a little bit.
So TMJ, Temporal Mendibular Joint, but it really should, it's really TMD, Temporal
Mendibular Dysfunction or TMJ Dysfunction.
So everyone has a T, but Rebecca, you're just demonstrating what most, what the lingo
how it's evolved.
Yeah.
How we hear it as parents.
Yeah.
TMJ, everyone has a Temporal Mendibular Joint.
It's just, it's the dysfunction.
So TMD is probably, but I go ahead.
Sorry.
What it should be.
Yep.
No, no, no, that's why you're here.
It's a good clarification.
And by the way, you have two of them.
Right.
Not just one side.
They're all.
And they need to work together.
Yeah.
Exactly.
So Bill.
Can we talk a little bit about the, the signs and symptoms that parents can look for?
Yeah.
And, you know, in children, you know, maybe things don't show up because you think about
TMJ disorders, you think about arthritis and some of the destruction that occurs in the
joint.
Inside the joint is a little cartilaginous cap that sits on top of the bone of the lower
jaw.
And that's called the articular disc.
It moves as you open your mouth, your jaws just don't rotate.
They actually, they actually come down a slope.
So the jaw actually, as it, as it opens, it starts to rotate and then it actually translates
down and what keeps it in congruency so to speak is that little piece of cartilage.
I kind of tell parents it's like a piece of cartilage in a chicken leg.
They can kind of, they can kind of, it's not exactly like that, but they at least know
what that thing is.
But that is interposed between the bones.
And believe it or not, it can become displaced even in children.
And I saw a seminar just last week where the orthodontist, he was taking MRIs on all his
children and he was finding a fair number of them.
Their discs were displaced.
And I worked with, oops, I worked with Dr. Bill Farah, who was the, one of the pioneers
in TMJ a long time ago, especially an adult.
But, and we saw, we saw some kids, I see some as early as, you know, nine years old that
maybe their bite is looking something like that and is trapping the lower jaw.
And it actually, the jaw actually gets displaced posterior backwards and the disc comes forward.
So if your child has clicking and popping, you can put, you know, you can actually put
your fingers in front of the ears and have them open and close and go side to side.
It should be smooth.
They should be able to open.
The normal opening is about three finger widths of your non-dominant hand.
If you just kind of want a quick little biometric measurement, if you take their fingers, non-dominant
hand, you should be able to put it easily between, between your teeth.
And it, you should have no clicking, popping or locking.
But if you have two finger widths, then something, it could be muscular, it could be that the
internal part of the joint are actually not functioning properly.
So a bite like this is terrible on a, on a jaw joint.
Now parents will look at that and say, well, their teeth are crooked a little bit, but
they really don't look.
If you look at that case, you can see where you don't see any lower teeth at all.
They're biting up number one in the roof of the mouth, which is not healthy.
But think about them trying to move their jaw forward.
What happened?
They can't really, they're locked in.
Right.
TMJs are locked and sometimes they're sitting backwards and they're off these discs and
they develop that way.
Then all of a sudden they get to be at orthodontic age and then you put braces on these kids
and, and line the teeth up and make them look pretty.
But their discs may be totally out of place and it really, the problems don't show up
until their 20s or 30s or 40s when they maybe starting getting locking, they end up having
to have surgery and all sorts of other stuff.
So between sleep disorders and children and then, you know, early signs of TMJ disorders,
you know, those are really important as for a parent to understand that and try to look
for things.
And you go to the dentist and say, Hey, my kids, Jaws are clicking and popping or they're
locking and they go, Ah, that's just normal.
They'll grow out of it.
No, they don't.
All right.
Just watch for waiting.
Like Rob said, is sometimes very, it's not good because it leads to more serious things
and more treatment.
Right.
Absolutely.
And I also want to touch on something that was interesting that you said and I've heard
it, uh, new Ben Moralia has said this Felix Liao.
It y'all aren't teeth doctors, your mouth doctors.
And that to me is another paradigm shift that needs to happen because straight teeth.
That's awesome.
But straight teeth with everything else messed up.
There's no point.
Yep.
I wrote an article for the dental sleep practice journal called the breathing smile connection
and it goes into the introduction is kind of how orthodontics kind of has pushed itself
toward smile aesthetics and pretty smiles and pretty faces.
And okay, we create healthy gums and we create those kinds of things and theoretically we've
been taught that if we can get the bite into what's called class one or a normal relationship
of the teeth, then they're not supposed to have TMJ problems and they're not supposed
to have a way problem.
Well, guess what?
That's not true.
Right.
And that's kind of why I wrote that article because it's the breathing, the airway is
critical and airway and jaw joint problems all go together.
So Rebecca, I shared my screen.
I don't know if you see it.
Uh, nope.
Right now we see says you are sure to division to.
Yeah.
Is that you?
Oh, okay.
That's you.
I thought Dr. Harold did that.
I didn't see that.
So, you know, again, kind of showing what a parent might see.
If you have a child who has it, what we would describe this as a very deep bite.
You can't see the lower teeth at all.
And if you can't see the lower teeth at all, that means that the manable is being held
in a posterior position.
It takes those con vials that Dr. Simmons talked about that TMJ and holds it up and
back.
And that's the beginning of the problem, you know, in a young kid.
So for mom and dad, if you see your child and they have a deep bite like this, that's
something you need to be concerned about.
Okay.
And, um, you know, that's one of the things that I would, I would tell you to see and,
uh, see if I can just quickly go back here.
Hopefully I can show you.
I can't.
I'll find it and pop it in for them to see it, uh, later on when they're looking at us.
Okay.
Cause I don't want to disrupt the talk, but I will include a couple of, uh, slides for
the presentation for this so that they can pull it into your thing.
But it basically is what does the face look like?
Okay.
That's, that's the key.
Wow.
What was the parents see in terms of their facial profile?
What does it look with their dentition?
What are some of the key things?
Are they thumbs suckers?
We'll show you some things that parents should really look at, which then go to one of the
things that Jerry should address.
Cause I see popped in here and it's like, how can we teach the parents to screen their
own kids?
Right.
