Hi everyone, and welcome to Airway First, a podcast from the Children's Airway First
Foundation.
I'm your host, Rebecca St. James.
On the show today, we have two guests, Dr. Kevin Boyd, a board-certified pediatric dentist
practicing from Chicago, Illinois, and Dr. Darius Legmani, the director of the Advocate Children's
Sleep Network at Advocate Children's Hospital in Chicago.
I'll include the bios of both of our guests in the show notes so that you can check out
all the great information about them, their background, and the work they do at your leisure.
I'm super excited about today's conversation.
Just want to get it out there.
I want to share it with everybody.
Without further ado, let's jump into my conversation with Dr. Darius Legmani and Dr. Kevin Boyd.
All right.
Thank you both for joining us today.
It's great to see you on a Friday afternoon.
Nice to see you too.
Really, I am so really looking forward to this.
Good.
Me too.
Just so everybody knows, we'll cover a few questions just for parents on sleep that I've
received.
But after that, the main focus today is to talk about collaboration on the two sides,
medical and dental, and the benefits, which is why you're both here.
One of the things that I got a question on, if you don't mind, I just made the Darius,
if you would just kind of elaborate on this, and I've heard you talk about this though.
Good sleepers, bad sleepers when it comes to children.
Can you just dispel that myth for us right out of the gate?
Yeah.
I mean, I think that there is a sense, and it goes beyond just sleep.
I think in all elements of life, we think that there are nice people and mean people.
We think that there are, you know, we just like to have dichotomies.
And we like to put people in a box and say, this is where they are.
I've met them.
You know, this is why there's so much emphasis on like first impressions and that sort of
thing, because you may never see them.
With children, it's different, right?
Because you're with them every day.
Every night is different.
And especially for young children, as they're growing and developing, they're different
every couple of weeks.
So I think to be able to step back from the idea of are they good sleepers or bad sleepers
and start to think about how are we nurturing this capacity to transition from the day to
nighttime, from wake to sleep.
Then we can think about it more like walking, right?
Like you wouldn't say that a baby is a good or a bad walker.
Right.
If they took a couple of steps and fell down, we wouldn't say, well, I guess that's it.
Right.
He's a bad walker.
Yeah.
You're going to be bad walkers and you never dance and never sing.
So if we think about it as a process, how are we fostering this process of transitioning
from the daytime to nighttime, it becomes easier.
And there's a likeness to it.
Right.
Now the parent can actually learn about how am I helping them wrap up the day?
What are the things that I can do to help them know that their day is done?
What are the physical signals and what are the mental things that we need to be able
to help them do?
So let's kind of build on that because one of the things that we talk to parents about
a great deal is when your kids are sleeping, go in there, listen to them, listen to the
sounds, are they snoring, are they restless, all these kinds of things.
As a parent, if I have a child that's a chronic habitual snore and I come into my airway-centric
dentist, how does this work?
Because a lot of what we're hearing, which is why we're here today, is a parent will
come in to a dentist and this refers to the pediatrician and we hear, no, don't worry
about it, they'll grow out of it, whatever the reasons are.
So let's talk a little bit about that.
A parent comes in to an airway-centric dentist, first, what can we expect?
One thing is airway-centric dentist, what does that mean?
Right.
So obviously, we know, you know, we know, you know.
So when I first started hanging out with Darius at then Children's Memorial Hospital, it's
called Lurie Children's now, but it was sort of like I learned all these things from him
and Stephen Sheldon and then I was like a new convert to a religion almost.
But I just sort of had to tell everybody about it and started doing a deep dive and then
I started getting invited to dental, you know, study clubs and meetings and I remember one
of the first ones that I talked at.
I brought up bedwetting and this older gentleman, kind of cantankerous, actually stood up, didn't
he raise his hand?
He goes, I thought this was a dental meeting.
What are you talking about bedwetting for?
He was getting ready to walk out and the person who invited me said, you know, Dr. Gillespie
or whoever you are, you know, just please listen to what Dr. Boyd has to say.
And then, you know, so and now it's so in the public domain that parents and, you know,
blogs and people come to my office, not anymore surprised as to why would you be asking me
all these questions?
I thought you were a dentist, you know, it's sort of like they come and they said, you
know, they not only get that they come preloaded.
I mean, it's just sort of like they know what's going on and they want to get to the bottom
of it.
So that's helped a lot for me.
And I don't really like the term airway centric dentist.
It's sort of I like it amongst us, but getting it out there, it's almost like an advertising
gimmick or something that, oh, you know, I'm different.
But I understand it.
