Hi everybody and welcome back to Airway First, the podcast from the Children's Airway First
Foundation.
I'm your host Rebecca Downing.
My guest today is Dr. William Harrell.
Dr. Harrell began his orthodontic practice in Alexander City, Alabama in 1977 and has
devoted most of his career to educating his peers, the public, and other health care professionals
on the importance of discovering and treating airway obstructions leading to altered growth
issues in children that can cause serious health conditions later in life.
Throughout his career, he has worked alongside pioneers such as Dr. William Farrow, the pioneer
of TMJ therapy, and Dr. Christian Jimmendow, one of the fathers of sleep medicine.
Dr. Harrell lectures to residents, medical doctors, and dentists worldwide.
He's also a professor at the University of Alabama Birmingham School of Dentistry Orthodontic
Department.
Dr. Harrell is the chairperson of RADSIDE Standards Committee on Combine CT for both medicine
and dentistry.
He's also on the American Dental Association's Children's Airway Screener Task Force.
The task force is tasked with developing a children's screening questionnaire called
Seek Hasp for uncovering early airway issues in children.
Dr. Harrell is the lead editor of a medical and dental textbook called, Growing into Breathing
Problems, the Quest for Collaborative Lifetime Solutions, which is scheduled to be published
by Springer Publishing in early 2023.
You can find out more about Dr. Harrell at drharrell.com.
And now let's jump into our podcast with Dr. William Harrell.
All right.
Thank you so much for joining us on the show today, Dr. Harrell.
I really appreciate it.
Yeah, glad to be here.
I appreciate the invitation.
Absolutely.
So we're going to jump in with something that was on your website that struck me.
It states that in order to diagnose and treat airway conditions, practitioners must achieve
anatomical truth.
So what exactly is that?
Yeah, I'm going to share my screen as we go through this.
This will be, it'll help me explain some of this.
But originally, in orthodontics, can you hear me?
I'm not muted.
I sure can.
Yeah.
Okay, good.
Let me see if this will, can you see my screen?
Nope.
Try it one more time.
Here we go.
This is what I want to do.
There we go.
Okay.
Can you see it?
Can you see that?
I can.
There we go.
And this is where the first foundation is.
Okay, great.
Yes, and I'll put links in our show notes too.
Yeah, I appreciate everybody.
I appreciate the invitation to do that.
I wanted to kind of mention first, you know, a book that we're in the process of writing
with a bunch of, bunch of people on growing into breathing problems.
David Gazal is the most prolific writer now in the world on sleep apnea.
And David McIntosh is a pediatric ENT.
We have a number of others.
One of them is actually chairman of ENT at Stanford, took over Dr. Gimenez's position,
Stanley Liu.
But anyway, I kind of wanted to say that's hopefully coming out in May of 2023 is what
we're looking for.
But I kind of wanted to talk about the anatomic truth because what we used to use in orthodontics
or what traditionally is still done, or just kind of two dimensional films, like a 2D
cell for a 2D pan, and that really doesn't give you the anatomic truth is giving you
a picture in time.
But as far as we know, there's geometric distortions in those images and they have been forever,
but we've kind of accepted that fact.
So when cone beam CT came on the scene, then all of a sudden we now have this is my grandson
actually that we take the 3D face on, but we can actually map it to the cone beam CT.
So not only does the professional get a better view of actually what the relationship, you
know, in three dimensions or the amount of airway, the airway size, the TMJs, the teeth,
the development of the teeth.
But also what it does, it gives the parents and patients a better idea of understanding
at a whole different level when they see this.
They're not only wowed by it, I mean, that's one reason you do it, but to be able to go
in and show them this kind of an image, you can just understand it at a whole different
level.
So the anatomic truth is really trying to represent true anatomy as it exists in nature.
And then now with, you know, with cone beam and being able to evaluate the tooth dimensions
along with the airway and evaluating tongue space just makes it that much better.
And if I understand correctly, your dental practice is one of the first to use this CVCT
technology in Alabama.
Right.
The cone beam CT was introduced to the world in about 1996 in Europe and Italy, actually.
And then 2001 was when the first machine was introduced in the United States at Loma Linda
University first.
And then at David Hatcher, who's an oral radiologist in Sacramento, was actually got it the next
day in claims to be the one that actually first used it in the United States.
We got ours, the ICAT, we got it in 2005.
So we were pretty early on, we were the first ones in Alabama, one of the first in the Southeast
to use cone beam.
And I wouldn't look, you know, now I couldn't practice without it.
Right.
Well, and I guess that begs the question, why aren't more dental practices using this?
I mean, clearly you get a far more robust picture of what's going on.
Well you do.
And then, of course, a lot of it's being used for an oral surgery for implants or a
periodite when they do an implant, implant kind of situations.
But orthodontics has kind of been a little bit slow, I hate to say that.
Even adopting it, I thought it would be pretty much standard of care.
I think it one day is going to be.
First of all, when it first came out, of course, the radiation doses were a little bit higher,
well significantly higher than just a pan in a cell.
So that was kind of part of the thing, oh, we're radiating too much.
The others cost, because, you know, these machines are not cheap.
So, but now the, actually I've got the Iket flex and in the machine that I have now, I
can take a, what you see over there on the right, like on my grandson, I can take that
for less radiation dose.
