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Hi everybody and welcome back to Airway First, the podcast from the Children's Airway First

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Foundation.

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I'm your host Rebecca Downing.

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My guest today is Dr. William Harrell.

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Dr. Harrell began his orthodontic practice in Alexander City, Alabama in 1977 and has

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devoted most of his career to educating his peers, the public, and other health care professionals

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on the importance of discovering and treating airway obstructions leading to altered growth

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issues in children that can cause serious health conditions later in life.

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Throughout his career, he has worked alongside pioneers such as Dr. William Farrow, the pioneer

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of TMJ therapy, and Dr. Christian Jimmendow, one of the fathers of sleep medicine.

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Dr. Harrell lectures to residents, medical doctors, and dentists worldwide.

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He's also a professor at the University of Alabama Birmingham School of Dentistry Orthodontic

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Department.

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Dr. Harrell is the chairperson of RADSIDE Standards Committee on Combine CT for both medicine

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and dentistry.

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He's also on the American Dental Association's Children's Airway Screener Task Force.

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The task force is tasked with developing a children's screening questionnaire called

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Seek Hasp for uncovering early airway issues in children.

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Dr. Harrell is the lead editor of a medical and dental textbook called, Growing into Breathing

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Problems, the Quest for Collaborative Lifetime Solutions, which is scheduled to be published

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by Springer Publishing in early 2023.

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You can find out more about Dr. Harrell at drharrell.com.

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And now let's jump into our podcast with Dr. William Harrell.

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All right.

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Thank you so much for joining us on the show today, Dr. Harrell.

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I really appreciate it.

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Yeah, glad to be here.

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I appreciate the invitation.

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Absolutely.

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So we're going to jump in with something that was on your website that struck me.

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It states that in order to diagnose and treat airway conditions, practitioners must achieve

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anatomical truth.

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So what exactly is that?

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Yeah, I'm going to share my screen as we go through this.

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This will be, it'll help me explain some of this.

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But originally, in orthodontics, can you hear me?

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I'm not muted.

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I sure can.

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Yeah.

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Okay, good.

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Let me see if this will, can you see my screen?

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Nope.

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Try it one more time.

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Here we go.

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This is what I want to do.

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There we go.

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Okay.

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Can you see it?

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Can you see that?

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I can.

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There we go.

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And this is where the first foundation is.

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Okay, great.

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Yes, and I'll put links in our show notes too.

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Yeah, I appreciate everybody.

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I appreciate the invitation to do that.

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I wanted to kind of mention first, you know, a book that we're in the process of writing

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with a bunch of, bunch of people on growing into breathing problems.

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David Gazal is the most prolific writer now in the world on sleep apnea.

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And David McIntosh is a pediatric ENT.

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We have a number of others.

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One of them is actually chairman of ENT at Stanford, took over Dr. Gimenez's position,

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Stanley Liu.

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But anyway, I kind of wanted to say that's hopefully coming out in May of 2023 is what

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we're looking for.

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But I kind of wanted to talk about the anatomic truth because what we used to use in orthodontics

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or what traditionally is still done, or just kind of two dimensional films, like a 2D

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cell for a 2D pan, and that really doesn't give you the anatomic truth is giving you

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a picture in time.

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But as far as we know, there's geometric distortions in those images and they have been forever,

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but we've kind of accepted that fact.

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So when cone beam CT came on the scene, then all of a sudden we now have this is my grandson

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actually that we take the 3D face on, but we can actually map it to the cone beam CT.

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So not only does the professional get a better view of actually what the relationship, you

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know, in three dimensions or the amount of airway, the airway size, the TMJs, the teeth,

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the development of the teeth.

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But also what it does, it gives the parents and patients a better idea of understanding

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at a whole different level when they see this.

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They're not only wowed by it, I mean, that's one reason you do it, but to be able to go

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in and show them this kind of an image, you can just understand it at a whole different

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level.

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So the anatomic truth is really trying to represent true anatomy as it exists in nature.

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And then now with, you know, with cone beam and being able to evaluate the tooth dimensions

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along with the airway and evaluating tongue space just makes it that much better.

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And if I understand correctly, your dental practice is one of the first to use this CVCT

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technology in Alabama.

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Right.

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The cone beam CT was introduced to the world in about 1996 in Europe and Italy, actually.

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And then 2001 was when the first machine was introduced in the United States at Loma Linda

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University first.

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And then at David Hatcher, who's an oral radiologist in Sacramento, was actually got it the next

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day in claims to be the one that actually first used it in the United States.

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We got ours, the ICAT, we got it in 2005.

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So we were pretty early on, we were the first ones in Alabama, one of the first in the Southeast

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to use cone beam.

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And I wouldn't look, you know, now I couldn't practice without it.

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Right.

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Well, and I guess that begs the question, why aren't more dental practices using this?

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I mean, clearly you get a far more robust picture of what's going on.

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Well you do.

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And then, of course, a lot of it's being used for an oral surgery for implants or a

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periodite when they do an implant, implant kind of situations.

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But orthodontics has kind of been a little bit slow, I hate to say that.

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Even adopting it, I thought it would be pretty much standard of care.

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I think it one day is going to be.

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First of all, when it first came out, of course, the radiation doses were a little bit higher,

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well significantly higher than just a pan in a cell.

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So that was kind of part of the thing, oh, we're radiating too much.

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The others cost, because, you know, these machines are not cheap.

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So, but now the, actually I've got the Iket flex and in the machine that I have now, I

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can take a, what you see over there on the right, like on my grandson, I can take that

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for less radiation dose.

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Oops, sorry about that.

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Less radiation dose than these two films.

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Really?

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Yes.

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I can take this, these two films normally a normal traditional dental orthodontic practice

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or anywhere from 25 to 30 microceverts.

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Now you get about eight microceverts a day just by living on the earth.

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So you get around almost 3000 microceverts of dose living at sea level.

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So this is about 30.

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If you take a full mouth digital imaging of the teeth, like what most dentists do, that's

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anywhere from 75 microceverts to 150 microceverts.

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Now traditional CT is like 600 to 8000 microceverts of dose, but they're looking for different

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things.

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They're looking for cancer and that kind of stuff.

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But now with ICATFLEX and some of these low dose protocols, I can do a scan, which will

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give me this kind of information in about less than 24 microceverts or even 18 microceverts.

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So I'm getting less dose.

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So dosage is not really a barrier to entry.

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It's cost.

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It's cost.

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But to me, the traditional 2D stuff is going to be a boat anchor one day.

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And so I would recommend doctors or orthodontists or dentists that are looking into airway and

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looking into TMJ.

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Hey, the return on investment will come.

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If you start doing it and then the amount of information that you're giving patients

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and the patient and how they can understand is just, it's night and day.

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Yeah, I would think so.

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And do you run into any issues as far as insurance goes for billing this over the standard panels?

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Well, no, because if it's in, I can create a pan in a set if I want to.

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I do create a pan because I do send those to the dentist, but the traditional stuff I

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can create, I mean, you can actually, it doesn't matter what machine you use.

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You can, if you want to buy off a traditional 2D images, you can.

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What we do, a lot of our stuff is TMJ and sleep related.

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So we bill it through medical.

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So it's a medical insurance, which is a whole different ball game.

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But you could, there's a CBCT code in dentistry too.

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So there are codes that you can use to file dental and medical insurance.

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Okay, good.

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So it's not more for the parents.

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That's good.

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Right.

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Yeah, you also mentioned on your practice website, which I will include links to, that

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your evaluation includes nasal resistance and nasal airflow.

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Right.

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So how do you obtain these measurements and, you know, how do they help you as far as your

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diagnosis and treating?

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Yeah, great question.

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And I want to start with a video from Dr. Christian Gemino, who's the father of, you

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know, father of sleep medicine while he in the bed and power and Riley.

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I got this video for Dr. Karen Davidson.

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We're going to be talking about rhinomanometry and nasal resistance and nasal airflow.

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And she's probably the world expert on this.

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But I want to kind of go over this video because I think this tells it all about nasal, you

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know, nasal resistance and what we need to be doing, whether we're on orthodontist or

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dentist, if we're looking at airway issues, pediatric dentists, pediatricians, ENTs, pulo

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neurologists, whatever that might be dealing with, with airway issues.

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I want to play this just a second.

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The treatment of any sleep disorder breathing is nasal breathing.

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The end treatment of any sleep disorder breathing is nasal breathing.

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Correct.

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We even published that.

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We see my colleague Dr. Sullivan, Sharon Sullivan.

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It's, it's absolutely necessary.

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If you don't obtain that during sleep, because you may do that during weight, but you have

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to check during sleep, you have not succeeded in treating your child.

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So, uh.

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Now I'm going to play that one more time.

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So the link is important here.

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Okay.

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Sleep disorder breathing is nasal breathing.

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The end treatment of any sleep disorder breathing.

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The end treatment of any sleep disorder breathing is nasal breathing.

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Correct.

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We even published that.

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We see my colleague Dr. Sullivan, Sharon Sullivan.

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Uh, it's, uh, it's absolutely necessary.

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If you don't obtain that during sleep, because you may do that during weight, but you have

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to check during sleep, you have not succeeded in treating your child.

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Now that's a pretty amazing, that's a pretty amazing, uh, statement by the man that discovered

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sleep apnea and then discovered pediatrics sleep apnea.

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And so you might ask, well, you know, how do you, how do you measure this?

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Uh, I've been looking at combing, you know, CT and looking at perennial airway, uh, maybe

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asking them about, you know, looking at them and if they mouth breathe, you know, we try

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to get them on nasal breathing.

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But really Karen Davidson introduced me to this, uh, to this technology.

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And then I got, I got to thinking about it and I said, well, this makes a lot of sense

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to start measuring, they get objective measurements of nasal air flow since that should be one

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of our main goals or probably the number one goal is to get these kids to breathe through

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the nose, at least outside proper tongue position and all that.

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So if we look at, if we look at these, I've got both of these in my office.

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One is called acoustic rhinometry.

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And what it does, it's on the left side.

