by Cappy C. Snider, RDH
Becoming an advocate for a child, especially one's own, is a task that most mothers feel just comes with the territory. When a mother knows her child has an issue that needs to be addressed, the frustration of trying to have these issues treated can become very discouraging. Recently, my daughter and I finally discovered a group of medical and dental professionals working together that ended a four-year-long struggle to solve her problem.
From infancy our daughter snored. At first it just sounded like heavy breathing, but as she grew older, a definite snore developed. The pediatrician noticed early on what large tonsils she had and felt this was part of the problem. He assured me that she would "grow out of it" as she got older. Fortunately, she was a healthy child that did not suffer from many ear infections or throat infections, so the tonsil issue was set aside. The snoring continued to worsen.
When she was four-years-old, an otolaryngologist, or ear, nose, and throat surgeon (ENT), was consulted. His first questions to me were of her illness history: Did she have frequent bouts of ear infections, throat infections, or difficulty eating or sleeping? Although she did snore loudly, she did not have problems with waking during the night, and had certainly not had more than a few ear and throat infections up to that point. In his eyes, she was a normal, growing and healthy child with large tonsils that "should shrink" as she got older.
I decided to get another opinion. The second ENT had the same opinions and answers for me, although in both instances I asked specifically that the issue of her labored breathing be addressed. The consensus of both doctors was that it would hopefully improve in time. I was beginning to feel as if I did not have a valid concern, after all. Maybe I was overreacting since this was my child. I had been told that my daughter was not "sick enough" to warrant surgery at this time, so I decided to take the doctors' advice and wait. After all, they were the professionals. Somehow I had forgotten that I, too, was a professional who would become educated about this very issue of airway obstruction.
The next few years passed with comments from relatives about how loudly my daughter breathed when she slept. The comments became routine with the family members, until my 10-year-old nephew decided it was time to make a few jokes about it to her! It brought her to tears, and my emotions and determination were renewed. I had also noticed that she was a chronic mouth-breather and had to position her tongue forward just to open her airway. This tongue-thrust habit was taking its toll on how her dentition was forming.
At one routine prophy appointment, it was revealed just how much damage had been done. My employer, Dr. Brooke Porter, noticed how my daughter's tongue position had caused her to develop an anterior open bite. Her palate and upper arch were restricted and narrow. Dr. Porter pointed out to me the orthodontic issues that we faced as a direct result of my daughter's airway obstruction and the failure to treat it earlier. I had spent 13 years in a periodontal practice, and was not aware at that time about how these two issues affected each other. I had spent most of my professional time exploring periodontal issues, and had lost touch with pediatric and orthodontic issues. I was now very interested.
Our next step was a visit to the orthodontist. The beginning of that visit found me with many questions to be answered. I had done my homework by visiting several Web sites dealing with airway obstructions as well as current guidelines and criteria for removal of tonsillar tissue. They also included information about treatments for correction of a tongue thrust.
That visit proved to be disappointing. Although the orthodontist was very thorough with his exam and had a treatment plan in place fairly quickly, the airway issue was not addressed. I questioned why we should address the orthodontic issues if the cause of the problem was not addressed also? Why correct the dentition only to have the tongue-thrust issue destroy all that work? I had discovered in doing my research on the subject that a recommendation from an orthodontist for removal of the tonsils would carry some weight when consulting an ENT. I asked about this and the response was to definitely pursue this avenue, but "good luck" finding anyone to do the tonsillectomy.
Since there was not a lot of support, we decided to move on. I was beginning to see a much larger problem that not only affected my family, but probably many others who had sought help for a more complicated dental/medical issue. Why did these two branches of medicine have such distant communication? The dental and medical communities seemed to have a separation in their treatment modalities.
The last time I checked, the mouth was attached to the body (to borrow a friend's phrase). It seemed to me that each specialty viewed these two parts of the whole person as separate entities. My husband knew our daughter's health was the issue and supported me in every way, but he was beginning to tease me about going to many doctors until one gave me the answer I wanted to hear!