I'm not passing judgment on people that use it.
I just, I don't like to call myself that.
I'm just a pediatric dentist to understand that sleep and breathing health is a component
of oral health.
And that's, you know, the American Dental Association now has a policy statement on
it.
So, you know, cavities, gum disease and airway, you know, they're all in the same plane.
Right.
So.
So hopefully it was, this does actually take a hold and it's hot in medical school or dental
school.
It could just be dentists because we know it's just part of what you look for.
Right.
Well, I never called myself a cavity centric dentist.
Right.
Or diet, a diet centric, because I am.
I mean, I studied nutrition before I became a dentist and I understand the dietary component
of, you know, sugar overconsumption.
That's what causes so much need for dentistry anymore.
Our whole dental industry is built upon sugar.
It just is whether people want to talk about it or not.
But so I don't know.
I like this change that attitude that we're not just putting out sugar fires all
day long, you know, but there's other things we can do for children.
And you know, that's one of the things we hear a lot though in our various podcasts
with guests.
Dentists at this point are kind of becoming the gatekeepers.
You know, you're seeing things in your, you're going past just like you said, just past cavities
or you're looking at, okay, is there airway blocked or are there other issues that we
need to see?
And then you've started this collaboration with Darius.
And let's talk about that a little bit because this is one of the things that calf really
is rallying for is we want this inclusive medical team.
You know, it's not just pediatricians over here, my own functional therapists here and
dentists here.
And we're looking at kids, particularly holistically.
Darius, why don't you talk a little bit about the evolution of our, you know, that one day
that you talk to me in, you know, in the telephone room back at the old children's.
That's where it all started.
You're the one who started it, not me.
We've been thinking a lot about this because the truth is that we don't see, there aren't
medical dental collaborations.
I can't name another dyad like this with Kevin and I.
I've been thinking a lot about it and is it the data is not strong enough?
Is it that people haven't been introduced to the concepts?
That's not it.
I mean, people really understand all that stuff.
I think the reality is that I think we have been underestimating the local nature of this,
how specific this kind of a collaboration has to be, that it's a person with a person.
Kevin and I are friends first.
And all of these collaborations, the way that we've been treating, I mean, if you look at
the way that Kevin's been practicing, it's changed over time.
If you look at the way that I've practiced it, it's changed over time.
It's not because Kevin said you should do XYZ.
We've been evolving towards each other because we have a common center.
He and I both care about the child.
When you keep the child at the center, if you move towards improving care or trying to understand
the reality of the child from these different perspectives, you see how we start to move
closer to each other.
If we were to try and move closer to each other without that common center, we're always
going to be necessarily somewhere we'll be further from the other.
I think that's...
Yeah, go ahead.
Well, do you remember when we first were introduced to each other?
And I found out that you did some of your training at Rush.
And I said, do you know so-and-so?
And you said, yes, he's a legend.
Do you remember who that person was?
I'll give you a hint.
He has no hair.
Did you know what I saw?
He just walked out of the room.
I'm in his office at Rush.
These are...
It's this level of...
The number of connect points that we had grew.
So I don't know how much of this is personality.
How much of this was just...
As soon as we met, Kevin and John Kelly and I, we just started having conversations because
we were interested.
We were trying to learn.
Right.
But the question isn't about learning anymore.
Like healthcare in general, it's not about learning.
It's distributing what you know.
So the fact that there aren't that many of people with this training makes this a scarce
resource so that people are fighting over access to this scarce resource.
And so then that drives up cost.
I think one of the things that we've recognized is one of the main barriers to this collaboration
is actually just culture in both these fields around money.
About how things are paid for.
Right.
Like in medicine, everything's paid through the insurance.
And doctors never have that conversation or their offices never have that conversation
with the patient.
Like it's always talk to your insurer.
Right.
But in dentistry, it's a different story.
Right.
And there's a service, this is something that's beyond what's covered with insurance.
And it's, oftentimes it's cash.
It's right out of pocket.
And what I've found is when I'm describing this to people, to physicians, they're like,
that's great.
This sounds really good.
And then they'll send a patient to be seen.
And when the price of the treatment comes back, that's the last referral that they'll
make to dentistry.
So this idea of like, how is it that we're also taking responsibility for the cost of
these procedures so that we can respect the expertise that goes into it.
We can respect the amount of money that a chair time is no joke.
Right.
Like if you can go in for cavities, like you have to be able to, we have to respect that.
But then how is it that in this collaboration, we're making it possible to take care of children
for less?
Kevin and I talk about this all the time.