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Can you see my cursor?

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I sure can.

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Okay, good.

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It's the one on the, on the right side, acoustic rhinometry.

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Basically it's in sound waves, they, the patient holds this on one side of the nostril and

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sends sound waves down the, uh, down the anatomy and it, it looks at minimum cross sectional

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area.

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It kind of maps out like sonar, so to speak, all the way down from the tip of the nose to

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the, to the sinuses and even a little bit beyond that.

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So acoustic rhinometry measures minimum cross sectional area volume, it's a structural thing,

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kind of like CBCT.

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Okay.

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It kind of, it measures that.

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Cause CBCT is a more of a static image.

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This is really static too.

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But rhino manometry, which people get these things mixed up, they go rhino, rhino metri.

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Rhino is really acoustic rhino manometry.

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It's a manometer.

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It measures flow, it measures nasal resistance.

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So it measures function, which is really important because you put a mask on, you have them stop

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up one side of their nose, they'll breathe normally for about four times and then, then

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they'll stop up the other side and breathe normally and then it makes a graft, which I'll

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show you in just a second what you're looking at.

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Okay.

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This one, acoustic rhinometry gives you a graft also and they are medical codes and medical

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insurances that these can be built for.

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Now, so you're, what you're looking at is objective measurements and rhino manometry

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is the one that measures functions.

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So here's kind of a graft of a person and Karen kind of came up with this where she

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relates the airflow.

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This is inspiration.

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This graft is inspiration on the right side when you inspire and this is expiration on

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the right side.

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So it's like a little S curve.

239
00:16:56,960 --> 00:17:03,600
It looks like an S and then here's inspiration on the left, here's expiration on the left.

240
00:17:03,600 --> 00:17:07,200
So it creates this little S shape curve.

241
00:17:07,200 --> 00:17:09,840
Now you can see this one actually passes through.

242
00:17:09,840 --> 00:17:12,240
It passes through the orange.

243
00:17:12,240 --> 00:17:21,880
And if you look over here on the AHA RDI side, it, that way it crosses this line is about

244
00:17:21,880 --> 00:17:25,440
up here at mild sleep apnea.

245
00:17:25,440 --> 00:17:34,120
So you can almost predict or maybe able to predict the problems that you could run into.

246
00:17:34,120 --> 00:17:40,080
So if you want it, you want it to be a big, lazy S is what you want.

247
00:17:40,080 --> 00:17:44,640
So here's those.

248
00:17:44,640 --> 00:17:50,720
And if you look at maybe normal or ideal, it would look more like this.

249
00:17:50,720 --> 00:17:55,240
So it would be up in this green area, which means you would be down here.

250
00:17:55,240 --> 00:18:03,680
So the more squatty the S's, so to speak, the more nasal resistance and lack of airflow.

251
00:18:03,680 --> 00:18:09,520
So if you look at this particular case over here, you've got, let's look at the right

252
00:18:09,520 --> 00:18:10,520
side first.

253
00:18:10,520 --> 00:18:15,680
It's kind of got that little lazy S. It goes this way.

254
00:18:15,680 --> 00:18:16,680
Okay.

255
00:18:16,680 --> 00:18:21,040
Now here's a little loop here, which kind of means it's congested.

256
00:18:21,040 --> 00:18:26,880
But when you decongest the nose, see how much taller it gets.

257
00:18:26,880 --> 00:18:31,560
This is a soft tissue issue, not as much of a structural issue.

258
00:18:31,560 --> 00:18:36,920
If you decongested the nose and didn't get a chain, then you could assume that it's

259
00:18:36,920 --> 00:18:38,760
more structural.

260
00:18:38,760 --> 00:18:44,800
But if the decongested improves it, then you're talking about more of a soft tissue.

261
00:18:44,800 --> 00:18:50,180
Now you can see the other side, the left side is more short and squatty.

262
00:18:50,180 --> 00:18:55,040
So they're having less airflow, more resistance on the left than they are on the right.

263
00:18:55,040 --> 00:19:00,080
The decongested right makes it actually go in a better place.

264
00:19:00,080 --> 00:19:04,560
When you get these open loops like this, that's called a nasal valve phenomenon.

265
00:19:04,560 --> 00:19:11,200
Now these are not necessarily the same patient, but this is what nasal valve phenomenon is.

266
00:19:11,200 --> 00:19:15,240
This is a picture of the patient breathing normally.

267
00:19:15,240 --> 00:19:22,280
This is the middle one is the inspiration and the one on the right is expiration.

268
00:19:22,280 --> 00:19:25,840
So you can see she's got nasal valve collapse.

269
00:19:25,840 --> 00:19:30,800
And when she inspires, her nose closes up.

270
00:19:30,800 --> 00:19:35,760
And then when she exhales, you can see the nasal areas get bigger.

271
00:19:35,760 --> 00:19:42,280
So these are things that you can pick up with rhinomonometry.

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00:19:42,280 --> 00:19:49,600
And it actually can correlate to AHI and RDI measurements, which is kind of interesting.

273
00:19:49,600 --> 00:19:54,520
Now here's acoustic rhinometry, which has kind of gotten a bad name.

274
00:19:54,520 --> 00:20:02,320
But it does measure minimum pro-sectional area and volume.

275
00:20:02,320 --> 00:20:08,160
What it does when you put the acoustic tube up by the nose, because what it does is it's

276
00:20:08,160 --> 00:20:12,680
sending sound waves from the tip of the nose back through the turbinates back into the

277
00:20:12,680 --> 00:20:14,320
sinuses.

278
00:20:14,320 --> 00:20:23,240
And if you look at the baseline, let's say of this patient, here's their breathing pattern.

279
00:20:23,240 --> 00:20:27,400
And they breathe normally, you breathe through one side and the other, and it shows you what

280
00:20:27,400 --> 00:20:32,560
the minimum pro-sectional areas are at these levels.

281
00:20:32,560 --> 00:20:38,920
Like in this region would be the tip of the nose, then back to the edge of the turbinate.

282
00:20:38,920 --> 00:20:43,480
You can see it decreases at the turbinate, and then it decreases a little more.

283
00:20:43,480 --> 00:20:46,480
But that's pretty good baseline.

284
00:20:46,480 --> 00:20:52,120
When you decongest them, you can see that the nasal airway measurement, the airway in

285
00:20:52,120 --> 00:20:55,960
centimeter square, increases, which is a good thing.

286
00:20:55,960 --> 00:20:59,400
So it gets better.

287
00:20:59,400 --> 00:21:04,280
So those are two things that I use as look at function, because I think function is the

288
00:21:04,280 --> 00:21:06,200
most important part of it.

289
00:21:06,200 --> 00:21:12,000
But we also can look at acoustic rhinometry to look at structure.

290
00:21:12,000 --> 00:21:15,920
Now here's a poor man's way to do rhinomanometry.

291
00:21:15,920 --> 00:21:22,080
It's called a peat nasal inspiratory flow meter, PNIF.

292
00:21:22,080 --> 00:21:29,240
What it has is a face mask part on the left that fits over the nose and mouth.

293
00:21:29,240 --> 00:21:36,200
It's got a simple tube that has a, see this little red wafer right here.

294
00:21:36,200 --> 00:21:38,280
It's got a magnet up at the top.

295
00:21:38,280 --> 00:21:43,720
So what you do is you put this thing up and tap it so the magnet takes that little strip

296
00:21:43,720 --> 00:21:46,400
and it puts it all the way at the bottom.

297
00:21:46,400 --> 00:21:52,040
And then you flip it over, the magnet comes back up, the red wafer stays down here.

298
00:21:52,040 --> 00:21:57,600
You have the patient put it on their nose, put it on their face, their nose.

299
00:21:57,600 --> 00:22:00,280
They first they exhale all the way out.

300
00:22:00,280 --> 00:22:06,560
They exhale, they put this thing on their nose and then they inspire real quickly.

301
00:22:06,560 --> 00:22:11,080
And then what happens, that little red wafer will move up and it's got a scale on the other

302
00:22:11,080 --> 00:22:16,240
side, zero to 800 or whatever it might be.

303
00:22:16,240 --> 00:22:20,520
But what it does, it measures that inspiratory flow.

304
00:22:20,520 --> 00:22:26,000
So there are measurements in children and adults that that inspiratory flow should be

305
00:22:26,000 --> 00:22:29,140
at a certain level by age.

306
00:22:29,140 --> 00:22:32,360
So this is a good one because it moves way up here.

307
00:22:32,360 --> 00:22:37,080
You get some of them, they don't move the meter.

308
00:22:37,080 --> 00:22:41,760
So then you know that they've got some inspiratory flow issues.

309
00:22:41,760 --> 00:22:49,480
So it's a real inexpensive way that I think every orthodontist or pediatric dentist or

310
00:22:49,480 --> 00:22:56,040
pediatrician or whatever should easily use because it's something that's real simple.

311
00:22:56,040 --> 00:23:00,320
Now these other machines, of course, are a little more expensive, but they give you

312
00:23:00,320 --> 00:23:02,840
significant data.

313
00:23:02,840 --> 00:23:07,520
And this is a quote that I actually gave to Karen.

314
00:23:07,520 --> 00:23:13,800
I can do rhino-monometry without cone beam, but I really can't do cone beam without rhino-monometry

315
00:23:13,800 --> 00:23:17,840
because cone beam doesn't give you function.

316
00:23:17,840 --> 00:23:23,160
It's a static measurement upright in the wake.

317
00:23:23,160 --> 00:23:25,960
They're not laid down in a sleep and it's not function.

318
00:23:25,960 --> 00:23:28,520
But rhino-monometry, you can do it upright in the wake.

319
00:23:28,520 --> 00:23:32,760
You can do it lay down, not necessarily sleep because I'm not going to put them to sleep.

320
00:23:32,760 --> 00:23:36,000
But you get a pretty good idea of what's going on.