Oops, sorry about that.
Less radiation dose than these two films.
Really?
Yes.
I can take this, these two films normally a normal traditional dental orthodontic practice
or anywhere from 25 to 30 microceverts.
Now you get about eight microceverts a day just by living on the earth.
So you get around almost 3000 microceverts of dose living at sea level.
So this is about 30.
If you take a full mouth digital imaging of the teeth, like what most dentists do, that's
anywhere from 75 microceverts to 150 microceverts.
Now traditional CT is like 600 to 8000 microceverts of dose, but they're looking for different
things.
They're looking for cancer and that kind of stuff.
But now with ICATFLEX and some of these low dose protocols, I can do a scan, which will
give me this kind of information in about less than 24 microceverts or even 18 microceverts.
So I'm getting less dose.
So dosage is not really a barrier to entry.
It's cost.
But to me, the traditional 2D stuff is going to be a boat anchor one day.
And so I would recommend doctors or orthodontists or dentists that are looking into airway and
looking into TMJ.
Hey, the return on investment will come.
If you start doing it and then the amount of information that you're giving patients
and the patient and how they can understand is just, it's night and day.
Yeah, I would think so.
And do you run into any issues as far as insurance goes for billing this over the standard panels?
Well, no, because if it's in, I can create a pan in a set if I want to.
I do create a pan because I do send those to the dentist, but the traditional stuff I
can create, I mean, you can actually, it doesn't matter what machine you use.
You can, if you want to buy off a traditional 2D images, you can.
What we do, a lot of our stuff is TMJ and sleep related.
So we bill it through medical.
So it's a medical insurance, which is a whole different ball game.
But you could, there's a CBCT code in dentistry too.
So there are codes that you can use to file dental and medical insurance.
Okay, good.
So it's not more for the parents.
That's good.
Right.
Yeah, you also mentioned on your practice website, which I will include links to, that
your evaluation includes nasal resistance and nasal airflow.
Right.
So how do you obtain these measurements and, you know, how do they help you as far as your
diagnosis and treating?
Yeah, great question.
And I want to start with a video from Dr. Christian Gemino, who's the father of, you
know, father of sleep medicine while he in the bed and power and Riley.
I got this video for Dr. Karen Davidson.
We're going to be talking about rhinomanometry and nasal resistance and nasal airflow.
And she's probably the world expert on this.
But I want to kind of go over this video because I think this tells it all about nasal, you
know, nasal resistance and what we need to be doing, whether we're on orthodontist or
dentist, if we're looking at airway issues, pediatric dentists, pediatricians, ENTs, pulo
neurologists, whatever that might be dealing with, with airway issues.
I want to play this just a second.
The treatment of any sleep disorder breathing is nasal breathing.
The end treatment of any sleep disorder breathing is nasal breathing.
Correct.
We even published that.
We see my colleague Dr. Sullivan, Sharon Sullivan.
It's, it's absolutely necessary.
If you don't obtain that during sleep, because you may do that during weight, but you have
to check during sleep, you have not succeeded in treating your child.
So, uh.
Now I'm going to play that one more time.
So the link is important here.
Okay.
Sleep disorder breathing is nasal breathing.
The end treatment of any sleep disorder breathing.
The end treatment of any sleep disorder breathing is nasal breathing.
Correct.
We even published that.
We see my colleague Dr. Sullivan, Sharon Sullivan.
Uh, it's, uh, it's absolutely necessary.
If you don't obtain that during sleep, because you may do that during weight, but you have
to check during sleep, you have not succeeded in treating your child.
Now that's a pretty amazing, that's a pretty amazing, uh, statement by the man that discovered
sleep apnea and then discovered pediatrics sleep apnea.
And so you might ask, well, you know, how do you, how do you measure this?
Uh, I've been looking at combing, you know, CT and looking at perennial airway, uh, maybe
asking them about, you know, looking at them and if they mouth breathe, you know, we try
to get them on nasal breathing.
But really Karen Davidson introduced me to this, uh, to this technology.
And then I got, I got to thinking about it and I said, well, this makes a lot of sense
to start measuring, they get objective measurements of nasal air flow since that should be one
of our main goals or probably the number one goal is to get these kids to breathe through
the nose, at least outside proper tongue position and all that.
So if we look at, if we look at these, I've got both of these in my office.
One is called acoustic rhinometry.
And what it does, it's on the left side.
Can you see my cursor?
I sure can.
Okay, good.
It's the one on the, on the right side, acoustic rhinometry.
Basically it's in sound waves, they, the patient holds this on one side of the nostril and
sends sound waves down the, uh, down the anatomy and it, it looks at minimum cross sectional
area.
It kind of maps out like sonar, so to speak, all the way down from the tip of the nose to
the, to the sinuses and even a little bit beyond that.
So acoustic rhinometry measures minimum cross sectional area volume, it's a structural thing,
kind of like CBCT.
Okay.
It kind of, it measures that.
Cause CBCT is a more of a static image.
This is really static too.
But rhino manometry, which people get these things mixed up, they go rhino, rhino metri.
Rhino is really acoustic rhino manometry.
It's a manometer.
It measures flow, it measures nasal resistance.
So it measures function, which is really important because you put a mask on, you have them stop
up one side of their nose, they'll breathe normally for about four times and then, then
they'll stop up the other side and breathe normally and then it makes a graft, which I'll
show you in just a second what you're looking at.