But I mean, there's so much in some of the detail that we've just conveyed here, maybe
a little bit beyond what the parent may be able to pick up.
But it's a big picture.
There's a spectrum to the degree of the problem.
And look, we, I don't know that it's appropriate for us to put out information with the expectation
that the most subtlest kids that are the mildly, the ones that are most mildly affected are
going to be captured by the information we can hear.
I think let's go up to the bigger picture of those children that are more seriously
affected.
So if the child will say tosses and turns all night long, they're just not good or they're
hard to wake up in the morning.
You know, they're throwing the sheets off the bed.
They can't focus in school.
And, you know, they're always talking at a turn and they're hyperactive and they're
a real problem.
The behavior leader of a problem.
And then you see that there's these issues with their teeth.
They're clenching, they're grinding.
Their mouth breathing.
Okay.
The pathway of least resistance should be through the nose.
So if a child's not getting the air that they need through the nose, they're going to compensate
and do what we call rescue breathing.
They're going to open their mouth and they're going to start breathing through their mouth.
They may be drooling on their pillow at night.
When you see a child like that, if you have a child like that and you go to your, now,
so now we're not talking about just a little problem that I'm noticing that their bite is
deep.
And if that's the only problem and your child sleeps really well and their behavior really
is doing well and they're well rested and nothing else is a problem, you're not going
to get too many people to take that too seriously.
And yes, it may be a problem and maybe anatomically they are predisposed to other issues and maybe
come to a problem later in life.
But let's get to the bigger, more serious scenario when your child is having these other symptoms
I've talked about and you go to your dentist or you go to your pediatrician and they disregard
your concern.
You've got to go somewhere else.
Yeah.
And we'll put some links, by the way, within the show notes as well for you can find providers.
And let me, though, I want to prepare the parents for the scenario here and then I'm
going to segue here in a second because you actually get a clinician that's going to say,
okay, I take you seriously.
Let me order a sleep study and then they're going to send you to a lab and your child
maybe let's say seven or eight years old and the lab will do the study and it comes back
saying no significant problem.
So I'm going to let Jaten now talk a little bit about that, about what goes on with these
tests and how it could be all over the map.
And do you trust a test that comes back normal when clinically you've got a gut feeling my
child's got a problem?
So Jaten, maybe you can talk a little bit more about the testing aspect.
Sure.
Thank you, Dr. Simmons.
So we've heard a lot of discussion today about sleep disorders.
In previous episodes, we heard from Dr. Simmons as well as Dr. McCarty about a few things
like sleep staging, REM non-REM, deep sleep.
We heard from Dr. McCarty about the AHI.
It's very important that these numbers come from what Dr. Simmons just mentioned is a
sleep study.
So what is a sleep study?
To get these things, you have to measure multiple things, measure brain activity, eye movement,
airflow, effort, leg movements, and oximetry.
When you gather all of these different things, these are multiple sleep graphs.
Multiple sleep graphs translates to polysomnography.
It's one of the most comprehensive medical tests you can do.
It requires no blood, no radiation, and you spend overnight.
Similar to a hotel stay, you will check in and check out.
You will be given snacks and drinks.
You will spend more time with the person performing that test, the sleep technologist, than you
will ever spend with the physician for a period of time.
And during the application of these sensors, we can take up to an hour, half hour to an
hour depending on the experience level and the cooperation of the patient.
You're going to get education educated by the technician.
As each wire is applied, they're going to explain to you this wire is applied and what
the reason is for it and how it relates to the end result and what we're going to do
about it as well.
Dr. Simmons also mentioned CPAP therapy, continuous positive air pressure.
Whenever the doctor prescribed CPAP, it's based off what's called a CPAP titration, where
the technician applies a small amount of pressure and then slowly increases and increases and
increases it until we get an open airway.
So we're talking about sleep.
You can't manage sleep until you can measure sleep.
If you haven't done a PSG, it's what it's called, then we should do one.
And even if you have done one, it may be time to do another one because you can't really
know if you're sleeping or if you're not, or if you're breathing or if you're not, unless
you are measuring it.
And for a pediatric population, there is no other alternative than an in lab PSG.
You can find out more about the Children's Airway First Foundation and our mission to
fix before six on our website at children'sairwayfirst.org.
The CAF website offers tons of great resources for both parents and medical professionals.
Visit our parents' portal, clinicians' corner, resource center, and video library to see
for yourself.
We also encourage parents 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.
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 today's episode.
And how does that work, you know, as far as some of these kids are little, it's scary
and totally get that.
So just kind of so to level set it for parents, do they stay with the child, the child in
a different room?
How does this process work?
So the parents will always be in the same room.
They may or not be in the same bed.
There will be rails to prevent the baby from falling off in some situations.
They have to have cribs.
So what you would do is you would confirm all of this when you schedule the test.
You will schedule, you'll have the age, you'll have all the issues.
There's also pediatric focused technologies.
And there's even pediatric focused labs and even hospitals.
We're going to have another guest on the podcast coming up soon, James Cardell of the Lucio
Packard Children's Hospital.
And they do nothing but pediatrics.
So he'll be able to explain a lot more about the actual logistics of getting that test
and getting the instructions for our parents.
What James and I work on is another collaboration, just like Dr. Simmons is collaborating with
a dentist and physicians.
What we're doing is collaborating between the technologist and the engineers, because
the engineers are developing the systems, but they may not understand quite how they're
actually are put into practice.
And the technologists are having issues with these problems, but they can communicate with
engineers.
So that's what we're going to try to focus on now is trying to get this collaborative
idea from the SEC and translate it to this other aspect of the story.
Yeah, and so, Jane, what would you say about a scenario where the child is already symptoms,
but the lab comes back with the test being normal?
I guess, let's talk about, you know, theoretically, every lab should do everything perfectly.
The reality, my experience is that a lot of times the labs aren't up to par to where we
would like them to be.
They're going to pick up the clearly abnormal kids where their oxygen level is dropping down.
Those are easy to find, but when you get these more subtle cases, how, you know, I mean,
so you know, a lot of labs may not have as much experience with kids, but also they're
going to do one here and there.