321
00:23:36,000 --> 00:23:42,160
The only way you really could technically understand how the airway collapses is you

322
00:23:42,160 --> 00:23:46,560
got to do drug-induced endoscopy and that's something that E&T does and you're not going

323
00:23:46,560 --> 00:23:48,280
to do that routinely.

324
00:23:48,280 --> 00:23:52,200
You just got to extrapolate out what things are.

325
00:23:52,200 --> 00:23:59,640
But you're looking at function and structure and how the function alters the structure.

326
00:23:59,640 --> 00:24:03,600
So that's kind of how I use rhino-monometry.

327
00:24:03,600 --> 00:24:09,720
And you mentioned that the audio had received kind of a bad rap.

328
00:24:09,720 --> 00:24:11,000
Why is that?

329
00:24:11,000 --> 00:24:27,120
Well, both of these are sensitive to knowing how to do these things.

330
00:24:27,120 --> 00:24:31,440
It's acoustic rhino-monometry.

331
00:24:31,440 --> 00:24:45,200
Now before 2015, a standards committee of rhino-monometry and rhino-monometry met and basically they

332
00:24:45,200 --> 00:24:52,560
declared that any publication before 2015 was obsolete.

333
00:24:52,560 --> 00:25:02,200
So a lot of the older data, the rhino-monometry and the acoustic rhino-monometry, it was pretty

334
00:25:02,200 --> 00:25:06,520
technique sensitive and a lot of things went on.

335
00:25:06,520 --> 00:25:11,320
And so before 2015, a lot of stuff was published.

336
00:25:11,320 --> 00:25:16,120
But because of the way it was done and some of the older equipment, it was kind of considered

337
00:25:16,120 --> 00:25:17,240
obsolete.

338
00:25:17,240 --> 00:25:23,040
So then all the physicians and everybody go, hey, well, this stuff's not true.

339
00:25:23,040 --> 00:25:32,240
Well, after 2015, they developed for phase rhino-monometry, which is a higher level

340
00:25:32,240 --> 00:25:33,640
type thing.

341
00:25:33,640 --> 00:25:36,800
And then you still got to be careful with it.

342
00:25:36,800 --> 00:25:46,680
But after 2015, the standards committee basically met and said, hey, for phase rhino-monometry

343
00:25:46,680 --> 00:25:51,960
has a use in medicine and dentistry at that time.

344
00:25:51,960 --> 00:25:58,120
So if you talk to some physicians early on, if they read the whole literature, they go,

345
00:25:58,120 --> 00:26:03,040
oh, that's not sensitive enough.

346
00:26:03,040 --> 00:26:04,680
It's not specific enough.

347
00:26:04,680 --> 00:26:08,480
The sensitivity is what I look at here, not necessarily the specificity.

348
00:26:08,480 --> 00:26:10,640
I'm looking for screening things.

349
00:26:10,640 --> 00:26:17,880
So the higher the sensitivity, the better it is as a not a diagnostic tool per se, but

350
00:26:17,880 --> 00:26:19,480
a screening tool.

351
00:26:19,480 --> 00:26:24,040
So what I use this for is when I start seeing flow limitations and things like that, what

352
00:26:24,040 --> 00:26:25,040
am I going to do?

353
00:26:25,040 --> 00:26:27,040
I'm going to send them to an ENT.

354
00:26:27,040 --> 00:26:32,960
Now the ENTs may not, this may not be in their armamentarium because guess what they're going

355
00:26:32,960 --> 00:26:33,960
to do?

356
00:26:33,960 --> 00:26:39,880
If they have a problem with nasal airflow, they're going to stick a scope up there and

357
00:26:39,880 --> 00:26:44,040
see where it is and go in there and get it.

358
00:26:44,040 --> 00:26:45,960
But I don't have that capability.

359
00:26:45,960 --> 00:26:51,680
So my whole thing is a screening thing up front so I can send it to the appropriate referral

360
00:26:51,680 --> 00:26:58,360
doctor and then be able to, the other thing I use it for is like expansion.

361
00:26:58,360 --> 00:27:03,000
When I'm doing early expansion in children, am I affecting their nasal flow?

362
00:27:03,000 --> 00:27:09,840
And if I'm doing a mandibular advancement, if I'm doing a maxillary advancement, I'm

363
00:27:09,840 --> 00:27:10,840
going to be able to do that.

364
00:27:10,840 --> 00:27:16,640
Whether it be on a doctor or whatever, at least it gives me some objective data that

365
00:27:16,640 --> 00:27:19,480
I can look at and say, hey, yeah, things improve.

366
00:27:19,480 --> 00:27:23,440
And it's not invasive basically.

367
00:27:23,440 --> 00:27:27,640
We do take comb beams and I compare these, but it's not like I'm going to take a comb

368
00:27:27,640 --> 00:27:28,640
beam every month.

369
00:27:28,640 --> 00:27:29,640
Right.

370
00:27:29,640 --> 00:27:33,040
I can do this every time they come in.

371
00:27:33,040 --> 00:27:34,040
Sure.

372
00:27:34,040 --> 00:27:42,160
And as far as data at home, I'm one of those people that uses a peak flow, which is different

373
00:27:42,160 --> 00:27:43,920
than this because this is inspiration.

374
00:27:43,920 --> 00:27:47,600
Peak flow is expiration.

375
00:27:47,600 --> 00:27:51,600
As a parent, if I were to come in and say, hey, I brought in my daughter's peak flow

376
00:27:51,600 --> 00:27:54,160
for the last month, is that helpful information?

377
00:27:54,160 --> 00:27:58,720
Or as a parent, can we help in that way?

378
00:27:58,720 --> 00:27:59,720
Yeah.

379
00:27:59,720 --> 00:28:00,720
I think so.

380
00:28:00,720 --> 00:28:06,000
I think this little piece right here lends itself to kind of telemedicine visits.

381
00:28:06,000 --> 00:28:07,240
Oh, yeah.

382
00:28:07,240 --> 00:28:13,320
I think some physicians that are doing something, I mean, you could send this thing, and this

383
00:28:13,320 --> 00:28:20,800
is not, it's less than a hundred bucks, but you could send these out.

384
00:28:20,800 --> 00:28:25,480
You could have them in your office and send them out, have patients do it at home and

385
00:28:25,480 --> 00:28:28,160
do it along and send you the data.

386
00:28:28,160 --> 00:28:33,200
What's the graph showing us today?

387
00:28:33,200 --> 00:28:43,520
And Karen Davidson's even invented the thing called Daphne score, DAF, any Daphne score,

388
00:28:43,520 --> 00:28:49,200
which actually takes these measurements, PNEF and rhinomagnometry and acoustic rhinometry,

389
00:28:49,200 --> 00:28:57,000
and it puts it in an algorithm and helps to actually interpret, not interpret, but screen

390
00:28:57,000 --> 00:29:04,560
to what these measurements kind of mean and maybe some suggestions of therapy, not a diagnostic

391
00:29:04,560 --> 00:29:14,600
algorithm, but it kind of lends itself to suggestions and say, hey, this means this,

392
00:29:14,600 --> 00:29:18,720
what it means in these graphs.

393
00:29:18,720 --> 00:29:26,960
This kind of a flow rate of whatever means this, and then you consider CPAP or plasma

394
00:29:26,960 --> 00:29:34,080
and pulse therapy, maybe expansion or mandible advancement at the child's class too or whatever.

395
00:29:34,080 --> 00:29:38,120
So it just kind of gives you some thought processes on it.

396
00:29:38,120 --> 00:29:39,840
Yeah, a little more for that.

397
00:29:39,840 --> 00:29:46,720
So, yeah, so I guess we'll just kind of build on that as far as what kind of options do

398
00:29:46,720 --> 00:29:51,560
parents have for younger children when it comes to treating these airway disorders?

399
00:29:51,560 --> 00:29:57,640
Well, I think they need to recognize a few things and some of the things are like, does

400
00:29:57,640 --> 00:29:58,640
your child snore?

401
00:29:58,640 --> 00:29:59,640
Even a little bit.

402
00:29:59,640 --> 00:30:00,640
They're not supposed to snore.

403
00:30:00,640 --> 00:30:05,320
People say, well, yeah, they snore a little bit.

404
00:30:05,320 --> 00:30:09,280
Now, if they got a cold or something like that, that's a different.

405
00:30:09,280 --> 00:30:10,680
You're talking chronic.

406
00:30:10,680 --> 00:30:11,680
It's chronic.

407
00:30:11,680 --> 00:30:12,680
Yeah.

408
00:30:12,680 --> 00:30:16,080
Have you ever witnessed them stop breathing or gasping at night?

409
00:30:16,080 --> 00:30:17,600
Do they have restless sleep?

410
00:30:17,600 --> 00:30:22,520
Do you go in there in the middle of the night and they're kicking the covers all over the

411
00:30:22,520 --> 00:30:23,520
place?

412
00:30:23,520 --> 00:30:28,480
Do they wet the bed inappropriate age to have behavioral issues?

413
00:30:28,480 --> 00:30:34,960
We don't say, I'm going to show you the CAS committee children's airway screener task

414
00:30:34,960 --> 00:30:36,680
force for the ADA, which I'm on.

415
00:30:36,680 --> 00:30:41,880
I'm going to show you that little five question there that we're trying to get validated.

416
00:30:41,880 --> 00:30:45,400
And that could be used easily enough for parents to fill out.

417
00:30:45,400 --> 00:30:50,080
I'll show you that in just a second.

418
00:30:50,080 --> 00:30:52,280
If you want me to, I'm going to show you this little video.

419
00:30:52,280 --> 00:30:53,840
Yeah, I would love that.

420
00:30:53,840 --> 00:30:56,120
Airway and TMJ.

421
00:30:56,120 --> 00:31:05,360
And it's really good because it kind of explains how airway and TMJ relate to each other.

422
00:31:05,360 --> 00:31:10,480
And then I'll tell you how I explain it to parents and patients when they come in also.

423
00:31:10,480 --> 00:31:12,840
But I think this is a really good.

424
00:31:12,840 --> 00:31:16,480
Airway and TMJ.