Okay.
This one, acoustic rhinometry gives you a graft also and they are medical codes and medical
insurances that these can be built for.
Now, so you're, what you're looking at is objective measurements and rhino manometry
is the one that measures functions.
So here's kind of a graft of a person and Karen kind of came up with this where she
relates the airflow.
This is inspiration.
This graft is inspiration on the right side when you inspire and this is expiration on
the right side.
So it's like a little S curve.
It looks like an S and then here's inspiration on the left, here's expiration on the left.
So it creates this little S shape curve.
Now you can see this one actually passes through.
It passes through the orange.
And if you look over here on the AHA RDI side, it, that way it crosses this line is about
up here at mild sleep apnea.
So you can almost predict or maybe able to predict the problems that you could run into.
So if you want it, you want it to be a big, lazy S is what you want.
So here's those.
And if you look at maybe normal or ideal, it would look more like this.
So it would be up in this green area, which means you would be down here.
So the more squatty the S's, so to speak, the more nasal resistance and lack of airflow.
So if you look at this particular case over here, you've got, let's look at the right
side first.
It's kind of got that little lazy S. It goes this way.
Okay.
Now here's a little loop here, which kind of means it's congested.
But when you decongest the nose, see how much taller it gets.
This is a soft tissue issue, not as much of a structural issue.
If you decongested the nose and didn't get a chain, then you could assume that it's
more structural.
But if the decongested improves it, then you're talking about more of a soft tissue.
Now you can see the other side, the left side is more short and squatty.
So they're having less airflow, more resistance on the left than they are on the right.
The decongested right makes it actually go in a better place.
When you get these open loops like this, that's called a nasal valve phenomenon.
Now these are not necessarily the same patient, but this is what nasal valve phenomenon is.
This is a picture of the patient breathing normally.
This is the middle one is the inspiration and the one on the right is expiration.
So you can see she's got nasal valve collapse.
And when she inspires, her nose closes up.
And then when she exhales, you can see the nasal areas get bigger.
So these are things that you can pick up with rhinomonometry.
And it actually can correlate to AHI and RDI measurements, which is kind of interesting.
Now here's acoustic rhinometry, which has kind of gotten a bad name.
But it does measure minimum pro-sectional area and volume.
What it does when you put the acoustic tube up by the nose, because what it does is it's
sending sound waves from the tip of the nose back through the turbinates back into the
sinuses.
And if you look at the baseline, let's say of this patient, here's their breathing pattern.
And they breathe normally, you breathe through one side and the other, and it shows you what
the minimum pro-sectional areas are at these levels.
Like in this region would be the tip of the nose, then back to the edge of the turbinate.
You can see it decreases at the turbinate, and then it decreases a little more.
But that's pretty good baseline.
When you decongest them, you can see that the nasal airway measurement, the airway in
centimeter square, increases, which is a good thing.
So it gets better.
So those are two things that I use as look at function, because I think function is the
most important part of it.
But we also can look at acoustic rhinometry to look at structure.
Now here's a poor man's way to do rhinomanometry.
It's called a peat nasal inspiratory flow meter, PNIF.
What it has is a face mask part on the left that fits over the nose and mouth.
It's got a simple tube that has a, see this little red wafer right here.
It's got a magnet up at the top.
So what you do is you put this thing up and tap it so the magnet takes that little strip
and it puts it all the way at the bottom.
And then you flip it over, the magnet comes back up, the red wafer stays down here.
You have the patient put it on their nose, put it on their face, their nose.
They first they exhale all the way out.
They exhale, they put this thing on their nose and then they inspire real quickly.
And then what happens, that little red wafer will move up and it's got a scale on the other
side, zero to 800 or whatever it might be.
But what it does, it measures that inspiratory flow.
So there are measurements in children and adults that that inspiratory flow should be
at a certain level by age.
So this is a good one because it moves way up here.
You get some of them, they don't move the meter.
So then you know that they've got some inspiratory flow issues.
So it's a real inexpensive way that I think every orthodontist or pediatric dentist or
pediatrician or whatever should easily use because it's something that's real simple.
Now these other machines, of course, are a little more expensive, but they give you
significant data.
And this is a quote that I actually gave to Karen.
I can do rhino-monometry without cone beam, but I really can't do cone beam without rhino-monometry
because cone beam doesn't give you function.
It's a static measurement upright in the wake.
They're not laid down in a sleep and it's not function.
But rhino-monometry, you can do it upright in the wake.
You can do it lay down, not necessarily sleep because I'm not going to put them to sleep.
But you get a pretty good idea of what's going on.
The only way you really could technically understand how the airway collapses is you
got to do drug-induced endoscopy and that's something that E&T does and you're not going
to do that routinely.
You just got to extrapolate out what things are.
But you're looking at function and structure and how the function alters the structure.
So that's kind of how I use rhino-monometry.
And you mentioned that the audio had received kind of a bad rap.
Why is that?
Well, both of these are sensitive to knowing how to do these things.
It's acoustic rhino-monometry.
Now before 2015, a standards committee of rhino-monometry and rhino-monometry met and basically they
declared that any publication before 2015 was obsolete.
So a lot of the older data, the rhino-monometry and the acoustic rhino-monometry, it was pretty
technique sensitive and a lot of things went on.