It's like, this is part of why we started a course.
We started like training more dentists to be able to think systematically and act systematically
in reviewing x-rays, reviewing records.
And to be able to identify patients that for any, any dispassionate observer would be able
to look at the data and say, this is a kid that needs, that needs to be expanded.
So how does this work then with the, the, the two of you?
I mean, it is something that is reproducible.
I think the, I think what we've found, at least in this, in, in like the, these initial
efforts that we've made in terms of bringing people together to think, to think together
about this.
I think when we know that there are common questions and people learn how to, how to,
how to step back from this idea of, I need to convince you.
Because this is usually the tone of the, of the, of the conversation between like, like
two practitioners, it doesn't matter what, what kind of person.
Right.
Like, I remember when I started at advocate, we were just starting this sleep program and
went and met pediatricians and I'd say, this is what we're doing.
This is what we're like, we're running sleep studies.
And they're like, oh, so you're here to sell sleep studies.
I see.
I was like, well, I don't want you to do a sleep study.
I don't want any of your kids to have sleep studies.
But if they're snoring and they have sleep apnea, I do think that this, like, I don't
want to do a sleep study.
I think, so the question becomes less about like, I want you to do this and becomes more
about, well, what kid would you actually send for a sleep study?
Now we have a question and now we have a partnership around that question that we know serves that
child.
So to develop more collaborations that Kevin and I are having, we're trying to, to help
people actually develop those attitudes and those qualities, right?
The quality of like humility.
I don't know what the kid needs.
I'm not going to say every kid needs to be expanded.
Like some of them, and some of them will need to be expanded for a malocclusion, right?
So that's well in the, that's in the wheelhouse of a dentist.
Don't call me about that kid.
But if there's a kid that has that snoring, gasping has it as signs of an airway issue
and needs expansion, let's think about which kids, which kids to be expand.
And then one of the targets, like how like, like Kevin now is measuring like now has,
as you know, he's got the Bogue index.
He's got, he just sent me today slides of about 81 and 82 that just showed like the
different, the different changes in the, in the airway, the nasal pharynx, the oral pharynx
after palate expansion, right?
Developing that common language to be able to, so that we're, so we're comparing apples
to apples, right?
Otherwise you end up with like, I'm looking at tonsils and he's looking at the interval
or width and neither of us really know what we're talking about.
Like, like the other one's talking.
Right.
So then when it comes to implementing this in schools, is it more that we have to get
everyone trained on airway or this new collaborative approach or is it both?
I think we need to be able to think systematically and think and act systematically.
So the questions are common and very simple actually.
We don't need, I don't know that we need like an elaborate screen.
Because your child's small more than three nights a week.
Do they have trouble following asleep and staying asleep?
If the answer is no to both of those, you probably don't need to see a specialist.
Because even in asking the question, you've put it on the radar of the air.
And more and more pediatricians are seeing like ADHD, like in a type of activity or sign
of sleepiness as well as it could be ADHD.
So if as those three kind of, as we kind of socialize those questions, just help more
and more people know that these are important considerations when you're looking at a child.
Then I think we'll see, like more people will recognize the need for collaboration in this
regard.
I think what Darius and I have sort of, we've got a really good handle on it, is that, you
know, what does the face have to do, the face and jaws, what does that have to do with sleep
and breathing?
And it's like Darius knows as now that the, you know, the face is the front of the airway.
And you know, me, well, I'm a dentist, you deal with teeth and gums and, you know, the
palate, you know, what does that have to do with sleep and breathing?
And that is so obvious to both of us of how much I have learned about his world and how
he has taken the time to learn.
Like when I remember, well, he's, you know, John Kelly and I would go into a room with
one of his sleep patients that was referred there because the kid already has apnea and
maybe already had a sleep study or is going to get one.
And John, he would have us come and look.
So what about the mouth?
What's going on?
Well, he's crowded.
Crowdy.
What do you mean?
Crowdy.
What does that mean?
And the kind of, I don't know, glib comment that I always say is physicians, if they had
one lecture in medical school on dentistry, they either missed it or they forgot everything
they learned.
And, you know, so they're, they're new, but that's a good thing because they're a blank
slate, a tabla ratha.
You can, and somebody like Darius who's curious and hungry to inform his own science with
my science, it's magic what can happen when we're both collaborating on a single child
and parents, parents can feel it, they appreciate it.
And we want to teach other people how to do it.
And yes, you can package this and you can, you can show it to other people who want to
learn.
But if they don't want to learn, like Darius said, if they don't want to learn, you know,
that that's they, if they're not curious about this and it's a waste of time.