425
00:31:16,480 --> 00:31:19,000
The normal way to breathe is through your nose.

426
00:31:19,000 --> 00:31:24,080
As we grow and develop, certain things such as pollen, cow milk and other variables can

427
00:31:24,080 --> 00:31:29,320
cause an allergic reaction, causing the lymphoid tissues known as tonsils and adenoids to become

428
00:31:29,320 --> 00:31:30,320
swollen.

429
00:31:30,320 --> 00:31:35,080
As the tonsils and adenoids become swollen, they're developed into an obstruction for nasal

430
00:31:35,080 --> 00:31:40,880
breathing and slowly mouth breathing begins to be the primary effect of air into the body.

431
00:31:40,880 --> 00:31:44,760
In order to breathe through the mouth, the lower jaw comes down, the tongue comes off

432
00:31:44,760 --> 00:31:47,800
the palate and settles on the lower teeth.

433
00:31:47,800 --> 00:31:50,880
Nasal breathing is the correct way for air to enter the body.

434
00:31:50,880 --> 00:31:55,160
And during nasal breathing, the tongue rests up the palate and the pressure of the cheeks

435
00:31:55,160 --> 00:31:57,160
to the bound spider tongue.

436
00:31:57,160 --> 00:32:01,680
During mouth breathing, the pressure from the cheeks on a post-bacter toe, the oral

437
00:32:01,680 --> 00:32:07,120
system becomes unbalanced and results in the deformation of the upper jaw creating a V-shaped

438
00:32:07,120 --> 00:32:10,400
arch as opposed to a correct V-shaped arch.

439
00:32:10,400 --> 00:32:14,960
This also produces an incorrect swallowing function.

440
00:32:14,960 --> 00:32:19,760
Upon swallowing, the tongue rests on the lateral teeth hindering normal tooth erections, causing

441
00:32:19,760 --> 00:32:21,760
a lateral tongue thrust.

442
00:32:21,760 --> 00:32:31,560
A constantly open mouth causes the incisors to over-erup.

443
00:32:31,560 --> 00:32:37,480
The result is a deformation of the lower arch known as the bifrusted drop off.

444
00:32:37,480 --> 00:32:43,000
The result of this deformation of the upper and lower arch is the presence of premature

445
00:32:43,000 --> 00:32:48,680
contact upon closing, which shifts the lower jaw distally off of the physiologic trajectory.

446
00:32:48,680 --> 00:32:52,640
The narrowing of the upper arch pushes the lower jaw back.

447
00:32:52,640 --> 00:32:58,640
This forces the TMJ condyle to shift distally while the TMJ disc shifts forward.

448
00:32:58,640 --> 00:33:04,160
Upon opening, the disc can shift onto the condyle to restore the TMJ correct position

449
00:33:04,160 --> 00:33:10,160
of the disc and then shifts back through an incorrect forward position upon closing.

450
00:33:10,160 --> 00:33:13,160
This is what causes a reciprocal split.

451
00:33:13,160 --> 00:33:18,280
In addition, the muscles can be in a state of hypertonic or spasm, which can result in

452
00:33:18,280 --> 00:33:19,280
tension headaches.

453
00:33:19,280 --> 00:33:23,720
An incorrect position of the lower jaw can result in fair functional activity of the

454
00:33:23,720 --> 00:33:28,240
muscle such as clenching and grinding.

455
00:33:28,240 --> 00:33:31,480
Over time, grinding can result in severely worn down teeth.

456
00:33:31,480 --> 00:33:36,280
As a result, the teeth becoming shorter, the lower jaw shifts distally even further, and

457
00:33:36,280 --> 00:33:37,880
the verticals of the bifrusted teeth.

458
00:33:37,880 --> 00:33:39,880
In time, joint degeneration occurs.

459
00:33:39,880 --> 00:33:43,880
The joint becomes deformed and the ligaments of the joints come damaged.

460
00:33:43,880 --> 00:33:47,880
As a result, the TMJ disc can get trapped in front of the condyle.

461
00:33:47,880 --> 00:33:52,880
While the clicking go away, limited mouth opening will occur.

462
00:33:52,880 --> 00:34:02,880
A disc with shifted jaw and tongue positions results in even further restriction of the

463
00:34:02,880 --> 00:34:03,880
airway.

464
00:34:03,880 --> 00:34:08,880
In order to open up the airway, the neck moves forward and the head feels backwards.

465
00:34:08,880 --> 00:34:14,880
This stresses the spine and defeats the neck muscles, which results in neck, back, and

466
00:34:14,880 --> 00:34:17,880
shoulder pain.

467
00:34:17,880 --> 00:34:18,880
Airway?

468
00:34:18,880 --> 00:34:23,880
It's interesting how that works together.

469
00:34:23,880 --> 00:34:32,120
A lot of times what I do when I'm explaining how TMJ and airway relate to each other is

470
00:34:32,120 --> 00:34:34,480
with doll tables.

471
00:34:34,480 --> 00:34:38,200
I'll get some little doll tables.

472
00:34:38,200 --> 00:34:42,480
I'll have one and it's got all their legs are intact.

473
00:34:42,480 --> 00:34:45,960
Then I've got another where I'll cut off one of the legs.

474
00:34:45,960 --> 00:34:51,520
I'll put a little wire in a hole in it so I can stick it back together and have it connected

475
00:34:51,520 --> 00:34:53,080
with a piece of dental floss.

476
00:34:53,080 --> 00:35:01,400
What it does, I show them the table and I say, the table needs to be stable.

477
00:35:01,400 --> 00:35:05,760
All four legs need to fit just right to make the table top level.

478
00:35:05,760 --> 00:35:10,880
I flip it upside down and say, here are your two jaw joints.

479
00:35:10,880 --> 00:35:17,040
The body of the top of the table is actually the mandible and then the two other little

480
00:35:17,040 --> 00:35:19,840
guys out here are the teeth.

481
00:35:19,840 --> 00:35:24,400
When you put it all together and you flip it over, look at the airway space under the

482
00:35:24,400 --> 00:35:27,280
table top with all four legs intact.

483
00:35:27,280 --> 00:35:32,880
Then take the one that's cut and you get a wobble to it.

484
00:35:32,880 --> 00:35:33,880
That's what's happening.

485
00:35:33,880 --> 00:35:39,440
Either your bite may be off or maybe you got degeneration in the TMJ or whatever.

486
00:35:39,440 --> 00:35:43,880
What you have is like a rocky table.

487
00:35:43,880 --> 00:35:51,320
Then I say, well, look at the airway space now under that table versus the one that's

488
00:35:51,320 --> 00:35:52,320
intact.

489
00:35:52,320 --> 00:35:53,320
They go, aha.

490
00:35:53,320 --> 00:36:02,320
I see what you're talking about because it's a little bit, I like to use simple little

491
00:36:02,320 --> 00:36:03,320
things like that.

492
00:36:03,320 --> 00:36:08,240
Then I put the little piece back in there with my wire and stick it back in the hole.

493
00:36:08,240 --> 00:36:11,880
Okay, that's what we're trying to do with the TMJ splint or whatever.

494
00:36:11,880 --> 00:36:14,600
We're trying to stabilize that.

495
00:36:14,600 --> 00:36:15,600
To keep it up.

496
00:36:15,600 --> 00:36:16,600
To keep it in any place.

497
00:36:16,600 --> 00:36:23,320
But say, hey, a lot of times, TMJ issues and sleep tend to go together.

498
00:36:23,320 --> 00:36:30,440
They can be independent of each other, obviously, but a lot of times they do coexist.

499
00:36:30,440 --> 00:36:31,920
Does one lead to the other?

500
00:36:31,920 --> 00:36:35,480
We really probably don't know, but exactly.

501
00:36:35,480 --> 00:36:38,480
But still, they tend to coexist with each other.

502
00:36:38,480 --> 00:36:39,480
Travel together.

503
00:36:39,480 --> 00:36:44,160
The video mentioned something that I and all the research that I've done have never heard

504
00:36:44,160 --> 00:36:50,320
of, but it's logical that you'll end up with shoulder and neck pain.

505
00:36:50,320 --> 00:36:53,520
I've never heard that listed as a symptom before.

506
00:36:53,520 --> 00:37:00,320
Well, it's forward head posture because what they do when you can't, if you're not breathing

507
00:37:00,320 --> 00:37:04,080
properly and the lower jaw sitting back, what are you going to do?

508
00:37:04,080 --> 00:37:07,960
The body is going to adapt to breathing.

509
00:37:07,960 --> 00:37:12,240
It's going to make, you got to breathe to stay alive.

510
00:37:12,240 --> 00:37:19,280
It doesn't care what it does to the teeth or to the skeleton or to the spine or whatever.

511
00:37:19,280 --> 00:37:21,920
It's going to compensate to make.

512
00:37:21,920 --> 00:37:27,200
Now it may not be ideal breathing, but it's survival breathing.

513
00:37:27,200 --> 00:37:32,400
See, that's what we're going to get into this thing of, okay, well, I'm breathing good enough

514
00:37:32,400 --> 00:37:34,160
and I'm staying alive.

515
00:37:34,160 --> 00:37:36,400
Well, great.

516
00:37:36,400 --> 00:37:40,200
But if you got this forward head posture now, all of a sudden your head weighs more because

517
00:37:40,200 --> 00:37:46,640
it's hanging out over the spine causing your neck pain, but it's holding the airway so

518
00:37:46,640 --> 00:37:53,480
you can continue to breathe.

519
00:37:53,480 --> 00:37:58,600
You're listening to airway first with today's guest, Dr. William Harrell.

520
00:37:58,600 --> 00:38:02,320
You can find out more about the Children's Airway First Foundation and our mission to

521
00:38:02,320 --> 00:38:08,000
fix before six on our website at children'sairwayfirst.org.

522
00:38:08,000 --> 00:38:12,920
The GAF website offers tons of great resources for parents and medical professionals, including

523
00:38:12,920 --> 00:38:18,600
videos, blogs, recommended reading lists, a comprehensive medical research library, podcast

524
00:38:18,600 --> 00:38:21,160
and so much more.