And so before 2015, a lot of stuff was published.
But because of the way it was done and some of the older equipment, it was kind of considered
obsolete.
So then all the physicians and everybody go, hey, well, this stuff's not true.
Well, after 2015, they developed for phase rhino-monometry, which is a higher level
type thing.
And then you still got to be careful with it.
But after 2015, the standards committee basically met and said, hey, for phase rhino-monometry
has a use in medicine and dentistry at that time.
So if you talk to some physicians early on, if they read the whole literature, they go,
oh, that's not sensitive enough.
It's not specific enough.
The sensitivity is what I look at here, not necessarily the specificity.
I'm looking for screening things.
So the higher the sensitivity, the better it is as a not a diagnostic tool per se, but
a screening tool.
So what I use this for is when I start seeing flow limitations and things like that, what
am I going to do?
I'm going to send them to an ENT.
Now the ENTs may not, this may not be in their armamentarium because guess what they're going
to do?
If they have a problem with nasal airflow, they're going to stick a scope up there and
see where it is and go in there and get it.
But I don't have that capability.
So my whole thing is a screening thing up front so I can send it to the appropriate referral
doctor and then be able to, the other thing I use it for is like expansion.
When I'm doing early expansion in children, am I affecting their nasal flow?
And if I'm doing a mandibular advancement, if I'm doing a maxillary advancement, I'm
going to be able to do that.
Whether it be on a doctor or whatever, at least it gives me some objective data that
I can look at and say, hey, yeah, things improve.
And it's not invasive basically.
We do take comb beams and I compare these, but it's not like I'm going to take a comb
beam every month.
Right.
I can do this every time they come in.
Sure.
And as far as data at home, I'm one of those people that uses a peak flow, which is different
than this because this is inspiration.
Peak flow is expiration.
As a parent, if I were to come in and say, hey, I brought in my daughter's peak flow
for the last month, is that helpful information?
Or as a parent, can we help in that way?
Yeah.
I think so.
I think this little piece right here lends itself to kind of telemedicine visits.
Oh, yeah.
I think some physicians that are doing something, I mean, you could send this thing, and this
is not, it's less than a hundred bucks, but you could send these out.
You could have them in your office and send them out, have patients do it at home and
do it along and send you the data.
What's the graph showing us today?
And Karen Davidson's even invented the thing called Daphne score, DAF, any Daphne score,
which actually takes these measurements, PNEF and rhinomagnometry and acoustic rhinometry,
and it puts it in an algorithm and helps to actually interpret, not interpret, but screen
to what these measurements kind of mean and maybe some suggestions of therapy, not a diagnostic
algorithm, but it kind of lends itself to suggestions and say, hey, this means this,
what it means in these graphs.
This kind of a flow rate of whatever means this, and then you consider CPAP or plasma
and pulse therapy, maybe expansion or mandible advancement at the child's class too or whatever.
So it just kind of gives you some thought processes on it.
Yeah, a little more for that.
So, yeah, so I guess we'll just kind of build on that as far as what kind of options do
parents have for younger children when it comes to treating these airway disorders?
Well, I think they need to recognize a few things and some of the things are like, does
your child snore?
Even a little bit.
They're not supposed to snore.
People say, well, yeah, they snore a little bit.
Now, if they got a cold or something like that, that's a different.
You're talking chronic.
It's chronic.
Yeah.
Have you ever witnessed them stop breathing or gasping at night?
Do they have restless sleep?
Do you go in there in the middle of the night and they're kicking the covers all over the
place?
Do they wet the bed inappropriate age to have behavioral issues?
We don't say, I'm going to show you the CAS committee children's airway screener task
force for the ADA, which I'm on.
I'm going to show you that little five question there that we're trying to get validated.
And that could be used easily enough for parents to fill out.
I'll show you that in just a second.
If you want me to, I'm going to show you this little video.
Yeah, I would love that.
Airway and TMJ.
And it's really good because it kind of explains how airway and TMJ relate to each other.
And then I'll tell you how I explain it to parents and patients when they come in also.
But I think this is a really good.
Airway and TMJ.
The normal way to breathe is through your nose.
As we grow and develop, certain things such as pollen, cow milk and other variables can
cause an allergic reaction, causing the lymphoid tissues known as tonsils and adenoids to become
swollen.
As the tonsils and adenoids become swollen, they're developed into an obstruction for nasal
breathing and slowly mouth breathing begins to be the primary effect of air into the body.
In order to breathe through the mouth, the lower jaw comes down, the tongue comes off
the palate and settles on the lower teeth.
Nasal breathing is the correct way for air to enter the body.
And during nasal breathing, the tongue rests up the palate and the pressure of the cheeks
to the bound spider tongue.
During mouth breathing, the pressure from the cheeks on a post-bacter toe, the oral
system becomes unbalanced and results in the deformation of the upper jaw creating a V-shaped
arch as opposed to a correct V-shaped arch.
This also produces an incorrect swallowing function.
Upon swallowing, the tongue rests on the lateral teeth hindering normal tooth erections, causing
a lateral tongue thrust.
A constantly open mouth causes the incisors to over-erup.
The result is a deformation of the lower arch known as the bifrusted drop off.