A subsequent conversation with my employer about the situation led to another referral to a colleague of hers, Dr. Tamara Miller. Dr. Miller is an orthodontist with whom Dr. Porter had developed a good rapport. Dr. Porter thought that Dr. Miller's more recent graduation date would allow her to have more current information regarding chronic airway obstruction. She thought Dr. Miller would have a different perspective on the treatment of the orthodontic problems associated with it. Dr. Porter's recommendation would prove to be just what my daughter and I were looking for! This referral would secure Dr. Porter's place as the first member of my daughter's treatment Dream Team!
The day of our appointment with Dr. Miller finally arrived. When all the requisite paperwork had been filled out, we were escorted to the exam and consultation room. Dr. Miller arrived shortly and examined my daughter. She was very thorough and listened patiently as I voiced my concerns. We discussed the options of treatment and both agreed that the sooner we could get started, the better.
She then said that she had some information that would help me. She excused herself to go look for the information, and my daughter was taken to another area for further diagnostic records. I sat patiently in the reception area. A few moments later, Dr. Miller approached me and gave me a card with the names of a group of ENTs that she and a colleague worked with in cases such as my daughter's. I was elated — a dental professional who saw the value of treating the whole person and could refer me to a medical professional who shared the same view. With all our knowledge of how the health of the oral cavity affects the health of the body, why is this type of working relationship such a rarity? I decided that Dr. Miller would become Dream Team member two.
Our next appointment was to meet Dr. Charles Railsback, the ENT that was to become Dream Team member three. Upon our meeting, I immediately liked this doctor's easy-going manner and his way of thoroughly answering my many questions.
He agreed that an airway obstruction was present and also asked me if my daughter had difficulty hearing. That was a new one to me! Just recently, my husband had commented that he thought our daughter couldn't hear us well. I had just chalked it up to being a stubborn child who was getting pretty good at tuning out my requests to clean up her room. We often had to repeat ourselves a few times for her to respond to us, or go to the room where she was so she could see us talking to her. Thankful for a husband who was obviously more observant than me, I relayed his concerns to Dr. Railsback. The doctor ordered a more sophisticated hearing test to see if there was indeed a hearing loss.
The tests showed that our daughter was functioning with a 40-decibel loss of her hearing! She had always done well in school and compensated by looking at who was talking, watching for eye contact, and asking "what?" a lot. She said that she could understand what was said to her, it just sounded muffled. The doctor explained that due to the large size of the tonsils and adenoid tissue, the fluid could not drain through the Eustachian tubes as it normally would. Instead of air surrounding the middle bones of the ear, there was fluid. This fluid dampens the vibrations of these bones and conductive hearing loss is the result. He explained that this was an occurrence in approximately 50 percent of airway obstruction cases.
I was more concerned than ever for my daughter's health! As a mother, I felt as if I had let her down in some way. Maybe if I had pursued this issue when she was younger, this would not have happened. All the usual doubts of my skill as my child's advocate surfaced and I could not help feeling like I had failed her in some way. I quickly decided to shake off this mantle of guilt and be grateful for having finally found the doctors who recognized my daughter's issues and had the answers with which to treat them.
Dr. Railsback and his nurse went over the necessary surgical procedures that day and it was decided that my daughter would have a tonsillectomy, adenoidectomy, and a myringotomy — the procedure in which the eardrum is opened and the fluid is drained. Ear tubes are often placed at that time, but the doctor felt that this would be unnecessary. He assured me that after the adenoids were removed, the fluid from the ears would drain normally. Her hearing would then slowly return to normal.
The doctor told me that he seldom receives direct referrals for help in correcting malocclusion due to upper airway obstruction. He stated that the majority of his referrals came from pediatricians and pediatric dentists. Their primary reason for referral was the presence of obstructive sleep apnea in the patient. These cases result in surgery nearly 100 percent of the time.
