“The Best Decision I Ever Made”

by Kalli Hale, DDS, MPH, D.ABDSM, D. ABSB

There are few times in life that a decision you make completely disrupts your path. As a new dentist the idea of working in dental sleep medicine was so far off my radar it may have well not existed. As my journey in studying obstructive sleep apnea began, my plan was to focus on adults. I never planned to treat children and knew nothing about pediatric sleep related breathing disorders (SRBDs) – but all of that changed when I heard an extraordinary educator speak of this “fringe” aspect of healthcare known as pediatric sleep dentistry.

In 2019, I discovered that what I had been taught in dental school regarding pediatric snoring, bruxism, and tethered-oral-tissues was entirely wrong. Imagine my astonishment learning that a child’s inability to breathe well through their nose could be the root cause for their crowded teeth? I have some regrets in my early career, but the biggest was telling a parent their child’s snoring was normal and they would “grow out of it”. Little did I know that the snoring child would turn into a snoring adult…

The Best Decision I Ever Made? Foundation First, Teeth Second

I never thought I would be able to help children suffering from ailments such as ADHD, bedwetting, snoring, bruxism, mouth breathing, etc. by learning airway dentistry. I’m “just a dentist” clouded my thoughts many times as I’ve shared in previous articles, but little did I know there was no profession more qualified to treat these children by making sure their jaw growth/development was on track. I had no training in pediatric expansion, nor understood that the way our orthodontics was done in our early years would affect the way we breathed as an adult. The association between crowded teeth and SRBDs is the missing link for dentists and parents. I feel such guilt for the number of children I saw with major crowding that I recommended “waiting until the baby teeth fell out,” when I should have asked some very basic sleep questions. Our children deserve the best – imagine how you will change generations of kids by improving their breathing and sleep quality, which will affect every aspect of how they grow! It is heartbreaking that so many children are put on psychotropic medications for ADHD when there is a 50% chance they are in fact just tired.¹³ Given there is evidence that patients’ apnea hypopnea index (AHI) improves after dental arch expansion, and the correlation between underdeveloped jaws and ADHD, we must sleep test children suspected of ADHD!^9,12 The long-term consequences of medicating children for ADHD are not well understood and there are published variations in the adherence of the clinical guidelines for managing this condition across the globe.^10,11 We have to do better, and we can start by insisting on a sleep study for these kids.

Another regret? Ignoring pediatric bruxism. One of the most common parasomnias in children is sleep bruxism!¹ The evidence for this has been published supporting the correlation between sleep bruxism and OSA.² Although most of these studies were conducted in adult patients,² sleep bruxism has been reported to be more common in children than in adults.³ The watch and wait methods taught in dental schools have little merit given the lack of evidence of spontaneous resolution, and the vast evidence in its correlation to OSA.⁴ The dental community needs to reevaluate their approach to bruxism in children. Because bruxism is associated with OSA, a first-line question in the medical history intake form should be whether parents have noticed teeth grinding in their child, so that the child can be properly screened and referred to an airway dentist.^18,33

What about big tonsils, is removal the “cure” for pediatric OSA? While tonsillectomy is the most common surgery performed in children, with sleep-disordered breathing being the most frequent indication for this procedure,⁵ the cure rate for OSA after tonsillectomy hovers around 51%.^5,6 Many children with OSA are not helped by clearing the “breathing straw” through removal of the tonsils and adenoids, often because underdeveloped dental arches and a weak tongue that continues to fall back/obstruct the airway are the true cause of their apneas. Furthermore, adenotonsillectomy can be associated with numerous risks and sequelae, including severe postoperative pain, bleeding, dehydration, complications of general anesthesia, and potential long-term adverse effects.^5,7 Luckily, thanks to work from Dr. Audrey Yoon, we now have evidence that maxillary expansion shrinks the tonsil/adenoid tissue statistically significantly!¹⁴

So What Did I Do? I Started Redirecting My Patients’ Breathing & Musculature

When I learned about the guided growth appliances for children, my initial reaction was hesitation. Would they wear it? Could this habit-corrector monoblock appliance really do all the things I had seen in lectures? How can you get a 3-year-old child to wear something removable? If this is the first time you are reading about a pediatric nighttime oral appliance, I implore you to learn more. The craniofacial and dental changes that over 1,000 of my own personal patients have achieved deserves to put it on the map. When a child is actively growing, especially between the ages of 3-9 years old, these appliances are gold. If you can reestablish nasal breathing, improve tongue posture, and let that tongue do its job (i.e., expand the palate), you will change the trajectory of a child’s growth and development. While my own hesitation from self-inflicted bias delayed my offering this treatment to thousands of children, DON’T LET IT BE YOUR EXCUSE. Our own biases and misconceptions about the efficacy of these nighttime appliances have serious consequences for our pediatric patients.

The dental community needs to reevaluate their mindset and approach to pediatric OSA.

As my journey progressed, I was also empowered to learn about myofunctional therapy. I now have oral myofunctional therapists (OMT’s) in all my practices as it has proven to be a critical component in the progress of my pediatric and adult sleep cases. Tongue posture should be evaluated in patients with mouth-breathing. In an individual with appropriate tongue posture, the tongue can sit at the roof of the mouth; correct tongue posture helps ensure proper palate development, promoting palatal expansion naturally in children. Among patients who are chronic mouth-breathers, the tongue posture tends to be low and arch development is compromised.⁸

Pediatric sleep medicine is currently plagued by the inefficiencies caused by long wait times for PSG studies, while patients’ parents or caregivers frequently are given little to no information on treatment options for OSA other than CPAP therapy and surgery. Dental arch expansion, frenectomy, myofunctional therapy, and even simple interventions such as nasal hygiene are not commonly discussed with patients’ parents. Children with sleep-disordered breathing suffer not only from the complications and long-term effects of OSA, but from comorbidities linked to OSA such as ADHD and enuresis, which can be easily mitigated by proper airway management. The use of simple dental appliances for arch expansion and other noninvasive and nonpharmacologic interventions that promote proper oxygenation while preserving important lymphatic tissues can be life-changing for these children. The dental community needs to reevaluate their mindset and approach to pediatric OSA. It is the responsibility of orthodontists, general dentists, and pediatric dentists to examine the new research surrounding maxillary expansion and interceptive orthodontics to treat OSA and sleep-disordered breathing, so that the current epidemic of sleep disorders can be prevented for generations to come.

To avoid being misunderstood, please note I am not implying every patient is a candidate for a simple, removable, habit corrector appliance. My practice is full of fixed expander treatments, complex appliances, and clear aligners. The decision you must make as to which appliance to use will be your biggest challenge when you start. But rest assured you will not find a more powerful, minimally invasive tool, like the guided growth appliances for your little patients. It is my hope that this information motivates you to pick a tool to learn about, so you can save more children.

A special thanks to those who have helped me become the airway dentist I am today: Drs. Jay & Tracy Elliott, Dr. Kyle Hale, Dr. Ben Miraglia, Mrs. RaeAnn Byrnes, and my teams at New Teeth Dental & ToothPillow.