The result of this deformation of the upper and lower arch is the presence of premature
contact upon closing, which shifts the lower jaw distally off of the physiologic trajectory.
The narrowing of the upper arch pushes the lower jaw back.
This forces the TMJ condyle to shift distally while the TMJ disc shifts forward.
Upon opening, the disc can shift onto the condyle to restore the TMJ correct position
of the disc and then shifts back through an incorrect forward position upon closing.
This is what causes a reciprocal split.
In addition, the muscles can be in a state of hypertonic or spasm, which can result in
tension headaches.
An incorrect position of the lower jaw can result in fair functional activity of the
muscle such as clenching and grinding.
Over time, grinding can result in severely worn down teeth.
As a result, the teeth becoming shorter, the lower jaw shifts distally even further, and
the verticals of the bifrusted teeth.
In time, joint degeneration occurs.
The joint becomes deformed and the ligaments of the joints come damaged.
As a result, the TMJ disc can get trapped in front of the condyle.
While the clicking go away, limited mouth opening will occur.
A disc with shifted jaw and tongue positions results in even further restriction of the
airway.
In order to open up the airway, the neck moves forward and the head feels backwards.
This stresses the spine and defeats the neck muscles, which results in neck, back, and
shoulder pain.
Airway?
It's interesting how that works together.
A lot of times what I do when I'm explaining how TMJ and airway relate to each other is
with doll tables.
I'll get some little doll tables.
I'll have one and it's got all their legs are intact.
Then I've got another where I'll cut off one of the legs.
I'll put a little wire in a hole in it so I can stick it back together and have it connected
with a piece of dental floss.
What it does, I show them the table and I say, the table needs to be stable.
All four legs need to fit just right to make the table top level.
I flip it upside down and say, here are your two jaw joints.
The body of the top of the table is actually the mandible and then the two other little
guys out here are the teeth.
When you put it all together and you flip it over, look at the airway space under the
table top with all four legs intact.
Then take the one that's cut and you get a wobble to it.
That's what's happening.
Either your bite may be off or maybe you got degeneration in the TMJ or whatever.
What you have is like a rocky table.
Then I say, well, look at the airway space now under that table versus the one that's
intact.
They go, aha.
I see what you're talking about because it's a little bit, I like to use simple little
things like that.
Then I put the little piece back in there with my wire and stick it back in the hole.
Okay, that's what we're trying to do with the TMJ splint or whatever.
We're trying to stabilize that.
To keep it up.
To keep it in any place.
But say, hey, a lot of times, TMJ issues and sleep tend to go together.
They can be independent of each other, obviously, but a lot of times they do coexist.
Does one lead to the other?
We really probably don't know, but exactly.
But still, they tend to coexist with each other.
Travel together.
The video mentioned something that I and all the research that I've done have never heard
of, but it's logical that you'll end up with shoulder and neck pain.
I've never heard that listed as a symptom before.
Well, it's forward head posture because what they do when you can't, if you're not breathing
properly and the lower jaw sitting back, what are you going to do?
The body is going to adapt to breathing.
It's going to make, you got to breathe to stay alive.
It doesn't care what it does to the teeth or to the skeleton or to the spine or whatever.
It's going to compensate to make.
Now it may not be ideal breathing, but it's survival breathing.
See, that's what we're going to get into this thing of, okay, well, I'm breathing good enough
and I'm staying alive.
Well, great.
But if you got this forward head posture now, all of a sudden your head weighs more because
it's hanging out over the spine causing your neck pain, but it's holding the airway so
you can continue to breathe.
You're listening to airway first with today's guest, Dr. William Harrell.
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 GAF website offers tons of great resources for parents and medical professionals, including
videos, blogs, recommended reading lists, a comprehensive medical research library, podcast
and so much more.
Parents are 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 backslash groups backslash
airway huddle.
Are you a medical professional or parent that's interested in being a guest on the show or
do you just have an idea of for an upcoming episode?
If so, shoot us a note via our contacts page on our website or send us an email directly
at infoatchildrensairwayfirst.org.
As a reminder, this podcast and the opinions expressed here are non-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. William Harrell.
So those are things that I think we have to kind of take into consideration as we start
looking at all this.
Or we're looking holistically again at that.
Yeah.
Yeah, and totally makes sense.
So one of the things that we've talked about on the podcast before and in blogs is specifically
retractive braces.
We know that retractive is dangerous.
We know that as parents.
Now, now we know that.
So when are braces or orthodontics the right answer and how do parents know, okay, this
is the way to go or when to proceed with caution?
Yeah, it's a great question.
And you know, my whole philosophy of things changed.
I mean, we were taught in school.
One thing you have to do, you have to understand orthodontic education and how it's set up.
The residents are there for three years, two years.
They got to learn how to move teeth.
Okay.
They don't get exposed a lot to early treatment.
The only reason they would, you know, we, and even in our residency at UAB, which is
it's evolving and the airways getting to be more looked at, but still the orthodontic
education and especially in my day in 1975 to 77 when I was there is built on.
We don't want to see them till they're 12 or 14 years old or older because, you know,
we're not going to put braces on before then.
The only time we would treat maybe an early case, six M eight is to correct cross bite.
Okay.
And then or an underbite or maybe an over, you know, but a lot of times even back then,
if they were big class too, we'd say, Hey, we got to wait till the 12 or 14.