525
00:38:21,160 --> 00:38:25,400
Parents are encouraged to join the airway huddle, our Facebook support group, which was created

526
00:38:25,400 --> 00:38:29,320
for parents of children with airway and sleep related issues.

527
00:38:29,320 --> 00:38:35,680
You can access the airway huddle support group at facebook.com backslash groups backslash

528
00:38:35,680 --> 00:38:36,680
airway huddle.

529
00:38:36,680 --> 00:38:41,480
Are you a medical professional or parent that's interested in being a guest on the show or

530
00:38:41,480 --> 00:38:43,920
do you just have an idea of for an upcoming episode?

531
00:38:43,920 --> 00:38:49,720
If so, shoot us a note via our contacts page on our website or send us an email directly

532
00:38:49,720 --> 00:38:54,040
at infoatchildrensairwayfirst.org.

533
00:38:54,040 --> 00:38:59,440
As a reminder, this podcast and the opinions expressed here are non-medical diagnosis.

534
00:38:59,440 --> 00:39:04,320
If you suspect your child might have an airway issue, contact your pediatric, airway, dentist

535
00:39:04,320 --> 00:39:05,320
or pediatrician.

536
00:39:05,320 --> 00:39:27,320
And now let's jump back into my interview with today's guest, Dr. William Harrell.

537
00:39:27,320 --> 00:39:34,320
So those are things that I think we have to kind of take into consideration as we start

538
00:39:34,320 --> 00:39:35,320
looking at all this.

539
00:39:35,320 --> 00:39:37,760
Or we're looking holistically again at that.

540
00:39:37,760 --> 00:39:38,760
Yeah.

541
00:39:38,760 --> 00:39:40,960
Yeah, and totally makes sense.

542
00:39:40,960 --> 00:39:50,520
So one of the things that we've talked about on the podcast before and in blogs is specifically

543
00:39:50,520 --> 00:39:52,560
retractive braces.

544
00:39:52,560 --> 00:39:54,640
We know that retractive is dangerous.

545
00:39:54,640 --> 00:39:55,640
We know that as parents.

546
00:39:55,640 --> 00:39:58,120
Now, now we know that.

547
00:39:58,120 --> 00:40:06,320
So when are braces or orthodontics the right answer and how do parents know, okay, this

548
00:40:06,320 --> 00:40:09,600
is the way to go or when to proceed with caution?

549
00:40:09,600 --> 00:40:13,200
Yeah, it's a great question.

550
00:40:13,200 --> 00:40:20,800
And you know, my whole philosophy of things changed.

551
00:40:20,800 --> 00:40:24,720
I mean, we were taught in school.

552
00:40:24,720 --> 00:40:32,080
One thing you have to do, you have to understand orthodontic education and how it's set up.

553
00:40:32,080 --> 00:40:35,440
The residents are there for three years, two years.

554
00:40:35,440 --> 00:40:37,720
They got to learn how to move teeth.

555
00:40:37,720 --> 00:40:38,720
Okay.

556
00:40:38,720 --> 00:40:43,080
They don't get exposed a lot to early treatment.

557
00:40:43,080 --> 00:40:48,400
The only reason they would, you know, we, and even in our residency at UAB, which is

558
00:40:48,400 --> 00:40:56,400
it's evolving and the airways getting to be more looked at, but still the orthodontic

559
00:40:56,400 --> 00:41:05,320
education and especially in my day in 1975 to 77 when I was there is built on.

560
00:41:05,320 --> 00:41:09,880
We don't want to see them till they're 12 or 14 years old or older because, you know,

561
00:41:09,880 --> 00:41:12,360
we're not going to put braces on before then.

562
00:41:12,360 --> 00:41:18,600
The only time we would treat maybe an early case, six M eight is to correct cross bite.

563
00:41:18,600 --> 00:41:19,600
Okay.

564
00:41:19,600 --> 00:41:26,520
And then or an underbite or maybe an over, you know, but a lot of times even back then,

565
00:41:26,520 --> 00:41:31,840
if they were big class too, we'd say, Hey, we got to wait till the 12 or 14.

566
00:41:31,840 --> 00:41:33,000
We got two choices.

567
00:41:33,000 --> 00:41:38,520
We can take out teeth to try to resolve the occlusion or we can wait for surgery.

568
00:41:38,520 --> 00:41:47,560
So, but orthodontic residents are there for two or three years to learn how to move teeth.

569
00:41:47,560 --> 00:41:53,720
And the way it's just evolved is they've got to finish their cases up in that two or three

570
00:41:53,720 --> 00:41:55,960
year period of time.

571
00:41:55,960 --> 00:41:59,400
So they're not going to see them before six, they're not going to see them at six, seven,

572
00:41:59,400 --> 00:42:02,600
eight, unless they got a cross bite, but then they're not going to see they're going to

573
00:42:02,600 --> 00:42:06,960
correct the cross bite and then just let them sit until they're ready for braces.

574
00:42:06,960 --> 00:42:15,080
So you kind of have to understand that concept a little bit as to, as to why we orthodontist

575
00:42:15,080 --> 00:42:20,040
are trained in the way we, we are now in 1982 when all the monkey studies came out about

576
00:42:20,040 --> 00:42:23,960
breathing and all that kind of got me changing my mind a little bit.

577
00:42:23,960 --> 00:42:28,920
And especially when I got combi and started looking at the relationship of dental arches

578
00:42:28,920 --> 00:42:37,560
to mandibular position, maxillary position, narrow arches to the airway to the TMJ, then

579
00:42:37,560 --> 00:42:45,160
a light bulb came in, you get this aha moment and you go, okay, now this makes sense for

580
00:42:45,160 --> 00:42:55,440
me because early treatment was basically introduced by pediatric dentist and the general dental

581
00:42:55,440 --> 00:43:03,640
community, not necessarily orthodontics, unfortunately, if we're catching up to it, okay, we're catching

582
00:43:03,640 --> 00:43:05,280
up to it.

583
00:43:05,280 --> 00:43:13,840
Now their times, even me, you know, even me is when I get a case that's late and periodotally

584
00:43:13,840 --> 00:43:18,240
for whatever reason, I can't expand too much.

585
00:43:18,240 --> 00:43:23,200
I can't expand to get all the teeth in, but if I have to extract, I'm going to keep it

586
00:43:23,200 --> 00:43:25,960
as wide as I can.

587
00:43:25,960 --> 00:43:32,440
My whole focus is airway focused, okay, or airway, try to keep, I'm going to look at

588
00:43:32,440 --> 00:43:36,120
the airway first before I make a decision about extraction.

589
00:43:36,120 --> 00:43:42,400
Now I can't tell you the last time I've extracted, because I see kids at four, five, six, we expand

590
00:43:42,400 --> 00:43:43,960
them and guess what?

591
00:43:43,960 --> 00:43:45,440
They don't need air.

592
00:43:45,440 --> 00:43:51,640
When I'm treating a 12 or 14 year old case, I've got a class one minor crowded.

593
00:43:51,640 --> 00:43:54,560
I could put an Invisalign in there or whatever.

594
00:43:54,560 --> 00:43:56,160
It's just a simple little case now.

595
00:43:56,160 --> 00:43:59,560
I'm going to get all the deformity ahead of time.

596
00:43:59,560 --> 00:44:05,480
And I liken this to, and I tell orthodontics and I tell parents, they go, look, when do

597
00:44:05,480 --> 00:44:09,000
you treat a child's got club feet?

598
00:44:09,000 --> 00:44:11,320
You treat them at one month.

599
00:44:11,320 --> 00:44:15,600
They put cash on those kids at one month to three months at the most.

600
00:44:15,600 --> 00:44:17,080
They don't wait six months.

601
00:44:17,080 --> 00:44:18,080
Why?

602
00:44:18,080 --> 00:44:24,240
Because there's so much growth going on and there's so much moldability because you can

603
00:44:24,240 --> 00:44:29,360
take a child at one month, grow their feet over correct, come back.

604
00:44:29,360 --> 00:44:32,640
And by the time they're walking, you never know they had a problem.

605
00:44:32,640 --> 00:44:36,000
They can jump and play just like everybody else.

606
00:44:36,000 --> 00:44:42,840
But if you wait for those feet to grow, and the bones are strong, they're like, yeah.

607
00:44:42,840 --> 00:44:48,600
You've got a crippled child, now not saying orthodontic crippled, but I'm just saying

608
00:44:48,600 --> 00:44:50,920
the principle to me is the same thing.

609
00:44:50,920 --> 00:44:52,240
Right, do it earlier.

610
00:44:52,240 --> 00:45:02,720
But you've got to go get that education outside your traditional orthodontic field.

611
00:45:02,720 --> 00:45:07,840
Because unfortunately, that's what I try to bring to the table is show the cases, hey,

612
00:45:07,840 --> 00:45:12,480
look, here's a six year old child that has these symptoms and all this.

613
00:45:12,480 --> 00:45:14,440
Look at the nasal resistance.

614
00:45:14,440 --> 00:45:16,560
Let's do these expansions.

615
00:45:16,560 --> 00:45:21,320
Let's see how they develop over time.

616
00:45:21,320 --> 00:45:23,880
And then we can do the orthodontics and it's easy.

617
00:45:23,880 --> 00:45:25,960
It's simpler at that point.

618
00:45:25,960 --> 00:45:32,040
So that's more and more the education in the orthodontic community has got to be done by

619
00:45:32,040 --> 00:45:38,080
practitioners that are, you know, adjunct professors or whatever that do that kind of

620
00:45:38,080 --> 00:45:43,840
stuff that can show that progression because that's the only way you're going to get it

621
00:45:43,840 --> 00:45:44,840
into the system.

622
00:45:44,840 --> 00:45:46,880
And that's what kind of what I try to do.

623
00:45:46,880 --> 00:45:59,200
So it's, there's a controversy there and I can tell you though, there is this thing

624
00:45:59,200 --> 00:46:03,040
about retractive orthodontics, it just makes physical sense to me.