So we're very, we'll talk to anybody, but if it's a big group, we're lucky to have three
or four people out of 100 that will come up and they want more.
It's just, you know, but it's changing.
It's more and more people are really wanting to know about this.
And it's what you're going to dentistry.
I don't know what Darius is finding more physicians that want to know more about dentistry, but
I know a lot of dentists that want to know, you know, about sleep medicine.
Then it's groups like Airway Health Solutions or the Sleep Education Consortium.
They're both trying to reach, I say both sides.
I don't want it to sound like, you know, it's a worrying fraction here, but, you know, the
medical and dental, they're, they're focused on trying to bring in this collaboration.
I think theoretically it's very clear and it's easy, right?
You just say we just need, we just need medicine and dentistry to collaborate.
But I think we've underestimated just the difference, like the distance between the
two and it really traces back to like the early 1900s, like where like that, where educational
standards were put in place.
And that was where you really saw this divide where like the ACGME like, like, like the
standards for medical education and the standards for dental education became separate.
And the collaborations between the two also then became separate.
And then, you know, a date, a date that's a point of departure and it might be coincidental.
I don't know if it's cause and effect, but it's World War II, 1940.
I mean, I have so much literature and Darius and I, I've shared it with him.
I'm, I'm publishing on it and I'm putting in, I'm putting in references in my bibliographies
that, that in the, you know, not too long ago, they would have been rejected, but the,
the information like an invited commentaries or, or book chapters that I write, the information
is so compelling that the publishers will include references from 1912 that highlight
the collaboration between what they called right now, just they, we call them ENTs now.
And you know, dentists and orthodontists, it wasn't just orthodontists that did this.
It was, it was family dentists or what we call primary care dentists now.
This was on, there was so much communication between medicine and dentistry relative to
the comorbidity of malocclusion underdeveloped jaws and faces and airways and, you know,
the symptoms that they had.
And then what the, the old fashioned language that Dr. Bo gave DDS and the early 1900s used
was expanding the deciduous arch to gain nasal respiratory advantage.
That's how he described it.
And he was a physician who almost limited his practice to kids under six years old.
And, and you know, that to me was so enlightening when I discovered his body of work and it's
all evidence, you know, it's evidence-based.
It's, it's backed up by, by controlled observational trials that are published that, that all over
the place.
And Dr. Bo expanded his first kids seven years after the end of the civil war.
That's when he started expanding kids because he just, he had a hunch.
They're using vulcanized rubber.
Vulcanized rubber instead of acrylic, you bet.
So these are, I think these are the things that like to return to that would not be like,
it's not going to be a natural, like it took, it took a hundred years to get rid of that
collaboration.
It would take time to bring it back.
I think the key point is, because like, when we come back to like the question of cost,
like Kevin and I, when we're initially collaborated, like Kevin just ate the cost of those kids,
like, like, of care.
Like these are, most of the kids that we take care of in academic centers are public aid
kids.
They don't like, they don't have, they're not going to be able to come up with the amount
of money that often costs to do this.
So Kevin, it's not that he would do it absolutely for free because there has to be buy-in and
others, but this, but he was willing to work with them.
I think that willingness to sacrifice, I think is really important, right?
Because this is time and energy that nobody has extra, right?
Nobody has extra time.
Right.
The amount of like, I mean, if you like, Kevin will tell you, like our big breakthroughs,
like our, like on beaches after talks or in the pool before them, you know, like, it
takes a lot of time and just being like, I wonder why this is like this.
What if we looked at it from this perspective and then just a dedication to time, like,
okay, let's try this for a little while and see where we go.
But those are, I mean, really, this is like, it's mutual support.
It's encouragement, right?
Like we're, when we're getting in touch, we're, we're asking real questions.
We're challenging each other.
We're saying, tell me, why would you do that?
And then what else, what can we do to make this more accessible?
Often to our detriment.
This kind of collaboration.
Yeah.
I'm sorry.
I was going to say this kind of collaboration can go just beyond sleep medicine and dentistry.
I mean, you guys could truly expand this, right?
Yeah.
That's the, like the question is like, I mean, when you talk about like, we're lucky enough
to have Jody Walker, like as a my functional therapist in our area, right?
Who just as a person is remarkable.
And it's sort of to be able to spend time with like, when we get, when we get together and
we're talking about patients, we're not limiting it to like, are you going to send them to
me or not?
Right?
It's like, right?
Like how many more kids like this make their be?
How are we going to make this available to kids that maybe don't have these needs?
If we were to work in a school, how are we going to fund this?