We got two choices.
We can take out teeth to try to resolve the occlusion or we can wait for surgery.
So, but orthodontic residents are there for two or three years to learn how to move teeth.
And the way it's just evolved is they've got to finish their cases up in that two or three
year period of time.
So they're not going to see them before six, they're not going to see them at six, seven,
eight, unless they got a cross bite, but then they're not going to see they're going to
correct the cross bite and then just let them sit until they're ready for braces.
So you kind of have to understand that concept a little bit as to, as to why we orthodontist
are trained in the way we, we are now in 1982 when all the monkey studies came out about
breathing and all that kind of got me changing my mind a little bit.
And especially when I got combi and started looking at the relationship of dental arches
to mandibular position, maxillary position, narrow arches to the airway to the TMJ, then
a light bulb came in, you get this aha moment and you go, okay, now this makes sense for
me because early treatment was basically introduced by pediatric dentist and the general dental
community, not necessarily orthodontics, unfortunately, if we're catching up to it, okay, we're catching
up to it.
Now their times, even me, you know, even me is when I get a case that's late and periodotally
for whatever reason, I can't expand too much.
I can't expand to get all the teeth in, but if I have to extract, I'm going to keep it
as wide as I can.
My whole focus is airway focused, okay, or airway, try to keep, I'm going to look at
the airway first before I make a decision about extraction.
Now I can't tell you the last time I've extracted, because I see kids at four, five, six, we expand
them and guess what?
They don't need air.
When I'm treating a 12 or 14 year old case, I've got a class one minor crowded.
I could put an Invisalign in there or whatever.
It's just a simple little case now.
I'm going to get all the deformity ahead of time.
And I liken this to, and I tell orthodontics and I tell parents, they go, look, when do
you treat a child's got club feet?
You treat them at one month.
They put cash on those kids at one month to three months at the most.
They don't wait six months.
Why?
Because there's so much growth going on and there's so much moldability because you can
take a child at one month, grow their feet over correct, come back.
And by the time they're walking, you never know they had a problem.
They can jump and play just like everybody else.
But if you wait for those feet to grow, and the bones are strong, they're like, yeah.
You've got a crippled child, now not saying orthodontic crippled, but I'm just saying
the principle to me is the same thing.
Right, do it earlier.
But you've got to go get that education outside your traditional orthodontic field.
Because unfortunately, that's what I try to bring to the table is show the cases, hey,
look, here's a six year old child that has these symptoms and all this.
Look at the nasal resistance.
Let's do these expansions.
Let's see how they develop over time.
And then we can do the orthodontics and it's easy.
It's simpler at that point.
So that's more and more the education in the orthodontic community has got to be done by
practitioners that are, you know, adjunct professors or whatever that do that kind of
stuff that can show that progression because that's the only way you're going to get it
into the system.
And that's what kind of what I try to do.
So it's, there's a controversy there and I can tell you though, there is this thing
about retractive orthodontics, it just makes physical sense to me.
If you're going to start pushing things back, there's an airway back there.
The tone is going to go somewhere.
The tone, if you've got a narrow arc, if you've got a, if you've got a four bedroom house
and a two bedroom foundation to put it on and you got all this furniture in there, which
is the problem.
I mean, what we've been doing is cutting the toes off the foot and making it fit the shoe.
We need to make the shoe fit the foot.
Right.
And then all of a sudden when you expand that, guess what?
The tone that sits in there, there's one of the biggest corporate, you're making more
room for it.
So it just makes sense to me.
Now, unfortunately, there is really not ever, there's not a, there's not a good randomized
controls study that shows that extractions and that kind of stuff cause sleep apnea.
Okay.
And that's kind of what orthodontics, we kind of quote a lot of times and that's true.
I mean, there's not, but in my mind, it doesn't make physical sense cause it violates in
physical laws.
If you put, if you try to put the tone inside a smaller shoe, it just doesn't work.
Yeah.
You got a bigger shoe, it's got more, you've got more function.
I mean, it just makes sense to me.
It just makes common sense to me to do it, but the problem that you run into is people
say, well, there's no randomized control study.
So therefore I'm not going to believe that.
Well, here's the problem.
You can't do the study.
It would be unethical to do the study to prove that.
And what you would have to do is you would have to take a thousand kids and, you know,
treat them the normal traditional way, you have to take another thousand and treat a
function, you take another thousand, not treat them and do polysilography and all this kind
of stuff and see who dies first.
Right.
I mean, ethically, it cannot be done.
Correct.
Yeah.
To prove it beyond a shadow of a doubt.
So there are literature that kind of supports the idea that retractive things aren't good.
There's other literature this out there in our literature.
The problem is you got to get outside our dental literature.
You got to get into medical literature.
Yeah.
Which, which brings me to my next question.
You know, where, where have we gone wrong as far as medicine goes?
It feels like there was a misstep somewhere, not, you know, an intentional thing, but somewhere
we made a misstep because we have all these kids around the world that are experiencing
their way disorders and sleep issues and then all of us as adults that had retractive braces
and things like this done.
Yeah.
Where did we misstep?
Well, I don't know if it was a misstep other than an overlook.
Okay.
When this started, when Dr. Gemmano discovered sleep apnea, who was it on?
It was on a beast man.
Right.
It was on a beast man.
