Pediatric Airway in a Dental Setting

Diana Batoon, DMD
pediatric airway


Have you ever wondered if you slept well the previous night? You might have thought the dream you had was misplaced or related to the prior day’s events. For a child, sleeping may not have been given a second thought. The physical traits and behavior of a young child can tell many stories in a roundabout way and give insight to what really is going on. The growth and development of a child and his or her ability to thrive can be hindered by poor sleep quality and deficient release of important hormones. There are hormones that regulate temperature, hydration, and oxygen intake and promote the health of our brains and organs. 

From a parent’s perspective, if his or her child has a medical condition, such as asthma or recurrent illness, he or she will pay attention to the sleep pattern of his or her child. Sometimes the acts of sleepwalking and sleep talking may bring about concern by the parent. Yet a great deal of parents do not even know that nightmares and anxiety may be the result of sleep fragmentation. Poor sleep can then lead to behavior issues, anxiety, and food sensitivities.1

Poor sleep can be directly related to a weak immune system or gut biome deficiencies. However, we categorize this dilemma of poor sleep as sleep fragmentation or sleep-related beathing disorders. There may be other pieces of this puzzle, whether anatomical or neuromuscular, that are related or contributory. A small diameter in the airway can contribute to decreased airflow or flow limitation. How can we evaluate a small or restricted airway?  

As a parent, would you ever suspect that a gummy smile or crooked teeth could tell you a story about your child’s sleep pattern? Today, there is evolving research that supports that poor sleep can be a result of crooked teeth or improper jaw relationships. You may ask, “What constitutes whether the face is beautiful or misaligned?” Many factors play into this type of evaluation. As an airway-focused dentist, I ask many questions about total sleep time, oral habits, and breathing patterns.

Does your child get sick often? Does your child have a history of multiple ear infections and/or a history of respiratory issues such as asthma or allergies? Do you witness your child breathing loudly when sleeping or posturing his or her mouth open when asleep? Does he or she exhibit bed-wetting issues? These are just a few examples of questions that parents should ask themselves, and if they don’t know the answers, they perhaps should observe their child sleeping when he or she is fast asleep.

Finding a team of knowledgeable and open healthcare providers is the first step in ensuring proper treatment for a child who may have sleep-related breathing and airway concerns. Just like any other health concern, screening a child and knowing what to do next is an important step in ensuring the proper growth and development of a child’s face, jaw, and teeth.

Specifically, when a child struggles with nasal breathing, he or she may exhibit behavioral issues and oral habits such as thumb-sucking, fidgeting, or tics. Some children may struggle with speech, resulting from other conditions, such as a tongue-tie or narrow arch.

Some children who may have struggled with being breastfed or bottle-fed can develop a reverse swallow or become chronic mouth-breathers. It is possible that these children who struggle with bed-wetting or concentrating for long periods of time or present with anxiety lack strong coping mechanisms.2

These are the same children who favor certain textures of food or are bothered by the inside tags of their T-shirts. The tongue should rest like a thumbprint against the palate of the maxilla, allowing a child to use his or her nose properly. If nasal breathing becomes part of daytime breathing, proper growth of the upper and lower jaws can ensue.

Anatomical Considerations

The 8 bones of the cranium and 14 bones of the face all play a role in the growth and development of the child. The skull permanently fuses at around 20 to 24 months. The human brain is 90% fully grown at age 5. For females, puberty usually ends at 15 to 17 years of age, whereas for males, puberty ends at 16 to 17 years old. As the child is still growing, the opportunity to expand the upper and lower jaws is there, and it is the most opportune time to make room for expansion of all the teeth and space for the tongue.

Oral habits such as tongue thrusting and thumb- or finger-sucking can affect a child’s bite and eruption pattern of permanent teeth. Sometimes an anterior open bite occurs, and this, in turn, affects the size of the upper and lower jaws. A narrow or crowded jaw can affect the appearance of the face and lips. The face should appear balanced and symmetrical from the forehead to the bottom of the chin. In addition, nutrition and diet are factors that can contribute to the growth and development of the head and surrounding structures.

Finally, a healthy sleep pattern is one of the important pillars of health. Ultimately, a child’s open airway will support a healthy growth pattern and a healthy life.

Clinical Example

I offer a clinical example here to help make the point. My patient, a 10-year-old boy, was diagnosed with ADD/ADHD and was attending a charter school because he struggled in the public school system. He had a lot of anxiety and struggled with behavioral issues, according to his teachers. He quivered at the movements of my hands whenever we did an exam and had a strong gag reflex. He stayed away from certain textures of food and had speech therapy as a younger child.