625
00:46:03,040 --> 00:46:07,560
If you're going to start pushing things back, there's an airway back there.

626
00:46:07,560 --> 00:46:09,800
The tone is going to go somewhere.

627
00:46:09,800 --> 00:46:15,360
The tone, if you've got a narrow arc, if you've got a, if you've got a four bedroom house

628
00:46:15,360 --> 00:46:20,880
and a two bedroom foundation to put it on and you got all this furniture in there, which

629
00:46:20,880 --> 00:46:21,880
is the problem.

630
00:46:21,880 --> 00:46:27,320
I mean, what we've been doing is cutting the toes off the foot and making it fit the shoe.

631
00:46:27,320 --> 00:46:29,120
We need to make the shoe fit the foot.

632
00:46:29,120 --> 00:46:30,120
Right.

633
00:46:30,120 --> 00:46:34,720
And then all of a sudden when you expand that, guess what?

634
00:46:34,720 --> 00:46:38,200
The tone that sits in there, there's one of the biggest corporate, you're making more

635
00:46:38,200 --> 00:46:39,200
room for it.

636
00:46:39,200 --> 00:46:41,080
So it just makes sense to me.

637
00:46:41,080 --> 00:46:47,800
Now, unfortunately, there is really not ever, there's not a, there's not a good randomized

638
00:46:47,800 --> 00:46:59,400
controls study that shows that extractions and that kind of stuff cause sleep apnea.

639
00:46:59,400 --> 00:47:00,400
Okay.

640
00:47:00,400 --> 00:47:01,400
Okay.

641
00:47:01,400 --> 00:47:07,960
And that's kind of what orthodontics, we kind of quote a lot of times and that's true.

642
00:47:07,960 --> 00:47:15,280
I mean, there's not, but in my mind, it doesn't make physical sense cause it violates in

643
00:47:15,280 --> 00:47:16,280
physical laws.

644
00:47:16,280 --> 00:47:23,680
If you put, if you try to put the tone inside a smaller shoe, it just doesn't work.

645
00:47:23,680 --> 00:47:24,680
Yeah.

646
00:47:24,680 --> 00:47:26,200
You got a bigger shoe, it's got more, you've got more function.

647
00:47:26,200 --> 00:47:27,920
I mean, it just makes sense to me.

648
00:47:27,920 --> 00:47:34,880
It just makes common sense to me to do it, but the problem that you run into is people

649
00:47:34,880 --> 00:47:37,000
say, well, there's no randomized control study.

650
00:47:37,000 --> 00:47:38,920
So therefore I'm not going to believe that.

651
00:47:38,920 --> 00:47:41,920
Well, here's the problem.

652
00:47:41,920 --> 00:47:43,920
You can't do the study.

653
00:47:43,920 --> 00:47:47,800
It would be unethical to do the study to prove that.

654
00:47:47,800 --> 00:47:53,800
And what you would have to do is you would have to take a thousand kids and, you know,

655
00:47:53,800 --> 00:47:58,080
treat them the normal traditional way, you have to take another thousand and treat a

656
00:47:58,080 --> 00:48:03,960
function, you take another thousand, not treat them and do polysilography and all this kind

657
00:48:03,960 --> 00:48:06,960
of stuff and see who dies first.

658
00:48:06,960 --> 00:48:07,960
Right.

659
00:48:07,960 --> 00:48:11,560
I mean, ethically, it cannot be done.

660
00:48:11,560 --> 00:48:12,560
Correct.

661
00:48:12,560 --> 00:48:13,560
Yeah.

662
00:48:13,560 --> 00:48:15,480
To prove it beyond a shadow of a doubt.

663
00:48:15,480 --> 00:48:22,440
So there are literature that kind of supports the idea that retractive things aren't good.

664
00:48:22,440 --> 00:48:25,680
There's other literature this out there in our literature.

665
00:48:25,680 --> 00:48:28,560
The problem is you got to get outside our dental literature.

666
00:48:28,560 --> 00:48:31,120
You got to get into medical literature.

667
00:48:31,120 --> 00:48:32,120
Yeah.

668
00:48:32,120 --> 00:48:35,000
Which, which brings me to my next question.

669
00:48:35,000 --> 00:48:38,240
You know, where, where have we gone wrong as far as medicine goes?

670
00:48:38,240 --> 00:48:43,480
It feels like there was a misstep somewhere, not, you know, an intentional thing, but somewhere

671
00:48:43,480 --> 00:48:48,600
we made a misstep because we have all these kids around the world that are experiencing

672
00:48:48,600 --> 00:48:54,480
their way disorders and sleep issues and then all of us as adults that had retractive braces

673
00:48:54,480 --> 00:48:55,880
and things like this done.

674
00:48:55,880 --> 00:48:56,880
Yeah.

675
00:48:56,880 --> 00:48:57,880
Where did we misstep?

676
00:48:57,880 --> 00:49:02,720
Well, I don't know if it was a misstep other than an overlook.

677
00:49:02,720 --> 00:49:03,720
Okay.

678
00:49:03,720 --> 00:49:09,480
When this started, when Dr. Gemmano discovered sleep apnea, who was it on?

679
00:49:09,480 --> 00:49:10,880
It was on a beast man.

680
00:49:10,880 --> 00:49:11,880
Right.

681
00:49:11,880 --> 00:49:12,880
It was on a beast man.

682
00:49:12,880 --> 00:49:16,280
Which growing up, that's what we knew were a beast man.

683
00:49:16,280 --> 00:49:17,280
Sure.

684
00:49:17,280 --> 00:49:20,520
And then they would extract the autonomy to put a hole in the throat because they, they

685
00:49:20,520 --> 00:49:22,520
people are going to die.

686
00:49:22,520 --> 00:49:23,520
Right.

687
00:49:23,520 --> 00:49:24,520
So they bypass the obstruction.

688
00:49:24,520 --> 00:49:30,760
And then all of a sudden Sullivan in Australia and been in the CPAP by reversing a vacuum

689
00:49:30,760 --> 00:49:31,760
cleaner.

690
00:49:31,760 --> 00:49:33,920
That's how it is.

691
00:49:33,920 --> 00:49:39,520
And then all of a sudden CPAP was developed to treat these people.

692
00:49:39,520 --> 00:49:47,200
So there was a, you know, a small, you know, so the whole thing about sleep apnea was,

693
00:49:47,200 --> 00:49:53,120
it's in a beast man and we got to put a reverse vacuum cleaner on them to keep them alive.

694
00:49:53,120 --> 00:49:58,640
So that's all that research started in adults.

695
00:49:58,640 --> 00:50:07,520
And then you have a voluminous amount of information on CPAP and its efficiency and

696
00:50:07,520 --> 00:50:12,160
efficacy and all that kind of stuff in the medical field because they jumped on that.

697
00:50:12,160 --> 00:50:14,120
That's their, that's their gold standard.

698
00:50:14,120 --> 00:50:21,560
What are the other two, you know, the other two almost absolute treatments or tracheotomy,

699
00:50:21,560 --> 00:50:26,400
which has not really done it or double jaw surgery where they take the upper jaw, move

700
00:50:26,400 --> 00:50:27,400
it out.

701
00:50:27,400 --> 00:50:28,920
They take the lower jaw, move it out.

702
00:50:28,920 --> 00:50:29,920
And guess what?

703
00:50:29,920 --> 00:50:31,720
You open up the airway.

704
00:50:31,720 --> 00:50:39,840
So we never thought about that as a, as a treatment modality.

705
00:50:39,840 --> 00:50:47,240
Why don't we copy that treatment modality of maxillary advancement surgery in children

706
00:50:47,240 --> 00:50:50,000
by growth is my point.

707
00:50:50,000 --> 00:50:57,200
And so then it gets to, hey, if it makes sense in adults, the problem is in adults, it's

708
00:50:57,200 --> 00:50:58,200
already developed.

709
00:50:58,200 --> 00:51:01,000
The problem is there.

710
00:51:01,000 --> 00:51:02,000
It's already there.

711
00:51:02,000 --> 00:51:04,480
But back here, we could have fixed it.

712
00:51:04,480 --> 00:51:10,960
Back up here, we could, and we never made that connection until about 1976 when Dr.

713
00:51:10,960 --> 00:51:18,520
Gemino discovered sleep apnea in children and he spent his life work trying to figure

714
00:51:18,520 --> 00:51:25,600
out what can we do in young children rather than putting them on a CPAP because that ultra

715
00:51:25,600 --> 00:51:26,840
spatial growth.

716
00:51:26,840 --> 00:51:33,880
Yes, it blows air down the tube and opens up, but it, it creates some axillary recessiveness.

717
00:51:33,880 --> 00:51:38,760
So it's pushing back, which is not the way you really want to go.

718
00:51:38,760 --> 00:51:42,520
So you really want everything to come forward.

719
00:51:42,520 --> 00:51:44,040
And then I started looking at things.

720
00:51:44,040 --> 00:51:47,120
I said, well, you know, it just, it makes sense.

721
00:51:47,120 --> 00:51:56,160
Some of the sephalometric numbers that we orthodontically go by a lot, probably are

722
00:51:56,160 --> 00:51:57,960
too retrognathic.

723
00:51:57,960 --> 00:52:07,760
We just, we looked at normalness is not, I mean, things that are common are not necessarily

724
00:52:07,760 --> 00:52:08,760
normal.

725
00:52:08,760 --> 00:52:09,760
Not normal.

726
00:52:09,760 --> 00:52:10,760
Yep.

727
00:52:10,760 --> 00:52:11,760
We're hearing that a lot.

728
00:52:11,760 --> 00:52:14,040
There's commonness, but not normalness or idealness.

729
00:52:14,040 --> 00:52:21,120
I mean, there's probably no ideal out there, but at least normal or, or good quality breathing

730
00:52:21,120 --> 00:52:27,480
that creates good quality growth and good quality brain and cardiac development is one thing.

731
00:52:27,480 --> 00:52:31,200
Just getting by is another thing.