And so, so it's important, remember that there's two technologies.
One is the person that's applying the leads as the acquisitions knowledges.
And what Dr. Simmons is talking about is the second person.
The second person is called the scoring technologies.
Whenever they look at the signals, we have to make a classification after you decide
whether the patient's asleep or awake.
If they're REM or not, you classify whether that event qualifies as a respiratory event.
So there's clear cut criteria.
And what we're talking about is a desaturation as one type.
We call that the AASM.
There's also one that causes an arousal.
The D4% desaturation is the Medicare definition and the 3% or arousal is the American Academy
of Sleep Medicine.
So the technician on the daytime, the one scoring the study also has a very significant
impact on the result.
Because if they decide not to score that study or not to score that event, then the patient
will test negative versus if they use a different criteria using a different sensor, they might
test positive.
And with a pediatric population, the difference is like, is one per hour.
As long as you have one event per hour, they are now diagnosed.
So if you fail to miss one of those events, now your AHI, the apnea apnea index is less
than one, it's 0.9 or something lower, now you have a negative study.
So what Dr. Simmons is saying is you can have a negative study and solve a problem just
based off of how the study was conducted and how more importantly the study was scored.
There are also different quality sensors.
As the engineer putting these systems together, including the one in Dr. Simmons, we had to
calibrate those sensors.
If the calibration was off or the technician applied it incorrectly, the scoring technician
wouldn't be able to even score these events.
So the scoring technician and the acquisition technician have a severe impact on the end
result of it.
If you go on Tuesday versus Wednesday and the technician is a different person, you
may have a different result.
It does have that much of an impact.
As well as managing the actual situation, pediatric patients are the most challenging.
They're not cooperating because they don't know what's going on.
So a skilled technician will make the patient feel comfortable and also the parent comfortable.
And there are many times where we're testing the pediatric population, the children, and
we uncover a sleep disorder with the parent.
We see them snoring, gasping, having apnees.
Like, actually, maybe you're the one who used to get this study.
So we have to kind of navigate that situation as well.
But the technician isn't a doctor.
We can't diagnose.
We can't recommend treatment.
All we're there to do is just to apply the leads and generate these tables and generate
these plots for the doctor to make a decision.
But the doctor can only make a decision if the technician and the lab do the job correctly.
That's what Dr. Simmons is saying, is that the technician could get this done wrong.
It's very easy to miss an event.
It's very easy to misapply a lead or just put it one, submit it to the left side and
you won't pick up these arouses.
And also, I guess what I'm saying is go with your gut and don't always feel that maybe
you're crazy because the test didn't come up with the abnormal result.
Not all sleep labs have been created equal.
And I use an analogy asking women, are all beauticians the same?
I'll say, are all dentists the same?
Well, don't assume that all sleep labs are the same.
Right.
So if you clinically see your child has a problem and it seems to be related to sleep,
you're looking for confirmation from the sleep lab.
And if you don't get it, recognize the possibility that a lab just may have missed the diagnosis
and you may want to go to some other facility.
You might have traveled further away.
Another way to look at this is that the AHA is a language that has evolved differently.
And so every AHA must be unpacked.
And I think if every parent sort of accepts that, that the AHA you get on your study,
there is a lot of investigation that goes into what that metric is, how it was defined,
you know, whether it was defined by dissaturations or arousals.
And so every AHA must be unpacked is a good mantra for us to repeat.
You know?
Yeah.
I like that.
I think I saw this earlier podcast, which we'll put a link to also where you talk about
also its perception.
The story you tell as an adult, but I think it applies to children as well.
Yeah.
This person didn't understand why they were having to come see you and sleep study and
I'm fine.
Kids are the same way you think as a parent.
Put them down.
They were in there for eight hours.
We're good.
We slept.
But how did they really sleep?
Right.
You got to get to that or what are they like when they wake up?
There's a lot of things that as parents we can look for.
So kind of, I guess, to build on that, what does good sleep hygiene or, or I'm trying
to remember another phrase instead of sleep hygiene, but what does that look like for
a child?
What should it be the various stages?
Toddler, that kind of middle group, five to 10 and then up.
What should it look like?
Oh.
I can do that Dave also, you know, can pitch in, but basically your sleep need changes as
you're growing.
Right.
And like a little infant is going to sleep.
The newborn's going to sleep most of the day and then it's going to sleep requirement
is going to get down lower and lower.
But still, I think the biggest problem is probably in adolescence and when these children
are needing to sleep, you know, maybe 10 hours, you know, they're probably maybe are getting
seven because they're staying up late at night.
You know, there's the after school activities and then they have homework and now in order
to get to school on time, they're waking up early early because, you know, we're living
their phones, their iPads, phones.
And so there's, so, you know, so there are a lot of children that are sleep deprived.
And you know, we're talking about airway as being a cause for ADHD in children, but just
something more basic of being sleep deprived can cause ADHD symptoms in children.
So if you're going to take your child to a clinician who's then going to say, oh, your
child's got ADHD and they're ready to plot a prescription pad and write a prescription
for a child and they don't even ask a history about sleep run.
Go somewhere else.
Yeah.
If they don't ask, they need to ask these basic questions about, you know, normal hygiene
that, you know, sleep hygiene and get a better understanding of the child's behaviors and
how much sleep are they getting?
What's the environment of their sleep, you know, their sleep environment?
Is it loud?
Yeah.
You know, is their bedroom right next to the street light?
Exactly.
And they're going to get the light blaring in or do they have the, you know, the parents
up in the next room with their TV blaring late at night?
Well, what about inner city kids when they're hearing, I mean, this is a public health issue
that I don't want to talk about.
They're hearing all of these sounds outside.
So it starts, sleep deprivation is going to result in difficulty with focus during the
day and reactive hyperactivity.
But then you can start looking at physiologic abnormalities and obstructive breathing would
be number one.
And another thing called restless leg syndrome or another thing called periodic leg movements
of sleep, either with restless leg syndrome symptoms or even without just periodic leg
movements of sleep.