His front teeth were crowded, and it took a while for him to get all his permanent teeth. The idea of brushing his teeth twice a day didn’t seem appealing to him. His mother was concerned about his sleep pattern, which was filled with bad habits of playing too much Xbox and tossing and turning in bed frequently. We checked his sleep quality with a cardiac pulmonary coupling unit, and his sleep quality was poor. In fact, the test ranked his sleep as having multiple episodes of sleep fragmentation.

In his study results, he constantly tossed and turned. Three-dimensional imaging established that his facial and jaw relationships were small and that his tonsils were a little large for a child his size. The imaging did allow me to take some initial measurements and compare them to measurements taken after we expanded his upper jaw. In addition, we diagnosed a tongue-tie. Turns out, when he was born, he was not breastfed, and mom stated she could not produce enough milk for him, so he was bottle-fed after birth until the age of 2.

Could his tongue have contributed to the clinical presentation of his jaws, teeth, and face?3 The resounding answer is yes. There is current research to support that oral restrictions or a tongue can affect the growth of both the upper and lower jaw.4 It can affect the primary functions of feeding and swallowing. We used a functional appliance to help with the habit of mouth breathing and tongue thrusting and then expanded his upper arch until we could see his upper teeth overlapping his lower arch.

When the lower teeth began to upright themselves into a better bite, the tongue space improved. His sleep pattern and his concentration in school improved because his sleep architecture improved. He did not get in trouble as much, and his teachers and parents felt he was making better decisions. At 12 years old, he has assimilated into the normal mainstream of a public middle school, and the use of electronics has been restricted to weekend use.

As a healthcare provider, you feel grateful for these results, not just because the child is improving in academics but also because the trajectory of a healthy growth and development pattern is being given the chance to succeed. A healthy airway can translate to many positive outcomes, one of which is improved nasal breathing. The benefits of nasal breathing include increased airflow to arteries, veins and nerves; increased oxygen uptake and circulation; and improved lung volume.

What We Can Do

As healthcare providers in dentistry, there are many tools to help us identify and screen adults and children. Screening and assessing our patients is important, but understanding the next steps to receiving a medical diagnosis such as a sleep-related breathing disorder is key to ensuring steps toward optimum health. Imagine the difference that a dental community can make if we paid attention to every patient’s airway.

The answer doesn’t always have to come back positive for sleep apnea, but it is a starting point in ruling out a condition that has many moving pieces. That next step may involve a medical provider such as a sleep physician, an ENT, or an allergist. The link between one’s oral and systemic conditions is an integral part of understanding why some people are susceptible to medical conditions such as diabetes, obesity, cardiovascular disease, and sleep apnea.

Let’s focus just a little more on children in the dental chair and look past the enamel and dentin. It just might change the trajectory of their overall health.


1. Duraccio KM, Krietsch KN, Chardon ML, et al. Poor sleep and adolescent obesity risk: a narrative review of potential mechanisms. Adolesc Health Med Ther. 2019 Sep 9;10:117-130. doi: 10.2147/AHMT.S219594. 

2. Kesintha A, Rampal L, Sherina MS, et al. Prevalence and predictors of poor sleep quality among secondary school students in Gombak District, Selangor. Med J Malaysia. 2018 Feb;73(1):31-40. 

3. Zaghi S, Valcu-Pinkerton S, Jabara M, et al. Lingual frenuloplasty with myofunctional therapy: exploring safety and efficacy in 348 cases. Laryngoscope Investig Otolaryngol. 2019 Aug 26;4(5):489-496. doi: 10.1002/lio2.297.

4. Yoon A, Abdelwahab M, Liu S, et al. Impact of rapid palatal expansion on the internal nasal valve and obstructive nasal symptoms in children. Sleep Breath. 2021 Jun;25(2):1019-1027. doi: 10.1007/s11325-020-02140-y. Epub 2020 Jul 9.


Dr. Batoon completed her undergraduate degree in microbiology at the University of California, San Diego, and earned her doctorate degree at Tufts University School of Dental Medicine. She then completed a GPR residency at the VA Hospital in Loma Linda, Calif. She has been in private practice since 1999 and maintains a general dentistry practice and a separate practice devoted to sleep, TMD, and cranio-facial dentistry. She can be reached at the websites or at 

Disclosure: Dr. Batoon reports no disclosures.