This is where like lessons that we've learned from cystic fibrosis or we learn from the
from the polio vaccine become really important.
Right?
Like if there are foundations that are interested in supporting, supporting the growth of this
work with the expansion of access to, to providers that currently is scarce, what cystic fibrosis
did is they said, is there an area that has access to these patients?
And what do they need to continue their work or to advance their work?
Do they need a nurse, a nurse coordinator?
Do they need a fellow to help cover the rest of their work so that they can, so that they
can get, that it came more attention to this?
But I think what they did is they supported the grassroots collaborations in service to
the patients.
Right?
I don't know.
I know there's been a lot of efforts are changing curriculum, medical and dental curriculum.
I don't know that that's going to lead the way.
Right?
Medical like when we take our boards, we know that you don't write the answer of what you
would do.
Right?
You write the answer for what they're looking for, which is usually maybe five years, right?
But we're actually.
You're listening to Airway First with today's guests, Dr. Darius Legmani and Dr. Kevin Boyd.
You can find out more about the Children's Airway First Foundation and our mission to
fix before six on our website at children'sairwayfirst.org.
The CAF website offers tons of great resources for both parents and medical professionals,
including videos, blogs, recommended reading, comprehensive medical research, podcasts, and
so much more.
We also encourage parents to join the Airway Huddle, our Facebook support group, which
was created for parents of children with Airway and sleep related issues.
You can access the Airway Huddle support group at facebook.com backslashgroups backslashairwayhuddle.
As a reminder, this podcast and the opinions expressed here are not a medical diagnosis.
If you suspect your child might have an airway issue, contact your pediatric airway dentist
or pediatrician.
And now let's jump back into our conversation with today's guests, Dr. Darius Legmani and
Dr. Kevin Boyd.
Yeah, it's interesting to kind of piggyback on that because in a meeting that Kevin and
I were in last weekend, I guess it was, it was talked about that the moms, the moms are
going to be the catalyst for this.
Yeah, I mean, is that, yeah?
100%.
But where do they, like what venue do moms have to be able to demonstrate that, that
like what they've learned to support each other, to be able to, right?
Like the Cystic Vibrosis Foundation started was started by parents of kids with Cystic
Vibrosis.
Right?
And they just started collecting data on what they were doing and what their child had
and what tests were being done.
And they started to registry, but that registry was focused on the number of patients, right?
The last thing we want is for every dentist to say, I took a class in dental school and
now I'm an airway centered dentist.
Right?
Like this is, this is like we are very early in our process.
And when you're an early in a process that's this complex, you have to move systematically.
You have to be able to document what you're doing in a systematic way.
And you have to be, you're interested more in the questions than the answers, right?
You don't take an answer that you got from an initial effort and say, now everyone should
do X.
Right?
We say, oh, that's how you saw it.
How did you see it?
What did you do?
So I think this is why, like really what we're, what we're moving from is, is a, the two fields
that like in healthcare in general, but dentistry and medicine certainly where you have certification
to do something.
And then you go out and you do it, but certification isn't, it's not sufficient.
I'm certified as a surgeon, but if I operated, someone's in trouble.
You know, I'm not, I'm not, I shouldn't be operating.
But if I was to say like, so rather than being focused on certification, we should be thinking
about who has access to what we want to learn about.
And truthfully, parents have the access to what we want to learn about.
How did you expand them every day?
What's it like to try and expand a four year old?
How did you explain to your, to your, to your spouse why your kid who was speaking fine
yesterday is having a little trouble today?
How long is that going to last with this pallet expander in place?
Now, how does Darius know how to be so eloquent because he's got his own children and he's
watched all these things.
It's not that I told him this happens or he, he's, he's experienced it with his own
kid and you know, it really adds depth to your opinion, Darius, about this.
I, I've never, I've never even thought about it.
You like, let's say boy, listen to him.
Oh, that's right.
His kids, he's got three kids.
Right.
I mean, but there's, I think what we've seen is healthcare has always been about the knower
telling somebody what to do.
In medicine, we are the knowers, right?
We have the, the robes and everything, right?
It's almost like a priesthood, right?
You come in, you tell me, you confess your sins.
I'll tell you what to do.
And then you, and then you go and you either do it or you don't come back to me.
Right.
So, but we have to flip that, right?
Physicians and dentists.
We are, we're at the service of our patients.
Right.
We, we are in a position to actually give voice to what we're hearing from our, from
these parents.
So I think, like to be able to do that most effectively, again, like it's a, it's a super
local process, right?