732
00:52:31,200 --> 00:52:37,160
It's, but we can see, I was going to say we consider it normal.

733
00:52:37,160 --> 00:52:38,560
We consider it normal.

734
00:52:38,560 --> 00:52:44,360
But then we go back in time a few hundred years ago, Kevin Boyd, Mariana Evans and I

735
00:52:44,360 --> 00:52:49,280
have been talking about what happened at the Nussel Revolution.

736
00:52:49,280 --> 00:52:57,120
Breastfeeding was because women went out to work and they bottle fed and the, the children

737
00:52:57,120 --> 00:53:01,080
don't chew on things like they used to and right.

738
00:53:01,080 --> 00:53:08,280
It's all soft food and soft foods and the diet changed, all this stuff changed, which

739
00:53:08,280 --> 00:53:10,920
we know that our face has gotten smaller.

740
00:53:10,920 --> 00:53:13,640
Our brain has gotten bigger.

741
00:53:13,640 --> 00:53:15,640
That's just, you know, evolution.

742
00:53:15,640 --> 00:53:20,080
And as our face has gotten smaller, you know, the airways just was left over after everything

743
00:53:20,080 --> 00:53:21,080
else takes this place.

744
00:53:21,080 --> 00:53:27,400
You know, it's just kind of the second thought, but it's the number one thing we got to do.

745
00:53:27,400 --> 00:53:28,400
Right.

746
00:53:28,400 --> 00:53:29,400
Right.

747
00:53:29,400 --> 00:53:30,400
Absolutely.

748
00:53:30,400 --> 00:53:31,400
It's brilliant.

749
00:53:31,400 --> 00:53:36,160
It was really kind of interesting how it all developed that way.

750
00:53:36,160 --> 00:53:37,160
It really is.

751
00:53:37,160 --> 00:53:38,160
Yeah.

752
00:53:38,160 --> 00:53:45,240
And then here is the, if you want me to go, this is a statement by the ADA policy on

753
00:53:45,240 --> 00:53:48,800
the role of dentistry in the treatment of sleep-related breathing disorder.

754
00:53:48,800 --> 00:53:54,720
I was at this reference committee when they adopted this and they had, you know, a lot

755
00:53:54,720 --> 00:54:00,160
of people talking about it and a lot of discussion about it.

756
00:54:00,160 --> 00:54:05,400
There was one person there that, that actually was against it and he was the past president

757
00:54:05,400 --> 00:54:07,400
of the American Army sleep medicine.

758
00:54:07,400 --> 00:54:09,200
And here was his point about it.

759
00:54:09,200 --> 00:54:13,640
And in fact, he's, he was correct when what he said, even though it wasn't taken very

760
00:54:13,640 --> 00:54:20,040
well, but what he said is, you know, physicians have to go through a year residency to become

761
00:54:20,040 --> 00:54:23,680
a sleep physician, to call themselves a sleep physician.

762
00:54:23,680 --> 00:54:30,400
They have to go through a year's worth of study in a, in a field to be a sleep physician.

763
00:54:30,400 --> 00:54:36,040
Then just all they have to do is take two impressions on a bike registration and they're

764
00:54:36,040 --> 00:54:38,360
a dental sleep medicine practitioner.

765
00:54:38,360 --> 00:54:40,440
And that's probably not correct.

766
00:54:40,440 --> 00:54:44,480
He said, you know, y'all don't, you just, you just don't get the same.

767
00:54:44,480 --> 00:54:47,720
So this is where the American Academy of Dental Sleep Medicine comes in.

768
00:54:47,720 --> 00:54:51,040
So I'm in the process of trying to get more certified there.

769
00:54:51,040 --> 00:54:56,960
You need, you don't, just because your license allows you to take two impressions on a bike

770
00:54:56,960 --> 00:55:03,840
registration and send it off to a lab to get a sleep appliance, you better be careful because

771
00:55:03,840 --> 00:55:08,880
you're touching, you're putting your toe, not really your toe, you're jumping into the

772
00:55:08,880 --> 00:55:11,800
medical lake.

773
00:55:11,800 --> 00:55:14,360
Okay.

774
00:55:14,360 --> 00:55:17,560
You are putting yourself, you need to know what you're doing.

775
00:55:17,560 --> 00:55:24,120
You need to study and get qualified, at least qualified by the American Academy of Dental

776
00:55:24,120 --> 00:55:30,240
Sleep Medicine and other, there's AAPMD, there's a bunch of other places where you can get

777
00:55:30,240 --> 00:55:36,440
good, good information, but you need to know what you're doing just because you can take

778
00:55:36,440 --> 00:55:40,960
a bike, make an appliance and stick that in somebody.

779
00:55:40,960 --> 00:55:43,920
Do not do that and take them off the CPAP.

780
00:55:43,920 --> 00:55:45,400
You're sticking your toe in medicine.

781
00:55:45,400 --> 00:55:48,760
I never tell patients to get off CPAP.

782
00:55:48,760 --> 00:55:51,800
I get with the physician and I say, hey, this patient's come in.

783
00:55:51,800 --> 00:55:53,720
They seem like they intolerant.

784
00:55:53,720 --> 00:55:55,040
Can we work together?

785
00:55:55,040 --> 00:55:56,040
Yes.

786
00:55:56,040 --> 00:56:02,640
I need a physician written order stating that this patient is CPAP intolerant and I need,

787
00:56:02,640 --> 00:56:08,040
the physician recommends me making an appliance for sleep apnea.

788
00:56:08,040 --> 00:56:10,640
I look at myself as a DME provider.

789
00:56:10,640 --> 00:56:11,640
Okay.

790
00:56:11,640 --> 00:56:16,000
I'm an adherable medical equipment provider by the physician.

791
00:56:16,000 --> 00:56:24,640
You're covering yourself if you get that letter from the physician stating that he

792
00:56:24,640 --> 00:56:28,640
recommended sleep appliances.

793
00:56:28,640 --> 00:56:32,880
So basically this did pass and it passed, it was appropriate.

794
00:56:32,880 --> 00:56:37,640
He was just making a point that dentists need to be educated.

795
00:56:37,640 --> 00:56:40,640
Yeah, more educated on the sleep side.

796
00:56:40,640 --> 00:56:41,640
Yeah.

797
00:56:41,640 --> 00:56:42,640
Yeah.

798
00:56:42,640 --> 00:56:47,600
Especially look in children, even in adults that every dentist should screen for these

799
00:56:47,600 --> 00:56:48,600
things.

800
00:56:48,600 --> 00:56:49,600
Hang on.

801
00:56:49,600 --> 00:56:50,600
Let me close this.

802
00:56:50,600 --> 00:56:51,600
Hang on.

803
00:56:51,600 --> 00:57:00,600
Sorry about that.

804
00:57:00,600 --> 00:57:04,120
My room above vacuum started up.

805
00:57:04,120 --> 00:57:05,120
I could hear it.

806
00:57:05,120 --> 00:57:06,120
No worries.

807
00:57:06,120 --> 00:57:13,520
But anyway, especially in children, every child should be screened and there's a pediatric

808
00:57:13,520 --> 00:57:14,520
sleep questionnaire.

809
00:57:14,520 --> 00:57:15,520
There's another one.

810
00:57:15,520 --> 00:57:20,280
I'm going to show you in just a minute from the ADA that we're working on.

811
00:57:20,280 --> 00:57:22,960
But we need to look for the risk factors.

812
00:57:22,960 --> 00:57:26,000
We need to screen these kids up front, especially even in adults.

813
00:57:26,000 --> 00:57:27,000
Does this screen?

814
00:57:27,000 --> 00:57:28,000
Do you have snoring?

815
00:57:28,000 --> 00:57:29,000
Do you stop breathing?

816
00:57:29,000 --> 00:57:31,000
Do you have excessive daytime sleep?

817
00:57:31,000 --> 00:57:39,560
Do you tend to fall asleep at the wheel for adults or whatever?

818
00:57:39,560 --> 00:57:42,640
Some of these questionnaire are just way too long.

819
00:57:42,640 --> 00:57:46,160
I mean, they're like 20, 30, 40, 50 questions.

820
00:57:46,160 --> 00:57:51,600
I mean, we're trying to boil it down into five or six questions that are specific to

821
00:57:51,600 --> 00:57:55,680
the point, and at least just as a screening device.

822
00:57:55,680 --> 00:57:58,400
Right, right.

823
00:57:58,400 --> 00:58:02,800
If any NES answer lists, hey, further information.

824
00:58:02,800 --> 00:58:04,960
So basically that's what this is.

825
00:58:04,960 --> 00:58:09,780
This is the ADA Children's Dayway Screener Task Force.

826
00:58:09,780 --> 00:58:11,160
This is a screener.

827
00:58:11,160 --> 00:58:17,680
And so basically what we're trying to do is hear the question, does your child mouth

828
00:58:17,680 --> 00:58:22,360
breathe or lips apart while awake or asleep?

829
00:58:22,360 --> 00:58:26,680
While sleeping or napping, do they snore, noisy breathing, difficulty breathing, pausing

830
00:58:26,680 --> 00:58:31,400
or gasping for breath, neck extended, weird sleeping postures?

831
00:58:31,400 --> 00:58:35,040
Do they have dry mouth or headache when they wake up?

832
00:58:35,040 --> 00:58:36,720
We don't call it ADHD.

833
00:58:36,720 --> 00:58:41,760
We just say, do they have tiredness, behavioral, emotional issues?

834
00:58:41,760 --> 00:58:45,960
So basically any NES answer lists more information.

835
00:58:45,960 --> 00:58:51,280
Now what I've done is I've taken it over here and say, okay, they check yes.

836
00:58:51,280 --> 00:58:53,600
Now why did they check yes?

837
00:58:53,600 --> 00:58:56,280
Because most of them, they say, well, I don't know if their mouth would be, but yeah, their

838
00:58:56,280 --> 00:58:58,840
lips are apart all the time.

839
00:58:58,840 --> 00:59:01,800
And then the snoring, noisy breathing and whatnot.