Less number two from a physiologic standpoint is the next most common cause of disrupted
sleep that can lead to daytime disturbances of ADHD kind of behaviors and difficulty with
that inattention.
So if your child has these kicking movements while they're asleep and they're kicking
the sheets off or if you've ever slept in bed with them and they're just having these
kicking movements, that's an abnormality.
And the child may actually have a low iron level as one of the contributing factors.
I mean, there's a lot of discussion.
I'm going to not to take up things.
I know Dr. McCarty knows this stuff really well.
I'm going to actually transition to give him a chance to speak on the topic as well and
give him a little bit.
Yeah, I want to make sure we talk about RLS because I will tell you, even with everything
that I've done, I sat in that conference and when we started talking about it, I was stunned
when somebody said something about children.
I thought, seriously?
Oh, yeah.
I just never occurred to me.
Oh, wait.
So the little monkeys is what we used to call them because they would turn upside down
in bed and their legs are going everywhere.
It never occurred to me.
Oh, that's a restless leg.
So they actually have it as well.
That's not again, not normal.
Yeah.
So it's a very common problem and it's got a it's got a bimodal population distribution.
So it happens in young children and it happens in seniors.
And the reason is because of the relationship with iron.
And it happens that growth is an iron consumptive phenomenon.
And when we consume iron, we can develop problems with iron transport to the brain.
And when that happens, it leads to these physical symptoms.
And in the old days, we used to call them growing pains, you know.
And nowadays, we sort of recognize there's this relationship with this semi movement
disorder that has to do with a physical sensation of discomfort.
So it is, in a sense, a chronic pain sort of issue.
If you think about it, it's a chronic discomfort syndrome that interrupts sleep.
And when we realize that it's, it's something that has no physical signs or symptoms that
you can actually demonstrate, you realize that this is something we have to have a high
index of suspicion for, you know.
So when kids, this is a very real phenomenon.
And as Jerry says, we need to be thinking about this as a source of sleep disruption.
And actually, there is a bi-directional relationship between restless leg syndrome and sleep apnea.
So it turns out that oxygen transport in the central nervous system is iron dependent.
And so if you have a regional iron transport efficiency, you cannot get oxygen to critical
places in the brain.
So the fact that you have restless leg syndrome indicates that you cannot transmit oxygen to
the brain.
And if you, if you cross that with rest, with, with a obstructive sleep apnea, you recognize
there's a problem.
You know, if you're having oxygen desaturating events in the setting of a problem that, you
know, eliminates oxygen transports to the brain, you've got a problem that now is augmented
by each other, you know.
So these problems tend to coexist.
And this complexity is something we should all be talking about, you know.
Yeah, absolutely.
Another thing that was mentioned along with RLS, and then we've talked a little bit about
ADHD is parasomnia, as I would like to just kind of dig into what that is a little bit
and how it applies to children, because again, that one surprised me.
And then sleep related eating disorders.
So can we can we touch a little bit on what these are and do you want to take on the parasomnias?
Okay, I'll take on the person because we can go into the sleep related eating disorders
with respect to, to restless legs as well, because that coexist as well.
Yeah.
So basically, pirisomnias are abnormal events during sleep behaviors.
So it's it when you have some kind of abnormal behavior during sleep like sleepwalking, sleep
talking would be the most, you know, most common.
So if your child does that once, okay, put them back to bed, don't worry about it, don't
lose sleep over it.
No, but do it twice.
Don't worry about it, put it back to bed, don't lose sleep over it.
But when your child starts doing it regularly, and it's going on for at least six months
now, you definitely want to seek out attention.
So it's it's common, especially if people are getting hurt, right, Jerry?
Well, yeah, there's an injury involved.
That's the you should get involved earlier.
But but the thing is, you know, it's common for a child to have a parasomniac event, you
know, as an isolated event.
And they sit up and talk to the company, you walk in and they walk in and they go back
out.
So they took they took a leak in the closet, right, thinking it was the bathroom with the
bed.
But it's an isolated event.
It doesn't happen very other times.
All right.
So do you need to get, you know, go to the pediatrician and get a whole thing, a workup
for it.
It's, you know, if it's a single event, it happens, it's just grow up.
All right.
And typically what's happening is when a person is in what we call slow wave sleep, not REM
sleep.
It's it's where the there's these high slow waves phenomena going on in the brain waves
that we measure.
It's hard to fully awaken when you're in that stage of sleep.
But if some kind of stimulus occurs that would otherwise have a woke you up, the brain doesn't
want to wake up when it's in slow wave sleep.
So it goes into this in between stage of this, you know, pseudo quasi state.
So you're talking about sleep disruptive forces.
And this could be sleep, destructive breathing.
And so that's something to say.
And it could be restless leg syndrome too.
So if it happens, that's a nice event.
It could just be, you know, whatever, could allow noise, a dog barked outside, right?
Or the child's got a cold and they're congested and they do have obstructive breathing, but
it's only on that one night.
Right.
But when it starts occurring on a regular basis, it may be a sign of obstructive breathing
during sleep.
It may be a sign of rest or periodic leg movements of sleep.
So those leg movements, instead of causing a complete awakening when it occurs in slow
wave sleep, the child's now in this quasi state.
And this is not just for children.
This could be for adults as well.
But then they'll start carrying out some behavior and start doing some abnormalities.
Now there's something called a night care.
Okay.
Now a night care is not the same as a nightmare.
Nightmare is a bad dream and you're not moving.
Someone's having a nightmare, you look at them, they're asleep.
You don't know that they're having a nightmare.
A night care with child's gonna be yelling and screaming and moving around.
And the nightmare is in REM sleep, rapid eye movement sleep.
A night care is usually in non REM sleep.
Right.
And the night care is going to be, could be a sign of another abnormality.
Now it could also be a sign of post traumatic stress disorder.
All these non REM parasomnias can be a sign of, and not to alarm you patients, but this
is the way I, my approach to these is that I'm looking for a physiologic cause.
And if I can't find a physiologic cause on a child that's having these parasomnias on
a regular basis, then I gotta start looking at psychological causes.
Right.
And I think about most common would be abuse.
And it could be part of a post traumatic stress phenomenon.