In Chicago, we have a unique opportunity because we, because we're here, but if we started
to bring together the parents of the kids that, that they've had this treatment, we
would learn a ton.
Right.
But where's like, there's no mechanism for that because Kevin's busy expanding them
and I'm busy.
I'm busy.
I don't like, right.
But that's, I think the organization and the structure that would be most effective
is getting those stories from the parents.
What did you see?
How did it affect them?
How far did you expand them?
What are some tricks that you did to be able to help them?
Yeah, absolutely.
And I think also this is why it's so important we always tell parents advocate for your child.
Right.
Because you know your child best.
Exactly.
Yeah.
I know the medical term, but you know your child can't sleep or you know your child's
having trouble swallowing or whatever it is.
Yeah.
And if they don't know, we don't argue with them.
Right.
Like if, if Kevin sees a kid and they say, are they snoring?
Like, yeah, snoring where it's not too bad.
Then he just says, well, look at these questions, take them home.
And then this is what is very, very, very, as the, as the, what does he call it?
The private eye?
Like the, where he says, just observe your kid.
Here's a list of things.
Just observe your kid.
And we'll talk again in a couple of months.
We'll talk in six months.
And then when they come back, they're like, yeah, you're right.
Every time I watch him, he's wide open.
And I'm like, yeah, he is snoring.
He's restless.
And you know, our job is not to convince people that there's a problem with the child.
I think that's another, another element of the, of the approach that's historically
been taken that I think is really making it hard is there's an alarmist kind of like,
if you don't do something tonight, your child's going to lose brain cells.
We have to step back from that because it's, it's frankly too frightening for parents to
think that they've been ignoring their child as their brain is, is, you know, after being,
you know, I had a consultation today on a seven, I think a seven year old that, you
know, the radiology report said that the airway is 80% occluded in the area of the ad noids
and nasopharynx.
And you know, the parents are very astute.
They just moved here, but they've been all over the country.
And you know, I brought up the term habitual chronic mouth breathing is dangerous.
And you know, they was like, is that a little extreme?
And I go, well, you know what, I, that's one thing I don't soft sell.
And then I explained to them and then I showed the x-rays and how important it is for nasally
inspired air to be cleaned and humidified and release nitric oxide, you know, all the
basics.
And at the end of the consultation, you know, the, the, the father was just sort of like,
wow, we've been to UCSF and we've been to, I don't know, various insiders.
And I've been to different institutions and nobody has really said he won't grow out of
it.
He'll just grow out of it.
And it's like, I said, well, you know what, nobody knows your child and nobody has an
instinct for your child like his parents.
And if you guys don't think this is right and like I'm maybe, but I, I don't soft sell
that part of it, but I might not be the right practice for you.
And this isn't for everybody.
Your instinct has to tell you this is something I need to know more about or the, the, I need
more information and that's fine.
And I'll just say, look, he's seven.
I, you know, if you want to wait a year, I'd rather see him at eight than 10.
And I really do.
I want parents to rely on their own instincts for their own child because the kid will pick
up on.
And even if one parent is in doubt, it's not going to work, you know, because the child
gets confused and it, and it can affect their ability to want to do, you know, to be compliant
and do the treatment.
I feel really strongly about that.
There's a, there's a, there's a shift then I don't know if it's happening in a public
position.
I know I'm definitely having this shift.
And maybe it's just that time, like the time of my career or what, but like, whatever,
what I realized is like initially I thought of myself like a detective.
Okay.
You know, like when I'm visiting with someone I'm listening and I'm like, tell me more about
this and what about this?
And I'm doing a physical exam and looking at it and I piece it together and I'm like,
I think I know what you have.
This is the diagnosis.
This is the treatment.
Let's see how it goes.
You come back and then we'll say, Oh, thank you, doctor.
I think increasingly what I'm realizing is I'm actually the sketch artists.
They're describing what's happening.
And I'm trying to piece it together.
I'm saying, okay, okay.
Tell me more about this part.
And then they're telling me and I'm writing it down.
I said, tell me more about this.
What about this piece here?
And they tell me because I know kind of like, I need to ask more questions about the eyes.
I need them to describe the ears and the hairstyle.
And that's, this is what's going to help them recognize what's going on.
Then when I reflect at the end of the, of the visit, I can say this is why I was asking
these questions.
And then after, after when they know, if they know why I'm asking those questions, then they'll
know the importance of their answers.
And then they'll say, Oh, okay, that's why.
So then they're not surprised at the end of the diagnosis or of the treatment recommendations.
