The Story Behind the Pathway

It seems like every dental course, every dental magazine, and every dental podcast is talking about sleep and airway.

It’s everywhere!

Big time, historically famous, post-graduate dental CE programs, particularly those focused on restorative dentistry, didn’t even have sleep apnea on their radar 10 years ago, blaming bruxism on 2nd molar interferences and insufficient canine guidance. Now evaluation of the airway is a primary focus and of greatest concern when treatment planning worn dentition cases and complex care.

Ten years ago there was 1 University-based mini-residency in Dental Sleep Medicine. Now there are 5.

Sleep and airway information is EVERYWHERE!

And now with all of us and our staff concerned about creating aerosols, unknown new standards, and costly infection control, and some patients being scared to return to the dentist, helping people with sleep apnea seems more appealing than ever!

You may feel like you’re drowning in a sea of information, and you’re searching for a lifeboat labeled WHAT TO DO!

In adults, implementation isn’t easy, but at least there is a fairly clear pathway.

  1. Screen the patient for a possible airway issue
  2. Refer for objective testing
  3. If the patient is found to have sleep apnea, then they are referred for treatment (CPAP, oral appliance therapy, or surgery).

Of course, the devil is in the details… but overall, the adult pathway is pretty well defined, and very similar from state to state and country to country.

But what about with kids?

With children, the pathway is far less distinct.

The steps are pretty much the same… screening, referring/working with medical colleagues, objective testing, and treatment when indicated.

But HOW to do all these things is VERY different in children and can be SUPER FRUSTRATING for all involved!

Before the covid crisis hit I was attending “grand rounds” for our local sleep community.

The presentation was given by a pediatric sleep doctor and was super interesting (regarding the use of a high flow nasal cannula, without supplemental oxygen, for children with OSA… cool stuff!).

At one point in the presentation, the doctor was reviewing various options in the treatment of children with OSA and he mentioned palatal expansion.

He then said, “I wish we had more communication and collaboration with our dental colleagues with regard to this treatment option.”

So I marched right up after he finished and introduced myself as a dentist that was very interested in “more communication and collaboration.”

I then said, “doctor, could you perhaps send me a list of pediatricians that I could refer patients to who will understand the need for further evaluation and won’t just blow off the patient/parent by saying ‘those tonsils don’t look that big to me.’”

His eyes looked up and away as he thought about my question.

And then he said, “I really can’t think of anyone in particular.”

So I followed up with, “so would I be able to refer patients directly to you?”

And he said that would be great.

The problem is that he’s at a children’s hospital, the sleep lab capacity is limited, and getting a patient in takes a long time.

A VERY LONG TIME.

The BIG POINT that I want to make by sharing this story is that the pediatric sleep doctor couldn’t think of A SINGLE NAME of a pediatrician that he thought I could refer patients to.

YIKES!

So that means, in my area, if any dentist was to screen a child in their practice for being at risk for sleep apnea, and encourage mom to get the child into their pediatrician to bring it up, MOST LIKELY the pediatrician will say that it’s nothing to worry about! Unless the child is “lucky enough” to have golf ball sized tonsils kissing at the back of their throat.

Sound familiar?

This is one of the most frustrating aspects of trying to help these kids!

You know they need help, but how do you get them to the next step?

And there’s a BIG difference with children versus adults…

Time is of the essence!

The 40-year-old fat guy who has been snoring since he was 18 also needs help, and the sooner the better.

But the 6-year-old who is still wearing a pull-up to bed, struggling with reading, and starting to feel like there is something wrong with him NEEDS YOUR HELP NOW!

I once heard a well-known speaker on sleep apnea ask the audience “how many nights without proper oxygenation of the developing brain would be too many nights for your child?”

Of course, the answer is “1 night would be too many.”

BUT YOU KNOW ALL THIS!

You know how important it is! You know how critical growth and development are to the long-term health and happiness of a child.

BUT WHERE DO YOU START?

This is, unfortunately, where the frustration level gets turned up to level 1000+!!!!

It seems like everyone talks about sleep and airway in children, but very few provide any guidance on what to do and how to do it.

The only people who seem to be providing any guidance at all happen to also be selling some device, functional appliance, advanced education course, special exercises, laser, etc., etc., etc.

These things are all great, and we’re lucky to have them, but when a program is industry-driven it always makes me question if I’m getting the whole story or just the story that supports whatever is being sold as the solution.

I went to a multi-day course once on a specific type of therapy that could be used in anyone but was more focused on children (bec