But you don't lead with that.
I'm not gonna right away start making accusations or start probing into, could this child be
abused?
My job is first exclude all the physiologic possibilities.
And when I can't find any, and this child's still having it, then I need to now probe
further with the parents about the possibility that maybe this child's being abused.
And it happens.
So, so that's sort of the topic.
You know, that means a big topic.
It's the next two hours talking about parasomnias.
And then there's something called rem behavior disorder, but that's not common in children
at all.
It does occur very rarely.
So I don't really want to go down the rem behavior disorder pathway of discussion.
But the non rem pair of parasomnias are common.
And the first thing we have to look at is obstructive breathing during sleep.
If it's going to be a recurrence phenomenon, because that's the most likely cause.
And the same child is grinding, clenching and, and you know, drooling other pillow,
the mouth, either either their mouth breathing or the clenching and grinding.
So, okay.
Okay.
Oh, everybody moved around.
Jayton, do you want to talk?
It was important.
Right.
So part of the sleep study, in addition to all the sensors we mentioned, the EEG, brain
wave, respiratory, SPO2 were also full time measuring audio and video.
So if there was a abnormal situation like a sleep terror or sleep blocking event, the
technician would actually be able to zoom in, move the camera, capture the audio.
In addition to having all of the observations from the data, the most important data set
is going to be the actual observation of the technician.
They are typing in whatever they're observing.
So we can go back to that individual frame of that individual video, look at everything,
including the EEG, because we're going to see on the EEG the patient was in slow
wave sleep, like Dr. Simmons is suspecting.
Or we might even see spikes, waves.
This will indicate some kind of epilepsy.
But this is all only able to be done by the doctor if the technician manages the study
the right way.
Okay.
Got it.
So.
Well, I guess one other thing to add to that is that the ability to identify seizures
during a sleep study is going to be more likely to occur if there is the addition to
a full set of electrodes to perform a complete electroencephalogram throughout the night.
Most sleep studies only consist of several different, maybe six different electrodes
on the head.
I'm looking at frontal, central, maybe occipital activity.
And seizures are most commonly going to occur over the temporal lobe.
All right.
And then you'll miss temporal lobe seizures unless the study is ordered in a fashion to
capture that.
So clinically.
So, you know, one thing that's different about our facility is we are not a testing
facility.
We do sleep studies all the time.
We test all the time, but we don't just do the test.
We don't take in referrals from other doctors that just, you know, like a primary care doctor
is going to refer for us through the sleep study.
And that's it.
We're going to take the results and send them back.
No, we want to see the patient clinically.
We're going to take a history.
We want to know what's going on with the patient so that way we order the right test.
And we want to be responsible for the results of the test to be involved with the treatment
plan.
So we're a comprehensive entity.
And you know, some doctors don't want, they just want to send just for the test.
And if a doctor knows, but if a doctor knows sleep really well and they contact me, I'm
fine with that.
But what I'm not fine with was it would be the primary care doctor that wants to, doesn't
know sleep very well and just looks at our facilities being nothing but a sleep test.
And in their mind, they don't even understand sleep as a specialty.
They understand it.
Sleep medicine is just a test.
And now that what's in the lab is now just with a home study.
So now you don't even have to send them to the lab.
All you have to do is do the home study.
And if the home study comes back negative, you've excluded the problem.
That is so far from the truth because the sensitivity of the home study is not as good
as the sensitivity of an in lab study that's done properly.
But unfortunately, the mentality has evolved within primary care.
They think that all you need now is a home sleep testing device.
And so they're just doing it and they're sending the results to some sleep specialist.
It's going to review it and sign their name on it.
And they think that they've done a good job because they had a sleep specialist reviewing
it.
And if the study comes back negative and they have a patient with clinical symptoms, there
has to be a further investigation done.
Yeah, for this service.
It's not done.
So, Jerry, could you just clarify for the parents out there the availability of home
sleep studies for children?
Okay.
So that's a point that's in transition right now.
It's been the standpoint of the American Academy of Sleep Medicine that there are pediatrics.
For pediatrics, you have to do in lab studies.
And most home studies have not been approved for pediatric use.
There are a few devices now that have been approved, which is fine.
I think it's totally okay to do a home study on a child.
If it comes back positive, you've now established the diagnosis.
The likelihood of having a false positive home study showing sleep apnea, false positive,
is very low.
The likelihood of it being false negative, meaning it's negative, but the child really
does have sleep apnea, is pretty high.
In other words, so if the study cannot provide what you need, you need to take a deeper dive.
So I'm more concerned about the overall treatment pathway or assessment pathway than say, should
you never do sleep studies in children?
Well, if in your community, there's a six month waiting list and your child's not breathing
at night and you see it night after night, you're going to wait six months or you're
going to put them on a home study, which might even consist of just a ring.
And it's going to come back positive.
Boom, you've just stayed six months off of establishing the diagnosis.
Now you talk about treating the child.
So I don't want to take the dogma and say you should never do sleep home studies on
children.
You just have to know what kind of study you're doing and what's the limitation of the technology
that you're using, because if it cannot give you the answer you are looking for, you have
to take a deeper dive.
That to me is a bigger issue.
So I want to do a follow up because I've got one coming up with Jayton, where we're
going to talk a little bit more about sleep, but I want to make sure that we do one with
you as well, Dr. Simmons, because there's a whole lot to unpack here and I think parents
need to hear it.
But for the sake of time, I want to make sure that we cover our last couple of questions,
because I really want everyone to have the opportunity to weigh in on these.
Rebecca, there's one important point between PSG in lab versus in home testing.
Those in-home tests are not really true sleep tests, they're just sleep apnea tests.
We discussed REM behavior disorder, parasomnia, slow way of sleep, REM.
They won't pick any of those up.
They won't pick up anything.
They'll pick up only one thing that is either you're breathing or you're not.
That's it, right?
If you have a strong suspicion of sleep apnea, fine.
We'll get an AHI, the AHI will likely be okay if it's moderate to severe, but if it's too
mild we'll pick it up.