All of that clicks for them because I've been able to explain like the scientific principles
involved as well as allowing them to fully explain what's happening with their child.
And they recognize their child in the principles and they can figure out what the next steps
are.
Yeah.
And that says a parent, that's helpful because we don't get it.
We don't understand where we're told your child has this go do this.
Well, unless you're one of those people that goes and digs and digs, you just take it at
face value and move on.
All right.
And so I think one of the, one of the things that Kevin and I really bad to do, especially
with the people that were in these initial cohorts was to say, look, these are the questions
that when you ask them, they help people understand.
These are the concepts that when you explain them, people start to understand.
I mean, and it's not 100.
It's like 10 things.
If you tell them, like, like when you say like, you know, prehistoric skulls, they all
had straight teeth and they didn't end their wisdom teeth fit.
And they didn't have cavities and there were no dentists.
People always like, really?
Like, yeah, straight teeth, no cavities, everything was great.
And the wisdom teeth fit.
So the skulls are changing shape.
It's like, it looks like the skulls are changing shape.
And this is what we're seeing.
It's a why.
And then what's the impact, right?
All that stuff, like when you provide someone with that background, then they're joining
you and looking at the child, right?
They're the most important.
Right.
They're the most important kind of element of this system.
They're the frontline workers.
We are working, we're supporting them to think clearly about their child.
Yeah, and that makes sense.
So usually at the end of a podcast, I turn it over to the guest.
And in this case, it's the guests.
For you guys, just to have the final thought or, you know, message for parents or medical
providers.
And then, please go first.
I like that.
Well, I just, I learned something new every time what he reflects on what we've been doing
over the last 10, 12 years.
And I just like to build on whatever he says.
I think the most important thing at this stage in the development of the field, at this stage
in terms of medical and dental collaboration.
And the most important thing is to be able to clearly state what are the questions that
we're asking together?
And what is the systematic way that we're pursuing answers to them?
Are we thinking and acting systematically in determining which kid needs what kind of
treatment?
The better we are at actually saying those things, the easier it'll be for people that
are interested in those same questions to join us.
And I think that really it's going to have to be at the level of people.
We're going to have to be able to say, we're going to start with these two people and then
maybe some of their friends.
And how do we support spaces where some of their friends can come together and to think
together, right?
I don't mean in terms of talks.
But when you have a speaker, you've limited the knowledge of the room to that one person.
Right, because it's one direction.
Yeah, it's one person's experience.
If you have a room full of providers that take care of sleep patients, why wouldn't you
want to hear from all of them?
That's what you have, you would multiply the number of insights you'd have access to.
So I think that having a systematic approach in that way of saying, I think Chicago's right
for it.
Kevin and I are going to be speaking at a symposium that we're organizing in this way,
where there would be sort of talks from an ENT, Kevin will share, the other sleep provider
that will share, and that'll follow a case.
And then afterwards there'll be a lunch where we'll get to hear from everybody.
I think this idea of actually allowing for reciprocity from other providers, from the
people that are participating, and from the parents.
There needs to be a space, like an interest in the parent voice.
What's been your experience, not as a patient, what's your experience as the parent taking
care of this child that is undergoing this process?
Dr. Boyd?
So I think what I'd like to leave people with is, if you think something's wrong, and what
you're hearing from trusted, respected, deservedly, wonderful healthcare providers that you've
had confidence in for yourself and for your child, when they say, well, relax, things will
get better, they'll grow out of it.
And that doesn't make sense to you, or there's just a little bell ring in there, a little
voice in your head that says, maybe not, listen to that voice.
And like today I was telling you, I had a consultation with these parents about this
child who's got some significant issues.
And the father was at the end of, I took him through everything.
He just said, well, everyone told us that he'd grow out of it, and they were right.
His snoring did after a few years.
It went away.
And so I didn't want to say, well, what happened in those few years?
We don't know.
And there's something called the chat study from Children's Hospital of Philadelphia,
where they did this watchful waiting with kids who had large adenoids, and let's not
do surgery.
Let's just see if the snoring and the mouth breathing gets better.
And sometimes it does.
And often it will.
But what's going on while the body is trying to come up with compensations for that?
I don't need to get into that with people.
It's their child.
And I just look, I'm here if you need me.
But that's the advice I would give.
And also, especially in the realm of orthodontics, is that the orthodontic association by age
seven, that's when a child should be seen for the first exam.
Or it's a diagnostic exam.
And that's like a kid with a nearsightedness.
And four, well, you know, ophthalmologists want to see kids at two before age two.
And they correct vision if there's a problem, because it will worsen and it could lead to
neurological problems.