That's when I asked him why it had taken so long to finally have my daughter's problems addressed. His opinion was that the common thinking among the medical community that the tonsils will just shrink over time is flawed due to the fact that the development of the dentition is occurring at the same time the airway is obstructed. By the time the airway obstruction may be relieved a bit by tissue shrinkage, the damage to the occlusion has already been done and has to be attacked by drastic orthodontic measures. I expressed my appreciation to him for his treatment of our daughter and also in validating that I had not been crazy after all!
The surgery was set to take place a few days after Christmas to take advantage of my daughter's school break and my work break for recovery time. We were directed to a pediatric outpatient facility and they even offered a pre-surgical tour to familiarize my daughter with their procedures. This was to be her first surgical experience and the staff did everything they could to ease her concerns and answer any questions she (and I) had.
Shortly after surgery we had the best affirmation of all from our daughter. Dr. Railsback had placed some local anesthetic in her throat to keep her comfortable awhile longer after leaving the surgery center. He wanted us to be able to administer the prescribed pain medication at home before the anesthetic wore off. This afforded my daughter a small window of comfort before the reality of the recovery period set in.
She asked me to come close to her. I put my face near hers thinking she was going to tell me something, but instead she just closed her mouth and drew a deep breath through her nose. A big smile crossed her face and she said, "I've never been able to breathe through my nose before, and now look!" She was so excited about the simple act of breathing through her nose!
Once at home the recovery went well. We played games, watched a few videos and she kept asking me to turn down the television. Sounds seemed so much louder to her almost immediately.
Since the surgery, the orthodontic phase of her treatment has proceeded full steam ahead. She is the proud wearer of enough hardware to make any home improvement store employee envious! We are also monitoring the tongue-thrust habit, which has almost completely resolved itself due to her improved breathing ability. I have explored different therapies available to treat any residual problems with this habit, such as speech therapy and myofunctional therapy, which is the establishment of correct functional activities of the tongue, lips and mandible. This allows for normal growth and development of these structures.
This experience has caused me to focus on my pediatric patients differently now. Having learned this information for personal reasons has made me a better hygienist and a more effective advocate for my patients. Hygienists are on the front lines of detecting an airway obstruction in our patients. We can educate the patient and the patient's parents about our findings. We can educate our employers on the long-term effects of upper airway obstruction on the dentition. We can also facilitate referrals by encouraging our employers to open a dialogue with the appropriate specialists.
Acknowledging these professionals with follow-up communication can only encourage a better relationship between our profession and theirs. Taking the time to send a letter or note not only reinforces the importance of better communication but also can raise the profile of hygienists as valued members of the healthcare team. We benefit, but most importantly, our patients benefit.
This experience has enabled me to see how dental and medical professionals can complement one another when mutual respect and knowledge is shared. How very privileged we all are when we are able to get optimal treatment from our own personal health-care Dream Team.Dental signs and symptoms that could indicate an upper airway obstruction:
• Upper dental arch is constricted compared to the lower arch. This is from the tongue and other facial muscles not maintaining the proper position to exert pressure on the developing arches.
• An anterior open-bite. This is a direct result of mouth breathing and a tongue-thrust habit. It causes the jaws to grow in a more vertical direction.
• Flattened cheekbones.
• Gingival inflammation in the maxillary anterior area, even if oral hygiene is good.
• Inability or difficulty breathing through the nose when the mouth is closed.
Author's Note: I would like to thank Drs. Brooke Porter, Tamara Miller, and Charles Railsback for the information they each contributed to this article, and, more importantly, the contribution they have made in my daughter's health.
Cappy C. Snider, RDH, graduated from Tarrant County College in 1987. She has practiced continually for the past 15 years. Snider currently practices clinical dental hygiene with Dr. Brooke Porter of Azle Dental Care in Azle, Texas. She may be reached by email at [email protected].