If it's anything other than sleep apnea and we'll pick it up because when you look at
home sleep testing, you say it this way, HSAT, home sleep apnea testing.
Only one indication to use this one.
That's an excellent clarification.
Thank you.
Again, we'll dive into that more when you and I have a chance to follow up.
One of the things that was discussed at the ASCC, and I know and I'll put links for any
physicians, medical, allied professionals that are listening that hasn't attended, the
APMD has something coming up called collaboration cures.
That word collaboration is huge.
I didn't realize how touchy it could be for some people, but I don't understand why it's
not quite as well received because when you're looking at a child, instead of siloing it,
if you're working collaboratively with a myofunctional therapist and the ENT and the pediatrician and
the dentist, there's so much more just this comprehensive health we can provide for this
child.
I realize this is a loaded question and it is opinion only question, but how do we make
this paradigm shift?
What is it going to take to go from siloed to collaborative approaches?
I'd like to address that.
We need a common language.
We need to be able to talk to each other in a language that favors the patient.
That's what I've been spending my career trying to do is to try to find a way to talk about
this problem in a way that involves everyone that doesn't.
Somehow this problem has evolved in a divergent evolution of language where the different
silos can no longer speak to each other and the patient who finds themselves between silos
will be to them.
If we can have a language that we all can share that somehow talks about the patient's
own experience in this phenomenon and all of us can share that, that's where we need
to go.
I would add as a practicing dentist that and someone who's been treating sleep patients
since the 90s, I have just found that I cannot be successful to the degree that I want to
be without collaborating.
What I have done is I just tell my patients that I can't really treat them unless they
are going to collaborate with my medical partner in this because I'm just not going to have
a chance to be successful.
It really just comes down to that.
What that means for me as a practitioner is some patients are not going to see me because
they want that quick fix, they want that dental appliance because they've convinced themselves
that they can't wear a seat pad or whatever it is that they've convinced themselves of.
They're looking for that person to fix them, but I can't be that person.
It doesn't mean that I won't refer to somebody else who might fulfill their need, but it's
not going to be me because I want to have a fighting chance to be successful at helping
them.
Part of the cure is education and experience.
I use myself as the example that over time, I hope that I'm getting better and better
at how I treat my patients.
It's changing how I treat my patients.
The other part of the cure are things that we're doing here, Rebecca, and I repeat what
I said at the beginning, which is the change really, in my opinion, come from being patient-driven,
parent-driven.
That's why any good product, whether it in the dental field like a liner's, do you think
that a liner therapy was driven by the dentist?
No, it's driven by patient needs, by these companies that went out to them and said,
hey, we can make your teeth straight and go find someone who can do that.
It's the same thing.
We need to educate the parents, educate the end user, and push them to push us to communicate
with each other.
I think they have to be demanding to want that cure.
Dave, you're muted.
We can't hear you.
I would say push us to communicate with each other.
That is so true.
One of the things, if you look on TV now, there's all these big ads about Inspire.
They have some great ads.
They got some of the other people wearing masks and then this one guy over there says, I have
Inspire.
Somehow, the American Academy of Dental and Sleep Medicine or something, we need to put
some ads out there like that.
Now, it's very expensive and that's how Inspire can do it because they're a big company and
they got a big budget.
That grabs their attention.
I guarantee you that gets people to say, I don't want to wear it.
I want to go see if I'm a candidate for Inspire.
Maybe some I'm more, but a lot I'm aren't because I got to get scoped and all this other
stuff.
If there was an ad campaign or something along with that to say, well, here's another alternative,
but I don't know if we have a big enough group to be able to go out there and afford some
ad campaign like that.
I wish we did.
I thought I just saw the ad on TV just an hour ago.
Oh yeah.
And you said Inspire and now the whole thing is going through my head.
It's Inspire Sheila.
I can do the whole commercial.
It works.
I don't even need it.
Yeah, but it's not as simple as the commercial patients think, oh, they don't even realize
it's a plan to a device.
I think there's something you just press right here.
I had to look it up to find out what it was.
But to his point, because it was there, I went and looked it up.
I'm thinking, what is she yelling at Sheila for?
What is she talking about?
And then I went and looked up what it was.
And now I know.
Just like Dr. V said, he can't function his best without having physicians.
I know that I need dentists to collaborate with.
When I first came relocated from California, I was in fact with the UCLA, and I came out
to Texas.
I was looking for a dentist, at least one that I could work with locally, because I
knew that I had to provide appliances for patients to stabilize the mandible.
Even though a lot of my patients that are on the CPAP, they'll do better if they're on
an appliance.
But I already recognized that it's part of the treatment pathway.
So I went on a my way to find someone to fit the niche.
And the person I've collaborated the most with was Dr. Ron Preen.
It was also one of the faculty members at the consortium.
He was there.
Yeah.
And he didn't know, when I first met him, he didn't know anything about sleep.
He was a TMJ dysfunction dentist.
But he was making appliances.
So I then taught him a little bit.
And he right away was like a sponge and learned a lot.
And he's a big educator now in the field.
But this was like back in 2001, 2002, when I first met him.
So part of the problem, though, with collaboration is where all these doctors are busy doing
their own thing, and they don't necessarily reach out.
And they're going to do what they, their pieces of the puzzle, and there's not a good
quarterback to really pull these patients together.
So if you look on a national level and see where things, where are things changing the
most, I think what you're going to find is that there's a new type of clinician called
a myofunctional therapist.
And the myofunctional therapists are basically physical therapists of the mouth, of the airway.
And they are either coming to the pathways being speech pathologists that then realize
what myofunctional therapy is, and they get on the board that way, or they're dental hygienists
and are looking at mouths all day long.
And they become empowered by learning what's going on with myofunctional therapy.
And then they get going to that professionally.
But these myofunctional therapists, in many instances, are functioning as the quarterbacks.
I was about to say that on the podcast, that's what I hear over and over.
Right.
And they are, and we're just coordinating and sending patients.
Right.
So they're almost like the care coordinator because they can't function on their own.
They need these different kind of clinicians and they're getting it and they're working
with the dentist and the sleep physician, you know, and, you know, the ENT doctor.