What does that sound like?
Malocclusion, if a jaw is too narrow, and if it's too far back, and it's too long or
too short, say at the age of three, four, five years old, it 100% will persist.
That's been known for 100 years.
Skeletal deficiency, maldevelopment of the craniofacial respiratory complex does not
self-correct.
It cannot self-correct.
It will only become more complex.
So that's what people need to understand.
That is a medically defensible statement that I just made.
It's a scientifically supportable statement.
And that's what I'd like to leave people with.
I think that those, I think as more of us are able to kind of speak to those kind of,
those kind of, the data around those things, I think it'll be easier to have those one-to-one
conversations.
I really don't envy institutions.
I don't envy the Academy of Sleep Medicine.
I don't envy the Academy of Pediatric Dentistry or the ADA or even foundations like CAP or
because the role of the institutions, it can't be to raise awareness because there's nowhere
for them to go.
We don't have, and I think this is a part of why pediatricians, when someone comes and
says my kid is snoring, pediatricians are like, you'll probably be okay because there
are only 300 pediatric sleep doctors in the country.
There aren't that many labs.
Like every time we open a bed, like there's a three-month wait time for it.
It just builds up to that.
The need far outstrips the capacity to respond.
So what is it that an institution does?
I think increasingly, I think the lessons from cystic fibrosis and polio come in.
I think we have to be able to figure out how do we support the groups that are doing this
work so that they have time to systematize their approach.
Then you raise up a number of locations around the country where people are doing this.
You just collect the data.
And then systematically, like cystic fibrosis, they used to just put out, they used to say,
these are all the centers.
This is the FBV-1 for each center.
I said, this one's better than this one.
Why is that?
So then they're thinking about, okay, how do we support more people?
The efforts of cystic fibrosis, like overtime, the commitment to long-term effort and supporting
work at the grassroots, now we have cure for CF.
This was a huge accomplishment.
But I think we're not going to have, it's not going to be one thing that changes and
then everything gets better.
It's going to take time.
So I think what Darius brings up about supply and demand is that the demand for sleep-related
services is starting to be in the public domain.
The demand is rising, but the supply of competent, qualified providers is minimal.
And it's the same thing that, I mean, recently I got a letter of referral of a six-year-old
who had malocclusion and sleep disorder, breathing comorbidity, and this orthodontist said, Kevin,
I'm downstate.
This family is three hours from you.
However, I'm aware of your work.
I'm aware of your successes.
I know this kid needs what you can do.
I unfortunately am not comfortable treating this child, but I, they said they'd be willing
to try.
This is an orthodontist.
I framed him who said, look, this is out of my purview.
I've not had much luck treating this, but I know it needs treatment.
And he sent this kid.
So let's see more that is still very rare.
But Darius and I are so determined to get more people competent and qualified so that
we can solve problems before they, you know, he has to see him.
He's responsible for 200,000 children in greater Chicago.
He can't do all that.
So he's ultimately selfish.
He's trying to create an army that can help parents solve these problems.
He's a valiant warrior.
Yeah, the rate-living step at this point isn't necessarily the skills.
It's the qualities and the attitudes.
Treating somebody that when they're doing it would be able to say, like, I actually don't
know.
I don't know how to do this.
Like for that orthodontist, if they had a relationship with Kevin where they could say,
like, okay, well, let's look at the films together.
Like, all right, now let's look and see what are our goals here.
And then maybe send them and I can get them started and you can follow them.
But we don't practice like that.
Right?
Interinstitutional collaboration doesn't happen.
Right?
Like, because like in medical world, it's because your insurance requires you to go to this
hospital or this hospital.
And in dentistry, every clinic is its own business.
Right?
So why would I help?
Like Kevin is an outlier.
He's like, I'll help you take great care of your kids.
I don't want you to, I don't like, you don't have to, I'm not going to build them for that.
I want to like send me the name of this.
I'll help.
But that's a quality.
That's a quality.
That's a like, that's humility.
That's that's courage.
That's dedication to the good of the child, which we need more of.
Well, I can't thank you both enough for being on the podcast today.
I really appreciate it.
Thanks, Rebecca.
You do yourself professional.
You just great questions and you really understand the depth of the problem.
And well, that's rewarding for me and Darius because, you know, the information that, that
you sort of extract out of us, it's going to help a lot of people.
But your skill is very much appreciated.
Thank you.
I appreciate it.
Thanks again to today's guests, Dr. Darius Likmani and Dr. Kevin Boyd for sharing their
medical insight and each of you for listening to today's episode.
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