Which growing up, that's what we knew were a beast man.
Sure.
And then they would extract the autonomy to put a hole in the throat because they, they
people are going to die.
Right.
So they bypass the obstruction.
And then all of a sudden Sullivan in Australia and been in the CPAP by reversing a vacuum
cleaner.
That's how it is.
And then all of a sudden CPAP was developed to treat these people.
So there was a, you know, a small, you know, so the whole thing about sleep apnea was,
it's in a beast man and we got to put a reverse vacuum cleaner on them to keep them alive.
So that's all that research started in adults.
And then you have a voluminous amount of information on CPAP and its efficiency and
efficacy and all that kind of stuff in the medical field because they jumped on that.
That's their, that's their gold standard.
What are the other two, you know, the other two almost absolute treatments or tracheotomy,
which has not really done it or double jaw surgery where they take the upper jaw, move
it out.
They take the lower jaw, move it out.
And guess what?
You open up the airway.
So we never thought about that as a, as a treatment modality.
Why don't we copy that treatment modality of maxillary advancement surgery in children
by growth is my point.
And so then it gets to, hey, if it makes sense in adults, the problem is in adults, it's
already developed.
The problem is there.
It's already there.
But back here, we could have fixed it.
Back up here, we could, and we never made that connection until about 1976 when Dr.
Gemino discovered sleep apnea in children and he spent his life work trying to figure
out what can we do in young children rather than putting them on a CPAP because that ultra
spatial growth.
Yes, it blows air down the tube and opens up, but it, it creates some axillary recessiveness.
So it's pushing back, which is not the way you really want to go.
So you really want everything to come forward.
And then I started looking at things.
I said, well, you know, it just, it makes sense.
Some of the sephalometric numbers that we orthodontically go by a lot, probably are
too retrognathic.
We just, we looked at normalness is not, I mean, things that are common are not necessarily
normal.
Not normal.
Yep.
We're hearing that a lot.
There's commonness, but not normalness or idealness.
I mean, there's probably no ideal out there, but at least normal or, or good quality breathing
that creates good quality growth and good quality brain and cardiac development is one thing.
Just getting by is another thing.
It's, but we can see, I was going to say we consider it normal.
We consider it normal.
But then we go back in time a few hundred years ago, Kevin Boyd, Mariana Evans and I
have been talking about what happened at the Nussel Revolution.
Breastfeeding was because women went out to work and they bottle fed and the, the children
don't chew on things like they used to and right.
It's all soft food and soft foods and the diet changed, all this stuff changed, which
we know that our face has gotten smaller.
Our brain has gotten bigger.
That's just, you know, evolution.
And as our face has gotten smaller, you know, the airways just was left over after everything
else takes this place.
You know, it's just kind of the second thought, but it's the number one thing we got to do.
Right.
Absolutely.
It's brilliant.
It was really kind of interesting how it all developed that way.
It really is.
Yeah.
And then here is the, if you want me to go, this is a statement by the ADA policy on
the role of dentistry in the treatment of sleep-related breathing disorder.
I was at this reference committee when they adopted this and they had, you know, a lot
of people talking about it and a lot of discussion about it.
There was one person there that, that actually was against it and he was the past president
of the American Army sleep medicine.
And here was his point about it.
And in fact, he's, he was correct when what he said, even though it wasn't taken very
well, but what he said is, you know, physicians have to go through a year residency to become
a sleep physician, to call themselves a sleep physician.
They have to go through a year's worth of study in a, in a field to be a sleep physician.
Then just all they have to do is take two impressions on a bike registration and they're
a dental sleep medicine practitioner.
And that's probably not correct.
He said, you know, y'all don't, you just, you just don't get the same.
So this is where the American Academy of Dental Sleep Medicine comes in.
So I'm in the process of trying to get more certified there.
You need, you don't, just because your license allows you to take two impressions on a bike
registration and send it off to a lab to get a sleep appliance, you better be careful because
you're touching, you're putting your toe, not really your toe, you're jumping into the
medical lake.
Okay.
You are putting yourself, you need to know what you're doing.
You need to study and get qualified, at least qualified by the American Academy of Dental
Sleep Medicine and other, there's AAPMD, there's a bunch of other places where you can get
good, good information, but you need to know what you're doing just because you can take
a bike, make an appliance and stick that in somebody.
Do not do that and take them off the CPAP.
You're sticking your toe in medicine.
I never tell patients to get off CPAP.
I get with the physician and I say, hey, this patient's come in.
They seem like they intolerant.
Can we work together?
Yes.
I need a physician written order stating that this patient is CPAP intolerant and I need,
the physician recommends me making an appliance for sleep apnea.
I look at myself as a DME provider.
Okay.
I'm an adherable medical equipment provider by the physician.
You're covering yourself if you get that letter from the physician stating that he
recommended sleep appliances.
So basically this did pass and it passed, it was appropriate.
He was just making a point that dentists need to be educated.
Yeah, more educated on the sleep side.
Yeah.
Especially look in children, even in adults that every dentist should screen for these
things.
Hang on.
Let me close this.
Hang on.
Sorry about that.
My room above vacuum started up.
I could hear it.
No worries.
But anyway, especially in children, every child should be screened and there's a pediatric
sleep questionnaire.
There's another one.
I'm going to show you in just a minute from the ADA that we're working on.