And so they're functioning and evolving to help fill this void.
Now in my practice, I mean, I have five nurse practitioners.
All my patients are seen by my nurse practitioners, otherwise I'd be the bottleneck of my practice.
And I'm behind the scenes working with my nurse practitioners and I see a lot of the
patients, but I don't see every patient.
I couldn't.
There's not enough time of the day.
We don't rely on the myofunctional therapist in my practice to be the quarterbacks because
we're at a level that we know how to do this and we don't need the quarterbacking.
We send a myofunctional therapist quite regularly to a month and not to one or two to many, depending
on the geographical area, or we're getting referrals from myofunctional therapists.
And then we're referring back.
But most practices aren't going to be like mine.
And these myofunctional therapists are great resources.
So I would encourage your parents that are on this, if they're in an area where they're
not sure who to go to, seek out a myofunctional therapist because they're going to be finding
someone that's already done the homework for you.
Yep.
And we'll put links because Airway Circle, for example, has a great doctor finder, clinician
finder that has so many myofunctional therapists that are airway focused, by the way.
I mean, they're really walking the walk on that.
Right.
And they've done the due diligence.
A lot of my orthodontic referrals now, guess where they're coming from?
Myofunctional therapists.
Yep.
A lot of them are three, four, five, six year olds.
They're early, early, most orthodontics don't sleep.
But I'm sleeping three and four and five year olds that have sleep at me, that have been
diagnosed.
And the myofunctional therapist has picked it up and I've discussed it with the sleep
physician.
And we're doing different types of expansion early on.
It's worth mentioning real briefly that we were going to have a myofunctional therapist
on.
We've got Dana Christy Gatto, who is also one of the faculty members.
She unfortunately had an unfortunate event of a friend of her that passed away.
So she could have thought, thought, thought, thought.
But I will be following up with her.
So parents will get to hear from her.
So I will be.
Yeah.
So she couldn't join us tonight on short notice, but, but I want to make sure people recognize
the role that the myofunctional therapists play.
And again, if you're having a hard time finding who to go to, the myofunctional therapists
has probably already done the homework in your geographical area and should know who is,
you know, good.
But sometimes they're also frustrated because, you know, we're dealing with a specialty that
has just it's, it's in its infancy.
And there are just not a lot of highly trained clinicians yet throughout the country to,
but then again, telemedicine is growing.
I was about to say we have quite a few myofunctional therapists that will do telework.
So as clinicians to, I mean, we're doing a lot of telemedicine.
I see patients around the country.
Yeah, which I didn't realize until I talked to Dr. Liao, he works with patients all over
the world and it just, I love technology.
It's mind blowing.
Well, and we're using it to get this message out.
Obviously, that form is what we're using to get the message.
Yeah, to get the message out.
So, all right.
So the last question and usually I leave this more as an open question for whoever I'm speaking
with, but I want to kind of tailor a little bit this evening and give you all an opportunity,
although it may be the same answer, I'm not sure.
But parents that are looking for support for their children, you know, for their sleep
and their airway journey.
I'll turn it over to each of you for the last word of guidance, encouragement, anything.
And I guess, you know, Jaden, let's start with you.
So I found that with my patients, whenever they are having some difficulty, the difficulty
looking to them is that they feel alone.
They don't, they go to their physician, they explain them to have this and that and they
need to be diagnosed with anxiety or depression or iron anemia or something.
And it's none of those things, right?
They get sleep and then they get those procedures, they get on medication and their problem never
goes away.
They feel better once they join a community.
That's what I think we're doing here, you know, joining dentists, functional therapists,
technologists like myself, parents like yourself.
The patients should do the same thing.
Patients should join a community.
There are multiple Facebook groups.
There are LinkedIn groups.
There are just communities that you can actually meet in person at the community center just
to share your story about what doctor I went to, what live I went to, what results I did,
what therapy worked for me.
And just that, even if you don't follow any recommendations, at least you know that you're
not alone in the journey.
Yep.
And that's great.
And I'll make sure that we have a couple like the airway huddle and there's a tooth pillow
one.
I'll make sure those are also in the show notes.
Rod?
Well, what I would say is the message I'd like to end with for the parents as well is to
say that every method of treatment that we have, they all work to some degree, but they
are band-aids.
They're not cures.
The cures prevention.
See, and we're talking about kids here.
So the reason I so desperately wanted to do this, Rebecca, is because I want to reach
out to these parents and say, you know, you need to pay attention.
You need to screen your children yourself.
And CSMA, go online.
They have great screening forms that we use in our offices.
There's a screening tool that a group of us are developing that will allow practitioners
to screen, but you can screen.
We can help you to look at your children to be the driving force to maybe prevent the
problem, to treat what's happening now, and then prevent them from growing into adults
that will only have band-aid therapy available for them unless it's a surgical approach,
which, you know, has its pros and cons.
So my message would be we're here to help educate you and help you and push you.
And what Jayden said is great to work in groups and start being the driving force yourself
to help your kids, your friends, kids to pay attention.
You know, that's that's my message and we'll do our best to help you do that.
Thank you.
Bill?
Yeah, I think one thing I would kind of build upon what Rob said is the prevention.
And that's where we've got to see these kids early.
And a lot of these things are structural because what happens is they start breathing
through the mouth, they can't breathe through the nose.
It changes the whole growth pattern of the face.
It makes the face narrower.
You have a narrow upper jaw and maybe a setback lower jaw.
Well that's a structural issue that orthodontists are supposed to deal with.
But a lot of treatment philosophies that we've done.
And I'm an orthodontist so I can complain about myself.
Okay.
And, and you know, we've had this idea that, hey, all we are just a bunch of estheticians
making the teeth pretty.
And we're giving them good pretty smiles and they can go to the prom and all this other
stuff.
But seek out an orthodontist or a dentist that understands about airway.
And yourself, you know, get some knowledge because you got to have, but a lot of times
you'll go, you know, and parent may go to the orthodontist and say, no, I don't want
these teeth taken out or no, I don't want these teeth moved back or whatever.
