Children’s Airways Present a Challenge and Opportunity for Dental Professionals

Steve Carstensen, DDS


The current COVID-19 pandemic has put a particular focus on the importance of breathing and lung function. For not yet determined reasons, children are at lower risk of COVID-19 than older people.

That said, while we don’t have a scientific basis for saying that fixing children’s airways will improve their resistance to virus decades later, it does make empiric sense that not struggling to breathe while they are developing will help them be healthier adults all around.

An Example

So why should dentists be so interested in how children breathe? Let’s consider a common scenario for a family that includes a kid who struggles to breathe well during sleep.

The child is difficult to wake in the morning for school. Often, there are reports from teachers about behavioral problems. It’s difficult for the child to focus on tasks or engage with other children in an appropriate way. And, sadly for everyone, there is no possibility of sleepaway fun because of embarrassing bedwetting.

The family’s frustration builds with unhelpful visits with the pediatrician. Busy with rooms full of sick kids, the nurses and doctor have little time to ask questions about sleep and breathing. And since they’ve received limited education about the issue in professional school, they may be unaware of what to ask in the first place.

Large tonsils might be addressed with a typical platitude: “They’ll grow out of it.” Other symptoms might trigger common, familiar therapy recommendations like medication or referrals to medical specialists without airway training.

An appointment with an airway-aware dental hygienist can change everything. While the hygienist is updating the health history, the family is asked new questions: “Does your child make breathing sounds during sleep?” and “Does your child ever mouth breathe?”

The parent is curious, giving the trained hygienist an opportunity to share how positive answers to key questions indicate the child is at risk of compromised breathing during the night.

Screening Tools

Airway screening tools for dental professionals have been around for several years. Some are validated with scientific rigor, but most dental teams aren’t using them daily. I’m very proud of our ADA for putting serious effort into resources for treating children’s airways. It has convened meetings of experts, hosted a series of CE events for dental teams, and passed a resolution to create a new screener tool to be used in every dental office.

This important work is ongoing. Dentists will see the results of the Children’s Airway Screener Taskforce (CAST), headed by neurologist and sleep specialist Jerald Simmons, MD, in the coming months as the screener it created passes validation testing.

The best screening tools today are the BEARS Sleep Screening Tool, which focuses on five major sleep domains including bedtime issues, excessive daytime sleepiness, night awakenings, regularity and duration of sleep, and snoring, and the Pediatric Sleep Questionnaire. Both of these tools are readily found online. But if the child is found to be at risk, dental professionals must have an answer for the family better than what they heard from the pediatrician.

Dentists and dental hygienists are trained to diagnose all sorts of oral cavity conditions. For airway issues, it simply means looking past the mouth and thinking about what else might be affected. After all, dentistry is defined by the ADA as having responsibility for the oral cavity, adjacent and associated structures, and their effect on the rest of the body.

When a 4-year-old is developing large tonsils and you notice mouth breathing, it’s totally appropriate to discuss allergies and habits with the family. Correcting bad habits in young kids might shrink those tonsils and help them avoid surgery! How’s that for prevention? Those bright-red gums around maxillary incisors? Think that’s all about toothbrushing? It’s likely connected to mouth breathing again.

There is something among young children that no other discipline of medicine other than dentists can diagnose. Can you guess what it is? It’s not the obvious—decay and gingivitis. It’s not crooked teeth, bruxism, or temporomandibular joint problems either.

Craniofacial Respiratory Complex

Think about these words: craniofacial respiratory complex (CFRC). Coined by one of the top leaders in this area, pediatric dentist Kevin Boyd, DDS, MS, of Chicago, this term encompasses the new challenge for dentistry, the new opportunity, and the way for every dental professional to add to their patients’ health and practice success.

Dentists are the only medical professionals who are trained to evaluate and treat CFRC. Only we are capable of identifying a child who is not growing the lower third of the face in the amount and direction to reach maturity with an optimum airway size. Because CFRC includes soft tissue, we can also identify and treat myofunctional problems such as poor swallowing habits. Many dental hygienists are being trained in myofunctional therapy.

But wait. Sleep-related breathing disorders are diagnosed by physicians, right? Identifying obstructive sleep apnea (OSA) requires testing, doesn’t it? Don’t we need sleep physicians to direct therapy? All these statements are true, currently, for adults. True for kids, also, if what we focus on is diagnosing symptoms. If the child has too small an airway because mouth breathing has created a narrow maxilla and a retrognathic mandible, is OSA a primary diagnosis or a symptom of another condition?

True, we treat symptoms in medicine all the time. But is there any logic that allows symptom management in a child while ignoring the underlying etiology? If we don’t recognize and set the growth pattern on a better path, that airway is going to stay inadequate for life!

I treat a lot of 60-year-olds with cardiovascular disease resulting from decades of stress, in part because they have struggled to breathe every night for decades. I think if we only knew 55 years ago what we know now, they’d be much healthier.

What’s a dentist to do? Right now, today, there are online and in-person courses for diagnosing problems with CFRC and applying functional therapy to help children grow in the right direction with the right habits.

Take advantage of CE offerings from organized dentistry associations and events, such as the Chicago Dental Society’s annual Midwinter Meeting in Chicago, where I recently presented to attendees on this subject.

Join social media learning groups. If you are an orthodontist or pediatric dentist, push your organization to embrace children’s airway issues and partner with the ADA and other industry associations advocating for policies that change how we take care of kids.

Dental professionals do prevention better than any other medical provider. It’s our turn now to prevent the child in our chair today from suffering a lifetime of medical compromise by creating an optimum airway and breathing pattern.

Dr. Carstensen has treated sleep apnea and snoring in Bellevue, Washington, since 1988. He’s the consultant to the ADA for sleep-related breathing disorders. He also has trained at UCLA’s Mini-Residency in Sleep and is a Diplomate of the American Board of Dental Sleep Medicine. He lectures internationally, directs sleep education at Airway Technologies and the Pankey Institute, and is a guest lecturer at Spear Education and the University of the Pacific and Louisiana State dental schools, in addition to advising other sleep-related manufacturers. He served as a board member, secretary-treasurer, and president-elect of the American Association of Dental Sleep Medicine. From 2014 to 2019, he was editor of Dental Sleep Practice Magazine. In 2019, Quintessence published A Clinician’s Handbook of Dental Sleep Medicine, written with a coauthor. He is a Fellow with the Academy of General Dentistry, American College of Dentistry, and International College of Dentistry as well.

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