But we need to look for the risk factors.
We need to screen these kids up front, especially even in adults.
Does this screen?
Do you have snoring?
Do you stop breathing?
Do you have excessive daytime sleep?
Do you tend to fall asleep at the wheel for adults or whatever?
Some of these questionnaire are just way too long.
I mean, they're like 20, 30, 40, 50 questions.
I mean, we're trying to boil it down into five or six questions that are specific to
the point, and at least just as a screening device.
Right, right.
If any NES answer lists, hey, further information.
So basically that's what this is.
This is the ADA Children's Dayway Screener Task Force.
This is a screener.
And so basically what we're trying to do is hear the question, does your child mouth
breathe or lips apart while awake or asleep?
While sleeping or napping, do they snore, noisy breathing, difficulty breathing, pausing
or gasping for breath, neck extended, weird sleeping postures?
Do they have dry mouth or headache when they wake up?
We don't call it ADHD.
We just say, do they have tiredness, behavioral, emotional issues?
So basically any NES answer lists more information.
Now what I've done is I've taken it over here and say, okay, they check yes.
Now why did they check yes?
Because most of them, they say, well, I don't know if their mouth would be, but yeah, their
lips are apart all the time.
And then the snoring, noisy breathing and whatnot.
So what this does, it's just kind of, it's a real simple little questionnaire.
We're going to get it validated.
What we're looking for is to get, well, Candy knows about it and your group knows about what
we're trying to do with Steve Carstensen and Jerry Simmons to get this thing validated
by polysynography and what Jerry's using as a sleep image ring and try to validate this
with objective data and then publish it and hopefully practitioners can easily use it.
So NES answer lists its further information.
And then it'll soon be available online, version, parents can fill it out online in
a research portal.
Wouldn't it be great if they also had like a PneF, you could send them a PneF or something
like that or be in.
So that's kind of the things that we're kind of looking at now.
We can, they're my grandkids.
I've actually fixed it to go in a little bit to go, she's cheering on one of the football
teams.
So we're heading to Birmingham.
It seems like it.
Oh, nice.
Very good.
So, okay.
So at the end of every episode, I always like to turn the floor completely back over to
our guests and just leave you with the final thoughts and words and it can be for our parents
that listen or for our medical professionals or both that's completely up to you.
Okay.
Well, I think we need, we need the professionals whether it be physicians, dentists.
Number one, we need them to work together.
One reason I showed the book that we got at the first because it's about interdisciplinary
management.
Go see your ENT.
The main, if you're an orthodontist or a dentist, track down medical professionals,
the pediatricians.
It may take you a little while to get people to listen to you, but look at the literature,
try to get stuff out of there from Dr. Gemino and Stanford group Stanley Lu, Audrey Yoon,
who's an orthodontist, out at Stanford.
She done a lot of stuff with expansion and showing how all that works.
Steve Carstensen, obviously with the general dental crowd.
And then, you know, David Gazal, because I mean, they've got, you go get the literature
that's the upper echelon literature.
Don't just, I mean, there's a lot of other stuff out there, but you really need, if
you're going to get their attention, you got to give them some people that they know or
they've heard of, or at least they can go, okay, yeah, Dr. Gazal is the most prolific
writer in the world on sleep at you.
Okay.
They're going to listen to it.
People, the stuff out of Stanford, people are going to listen to.
So, and we need to, you know, we need to get the information to the ENTs and the pediatricians
and all that too of what we can do as dentists or orthodontists, what part we play in this,
that we're going to adjunct to them is the way I look at it.
I don't want to go into them and go, hey, here's all my stuff and beat my chest.
I want to go, I want to learn from you.
I want to learn more about airway and where you're coming from, but I want to give you
some ideas on what the literature says about what we can do as far as expansion and this
that and the other that can help that.
But then we now need to get more like, you know, your group to, you know, as far as parents
understanding this, because I'm getting referrals a lot from 100 miles away now, but just because
of my reputation that's built up, I guess, that, hey, we look at airway now.
We're not just looking at straight teeth, even though that's, we want straight teeth.
We want pretty smiles.
We want pretty faces, but we want the patient to have a good airway and I want to relate
it to my airway focused kind of thing.
So I think the parents need to just ask, you know, when they go see a pediatric dentist
or orthodontist, just ask them how, how do they feel about airway?
And if they go, oh, that's just a bunch of, you know, unfortunately find somebody else.
But the problem now is you get on Facebook and all this other stuff and you read all
this stuff and half of it's hearsay and everything.
Stick to the experts and what they say, you got to get this.
I mean, you know, but you know, I mean, Candy and her husband about their daughter, I mean,
the, that's, that's impressive.
I mean, that's an unbelievable what they did and what they had to go through to finally
get some answers.
Yeah, I think it's heavy on so proud to be a part of this because I mean, she's opening
up, they're opening up a lot of eyes.
The other group is opening up a lot of eyes to parents and it needs to be even more, you
know, so they can.
So the perhaps going to ask the right questions.
Yep.
And that's kind of our goal.
That's why we're here.
Yep.
Well, thank you very much for being on the podcast today.
I really appreciate it.
Well, I appreciate it.
Thank you so much.
We glad to do it again.
Absolutely.
Thanks to today's guest, Dr. William Harrell for sharing his medical insights and each
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