840
00:59:01,800 --> 00:59:07,080
So what this does, it's just kind of, it's a real simple little questionnaire.

841
00:59:07,080 --> 00:59:09,160
We're going to get it validated.

842
00:59:09,160 --> 00:59:17,280
What we're looking for is to get, well, Candy knows about it and your group knows about what

843
00:59:17,280 --> 00:59:24,280
we're trying to do with Steve Carstensen and Jerry Simmons to get this thing validated

844
00:59:24,280 --> 00:59:31,240
by polysynography and what Jerry's using as a sleep image ring and try to validate this

845
00:59:31,240 --> 00:59:39,320
with objective data and then publish it and hopefully practitioners can easily use it.

846
00:59:39,320 --> 00:59:43,240
So NES answer lists its further information.

847
00:59:43,240 --> 00:59:48,800
And then it'll soon be available online, version, parents can fill it out online in

848
00:59:48,800 --> 00:59:49,800
a research portal.

849
00:59:49,800 --> 00:59:54,880
Wouldn't it be great if they also had like a PneF, you could send them a PneF or something

850
00:59:54,880 --> 00:59:58,320
like that or be in.

851
00:59:58,320 --> 01:00:04,360
So that's kind of the things that we're kind of looking at now.

852
01:00:04,360 --> 01:00:08,800
We can, they're my grandkids.

853
01:00:08,800 --> 01:00:15,000
I've actually fixed it to go in a little bit to go, she's cheering on one of the football

854
01:00:15,000 --> 01:00:16,000
teams.

855
01:00:16,000 --> 01:00:17,000
So we're heading to Birmingham.

856
01:00:17,000 --> 01:00:18,000
It seems like it.

857
01:00:18,000 --> 01:00:19,000
Oh, nice.

858
01:00:19,000 --> 01:00:20,000
Very good.

859
01:00:20,000 --> 01:00:21,000
So, okay.

860
01:00:21,000 --> 01:00:27,400
So at the end of every episode, I always like to turn the floor completely back over to

861
01:00:27,400 --> 01:00:34,160
our guests and just leave you with the final thoughts and words and it can be for our parents

862
01:00:34,160 --> 01:00:40,320
that listen or for our medical professionals or both that's completely up to you.

863
01:00:40,320 --> 01:00:41,320
Okay.

864
01:00:41,320 --> 01:00:49,080
Well, I think we need, we need the professionals whether it be physicians, dentists.

865
01:00:49,080 --> 01:00:51,240
Number one, we need them to work together.

866
01:00:51,240 --> 01:00:58,040
One reason I showed the book that we got at the first because it's about interdisciplinary

867
01:00:58,040 --> 01:01:00,480
management.

868
01:01:00,480 --> 01:01:01,880
Go see your ENT.

869
01:01:01,880 --> 01:01:08,360
The main, if you're an orthodontist or a dentist, track down medical professionals,

870
01:01:08,360 --> 01:01:10,720
the pediatricians.

871
01:01:10,720 --> 01:01:16,000
It may take you a little while to get people to listen to you, but look at the literature,

872
01:01:16,000 --> 01:01:24,000
try to get stuff out of there from Dr. Gemino and Stanford group Stanley Lu, Audrey Yoon,

873
01:01:24,000 --> 01:01:27,800
who's an orthodontist, out at Stanford.

874
01:01:27,800 --> 01:01:31,160
She done a lot of stuff with expansion and showing how all that works.

875
01:01:31,160 --> 01:01:35,760
Steve Carstensen, obviously with the general dental crowd.

876
01:01:35,760 --> 01:01:43,360
And then, you know, David Gazal, because I mean, they've got, you go get the literature

877
01:01:43,360 --> 01:01:46,640
that's the upper echelon literature.

878
01:01:46,640 --> 01:01:50,960
Don't just, I mean, there's a lot of other stuff out there, but you really need, if

879
01:01:50,960 --> 01:01:55,720
you're going to get their attention, you got to give them some people that they know or

880
01:01:55,720 --> 01:02:00,080
they've heard of, or at least they can go, okay, yeah, Dr. Gazal is the most prolific

881
01:02:00,080 --> 01:02:02,040
writer in the world on sleep at you.

882
01:02:02,040 --> 01:02:03,040
Okay.

883
01:02:03,040 --> 01:02:04,040
They're going to listen to it.

884
01:02:04,040 --> 01:02:07,640
People, the stuff out of Stanford, people are going to listen to.

885
01:02:07,640 --> 01:02:14,120
So, and we need to, you know, we need to get the information to the ENTs and the pediatricians

886
01:02:14,120 --> 01:02:25,000
and all that too of what we can do as dentists or orthodontists, what part we play in this,

887
01:02:25,000 --> 01:02:28,560
that we're going to adjunct to them is the way I look at it.

888
01:02:28,560 --> 01:02:33,360
I don't want to go into them and go, hey, here's all my stuff and beat my chest.

889
01:02:33,360 --> 01:02:36,000
I want to go, I want to learn from you.

890
01:02:36,000 --> 01:02:40,040
I want to learn more about airway and where you're coming from, but I want to give you

891
01:02:40,040 --> 01:02:45,640
some ideas on what the literature says about what we can do as far as expansion and this

892
01:02:45,640 --> 01:02:48,720
that and the other that can help that.

893
01:02:48,720 --> 01:02:56,600
But then we now need to get more like, you know, your group to, you know, as far as parents

894
01:02:56,600 --> 01:03:04,560
understanding this, because I'm getting referrals a lot from 100 miles away now, but just because

895
01:03:04,560 --> 01:03:09,520
of my reputation that's built up, I guess, that, hey, we look at airway now.

896
01:03:09,520 --> 01:03:13,760
We're not just looking at straight teeth, even though that's, we want straight teeth.

897
01:03:13,760 --> 01:03:14,920
We want pretty smiles.

898
01:03:14,920 --> 01:03:20,640
We want pretty faces, but we want the patient to have a good airway and I want to relate

899
01:03:20,640 --> 01:03:23,320
it to my airway focused kind of thing.

900
01:03:23,320 --> 01:03:28,360
So I think the parents need to just ask, you know, when they go see a pediatric dentist

901
01:03:28,360 --> 01:03:33,640
or orthodontist, just ask them how, how do they feel about airway?

902
01:03:33,640 --> 01:03:40,800
And if they go, oh, that's just a bunch of, you know, unfortunately find somebody else.

903
01:03:40,800 --> 01:03:46,400
But the problem now is you get on Facebook and all this other stuff and you read all

904
01:03:46,400 --> 01:03:51,920
this stuff and half of it's hearsay and everything.

905
01:03:51,920 --> 01:03:54,640
Stick to the experts and what they say, you got to get this.

906
01:03:54,640 --> 01:04:02,480
I mean, you know, but you know, I mean, Candy and her husband about their daughter, I mean,

907
01:04:02,480 --> 01:04:04,680
the, that's, that's impressive.

908
01:04:04,680 --> 01:04:11,120
I mean, that's an unbelievable what they did and what they had to go through to finally

909
01:04:11,120 --> 01:04:12,120
get some answers.

910
01:04:12,120 --> 01:04:19,880
Yeah, I think it's heavy on so proud to be a part of this because I mean, she's opening

911
01:04:19,880 --> 01:04:21,920
up, they're opening up a lot of eyes.

912
01:04:21,920 --> 01:04:26,200
The other group is opening up a lot of eyes to parents and it needs to be even more, you

913
01:04:26,200 --> 01:04:29,920
know, so they can.

914
01:04:29,920 --> 01:04:32,640
So the perhaps going to ask the right questions.

915
01:04:32,640 --> 01:04:33,640
Yep.

916
01:04:33,640 --> 01:04:34,640
And that's kind of our goal.

917
01:04:34,640 --> 01:04:35,640
That's why we're here.

918
01:04:35,640 --> 01:04:36,640
Yep.

919
01:04:36,640 --> 01:04:38,160
Well, thank you very much for being on the podcast today.

920
01:04:38,160 --> 01:04:39,160
I really appreciate it.

921
01:04:39,160 --> 01:04:40,160
Well, I appreciate it.

922
01:04:40,160 --> 01:04:41,160
Thank you so much.

923
01:04:41,160 --> 01:04:42,160
We glad to do it again.

924
01:04:42,160 --> 01:04:43,160
Absolutely.

925
01:04:43,160 --> 01:04:50,960
Thanks to today's guest, Dr. William Harrell for sharing his medical insights and each

926
01:04:50,960 --> 01:04:53,040
of you for listening to today's episode.

927
01:04:53,040 --> 01:04:57,040
If you're new to our podcast, please don't forget to subscribe.

928
01:04:57,040 --> 01:05:01,680
And if you enjoyed today's episode, leave us a review or comment telling us what you

929
01:05:01,680 --> 01:05:03,880
enjoyed most.

930
01:05:03,880 --> 01:05:07,680
You can stay connected with the Children's Airway First Foundation by following us on

931
01:05:07,680 --> 01:05:12,520
Instagram, Facebook, Twitter and LinkedIn.

932
01:05:12,520 --> 01:05:17,920
Parents can also join us via our Facebook Parents Support Group, the airway huddle, at facebook.com

933
01:05:17,920 --> 01:05:22,400
backslash groups backslash airway huddle.

934
01:05:22,400 --> 01:05:23,920
Looking for more from calf?

935
01:05:23,920 --> 01:05:26,720
Then check out our new YouTube channel.

936
01:05:26,720 --> 01:05:31,800
You can find a variety of informative original video content pieces as well as video recordings

937
01:05:31,800 --> 01:05:36,440
and excerpts from selected Airway First podcast episodes.

938
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If you'd like to be a guest or have an idea for an upcoming episode, shoot us a note via

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the contacts page on our website or send us an email directly at info at childrensairwayfirst.org.

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And finally, thanks to all the parents and medical professionals out there that are working

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to help make the lives of kids around the globe just a little bit better.

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Take care, stay safe and happy breathing everyone.