I mean, there are a lot of things we can do orthodontically to move teeth and bones around
all over the foot.
We can move them forward and we can move them out and we can move them back.
Well, when we start moving stuff back, you know, that tends to get involved with the
airway.
The airway is really nothing.
It's a structure that's left over after everything else takes its place.
Everything else gets put in position, the tongue, the teeth, the bones, everything.
And then the airways kind of what's left over, but it's like the most important part of the
whole thing.
Because if you can't, and it's not just that you can breathe, people go, well, I can breathe
okay.
It's the quality and quantity of breath.
And unfortunately, with some of the environmental stuff and the industrial revolution changed
a lot of things.
Women aren't breastfeeding like they're used to.
And that's a problem too.
And allergies and all this stuff is a big layer of onion.
But as Rob said, you know, the only way you can really cure and Dr. Christian Gemino, who
is the guy that discovered sleep apnea and spasitine children, he said specifically that,
you know, that sleep apnea in children is a craniofacial growth disorder.
And so the structural changes from an orthodontic standpoint, not the whole thing, but we need
to look at seek out or malfunction of therapists and doctors that understand airway.
And believe it or not, David McIngarves, who's a pediatric ENT, he's one of the co-editors
of the book we're writing, but he said, just because you're an ENT doesn't mean you know
it's not about airway.
You would think that all ENTs would, but they focus on different things.
It's just like dentistry.
If you got to end the dentist, they're going to do root canal or whatever.
So just, I would say, you know, be a little bit wary sometimes, you know, if you, when
you go to the orthodontist, it's not all just about straightening teeth and making them
look pretty.
You want the teeth and the jaws to fit in a certain way that it protects the airway.
So ask questions about that.
And if you don't get good answers, unfortunately find somebody else.
I like that.
And for parents that haven't heard it, I'll put the link for that as well.
Dr. McIntosh was on, gosh, I think it was 2022.
It's been a while, but it's a two part series and it is an absolute masterclass and airway
for any parent that hasn't heard that.
So I'll include that.
Dave?
Well, I'll just conclude by saying, I think everybody can see at this point that there
are many moving parts with sleep apnea, you know?
And so there is no one size fits all solution.
So I think everybody who's involved with this problem should educate themselves.
And I will conclude with once again saying that every AHA should be unpacked, you know,
before we draw conclusions about what should be done, we should ask why it should be done
and we should unpack the AHA in a responsible way.
It's a complex system.
So we should unpack it.
And I'll I'll do the shameless promotion for any parent that has not listened to empowered
sleep apnea.
The podcast, if you can't listen to anything, just listen to season one, because we're going
to talk about by being rid of.
Thank you.
Yeah, season season one gives you the vocabulary to navigate this.
That's true.
Thank you.
So start.
Start there.
Go get on the island and start.
So the islands.
Yeah, I'll sleep.
There you go.
So Dr. Simmons, if you would like to close us out.
Well, thank you.
So I guess, you know, in terms of words of encouragement, the fact that someone's watching
this and they're at this point where they're actually hearing my voice, that means they
watch this to its completion, you should be encouraged because you right now already
were exposed to more information than most parents know.
And you're already on the path to getting a solution and you're probably watching this
because you're concerned because you see your child or someone you know or whatever that's
impacted and you're trying to get more information to enable yourself to seek a solution.
And so, you know, we've all mentioned various sources, you know, and half, you know, Children's
Airway First Foundation is serving a purpose to get this kind of message out there.
And you're not alone because look, there are people that are giving you this information.
Because we know that these kind of problems are out there.
And we're trying to provide the solutions and to create the bridges for the patients
to get the care that they need.
And you may be geographically situated in an area where there are not many clinicians
right now that know very much.
Because of telemedicine, you could seek out help elsewhere.
You may have to transfer yourself, you know, mobilize yourself to get some kind of testing
or to see some people, you know, to see the dentist that's kind of understand.
So you may have to, depending on where you live, you may have to, you know, commute a
distance, but the care is out there.
And so don't give up until you finally feel comfortable with the clinician that can understand
your child's problem and can put together a pathway that will improve their health.
And you really need to be complimented for your perseverance to even, you know, watching
this, you know, podcast or this, you know, this webinar.
And there are others that I'm sure you're going to be watching as well.
So, you know, congratulations to you.
And hopefully you'll seek, you'll be successful in getting the care that you need for your
child.
And we're here to help.
Yep.
And I want to say, I'll close this out on a personal note, because you are all there
at the conference.
And I said this to all of you there.
And so now I will say this here as both a patient that is an airway person.
I'm an adult.
I'm the reason I'm an example of if you can fix it, they don't end up like me.
They don't end up like savvy.
So, and I'm also a parent.
I'm a parent that I didn't know.
And now I look back and think, oh, and I'm having to adjust these things in my, you know,
my grown children.
It's okay.
We've all made mistakes.
You guys made mistakes.
Parents have made mistakes.
I didn't know.
So start from where you are, but that guilt aside and trust your, your parental instincts,
because you know what to do.
Trust that mama gut, be that airway mama.
And on a personal note, I want to thank each one of you and every one of the luminaries
that I am so fortunate enough to talk to.
Your passion is infectious.
And I thank you so much for what you're doing because you guys are who are going to save
these 400 million children.
So thank you.
Well, thank you.
Thank you for giving us the opportunity.
It's great.
Thanks.
Thank you.
Thanks again to everyone on today's panel for joining us for this special episode of
Airway First.
And to each of you for listening.
You can stay connected with the Children's Airway First Foundation by following us on
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Don't forget to subscribe to the Airway First podcast on your favorite podcasting platform
so you won't miss an upcoming episode.
If you'd like to be a guest or have an idea for an upcoming show, shoot us a note via
the contact page on our website or send us an email directly at infoatchildrensairwayfirst.org.
Today's episode was written and directed by Rebecca St. James, video editing and promotion
by Ryan Dawn and guest outreach by Kristy Bojinkian.
And finally, thanks to all the parents and medical professionals out there that are
working hard to help make the lives of kids around the globe just a little bit better.
Take care and stay safe and happy breathing everyone.