Content Dam Rdh En Articles Print Volume 37 Issue 12 Content Dam The Airways In Our Pediatric Patients Leftcolumn Article Thumbnailimage File

The airways in our pediatric patients

Dec. 1, 2017
Shirley Gutkowski, RDH, shares the story of two pediatric patients who visited an oral-systemic dental practice. One patient received a fluoride varnish application, while the other’s misbehavior and oral health led to a suspicion of obstructive sleep apnea and several referrals.
Adding orthodontic, orofacial therapy evaluations for challenging kids

By Shirley Gutkowski, RDH, BSDH

At the morning huddle, I learned a family was up for a quick in-and-out visit—prophy, fluoride, exam—boom! Addison came in with her mother and little brother in tow. Her smile was disrupted by six missing front teeth, but she didn’t seem bothered. As if she worked there, Addison confidently led the way down the hall to treatment room No. 8. Each step she took was measured to get the most bounce out of her corkscrew curls, her arms moving to get the best swish out of her skirt with its tulle scaffolding. On her feet were sparkling ruby red Mary Janes.

Addison is a big girl of six, and her brother, Mason, is four years old and challenging. In sharp contrast to his big sister, the chart notes for Mason commented repeatedly on behavior, even charging out behavior management codes. He smelled of diaper, his mouth hung open, he exhibited adenoid facies, his lips were fire-engine red from licking, and when he wasn’t a tornado (for example, sitting on his mother’s lap), he looked comatose. Caroline, the children’s mother, looked exhausted. Fortunately, imaging was not on the schedule.

As expected, Addison’s mouth was a shining example of good dental hygiene. The six-year molars were in, sealants would be indicated in six months, and—“Mason, please don’t shake the dental chair.” Why isn’t this mother managing this kid? He dropped like a sack of potatoes and wailed.

“Mason, stop that,” Caroline scolded. Mason stopped bawling to jam his foot against the chair pedestal and push himself hard into the toe space of the cabinet. The wail pitch changed as Caroline picked him up. She parted his hair looking for blood as the hollering continued.

Meanwhile, Addison was having her teeth polished with mint paste and enjoying the attention. “What flavor of fluoride would you like?” I asked.

“Hmmm, you had a raspberry flavor that wasn’t very good the last time I was here.” Addison lifted her sunglasses to ponder the fluoride flavor she’d have on her teeth for the 24 hours to follow. “What other flavors do you have?”

“Well, we have a new kind this time. What do you think of strawberry?”

Addison’s dress rustled as she leaned up on her elbow, peering into the drawer. “Any other new flavors? Mint?”

“The company that makes our new fluoride varnish is GC America. It’s pretty advanced because it has minerals in it to help heal the teeth.”

“Oh,” Addison responded as she resettled herself in the chair.

Caroline chimed in, Mason on her lap quietly sucking his thumb, “How long do they have to wait until they can eat after the fluoride, 30 minutes? Addison, that means no treat until we get home.”

Addison resituated herself in the chair, putting the glasses back on her face. “I don’t need a treat,” she said, as if she were 30 years old instead of six. Caroline’s expression was unreadable as she held the now-sleeping Mason on her lap. His eyes had rolled back in his head, and his eyelids quivered, revealing a wet white line. His thumb was still in his mouth.

During the exam, Mason was adjusting the glasses, moving the napkin, putting his hands behind his head, telling Addison not to touch this or that, and looking at the floor to see where his shoe landed after it fell off his foot.

“You don’t have to wait with fluoride varnish; the 30 minutes is for the foam or gel application. With fluoride varnish, you get to take a 24-hour break from brushing and flossing. Just avoid foods that are hot in temperature or crunchy.”

Mason snorted himself awake, his eyes wide with surprise. Then, in a single movement, he leapt off his mother’s lap, looking at the room as if he’d landed on Mars.

After a hasty cleanup and room turnaround, it was Mason’s turn. The concerns about his behavior made me wonder about his oral health and airway. Caroline coaxed him into the chair with promises and threats. I offered an array of toothbrushes from which he could pick and asked him which flavor of prophy paste he wanted. Then I promised that the appointment would be quick and easy.

Finally, Mason was ready for me to take a quick look. His eyes were covered with Superman sunglasses, and we’d put him in a bib big enough to cover his clothes past his waist. Caroline started answering a few of my questions:

No, she couldn’t nurse him, but Addison was easy for about 14 months.

  • No, he doesn’t sleep well.

  • Yes, he has an IEP at preschool and will be evaluated for ADHD and oppositional defiant disorder. There is talk of putting him on Ritalin.

  • Yes, he eats well. Applesauce is his favorite fruit, next are nearly black bananas, and for dinner, he has been on a mac and cheese kick for a while.

  • Yes, he has night terrors also.

  • Yes, he grinds his teeth, sleeps with his mouth open, and snores loudly, just like his dad who now uses a CPAP device.

  • Yes, he still wets the bed.

Looking into his mouth, I noticed obvious interproximal decay on the molars that had developed since his last visit. Looking back a little further, into the oropharynx, I noticed the tonsils were nearly touching. His palate was high and vaulted, which used to be attributed to thumb-sucking, although today science is saying that the high narrow palate is an indication of obstructive sleep apnea or a tongue-tie. He had a short lingual frenum. Mason had been working with a speech pathologist from the school, but the results were slow. He had not been seen by a sleep specialist.

During the exam, Mason was adjusting the glasses, moving the napkin, putting his hands behind his head, telling Addison not to touch this or that, and looking at the floor to see where his shoe landed after it fell off his foot. At one point, he rolled over, put his chin in his hands, and asked if he could be done.

The incidence of pediatric sleep apnea is crawling upwards, but reporting is low due to the perceived cuteness of snoring babies. The current incidence is estimated at 3%.1 The most common causes are enlarged tonsils and adenoids and obesity, although hypotonic neuromuscular diseases and craniofacial anomalies are other major risk factors.1 More apropos to Mason’s symptoms, a 2013 meta-analysis concluded that sleep apnea in nonobese children was a function of facial growth.2 The high, narrow arch is a key indicator of potential obstructive sleep apnea, and so is the breathing stoppage I observed when Mason snorted himself awake. Mouth breathing is a precursor to dental and skeletal malocclusions3 that will cost big money down the road. In today’s health-care economy, prevention is the only way to save money.

An orthodontic evaluation is in order, and so is an appointment with a pediatric sleep physician. Orthodontics can expand the upper arch to open the sinus airway, and this has been successfully ending enuresis for scores of children.4 A new orofacial myofunctional therapist opened a practice close to the dental office so a referral there was in order as well.5 She had been a practicing dental hygienist, but after she took a series of courses through the Academy of Orofacial Myofunctional Therapy, she started a practice where she now sees clients two days a week. Her study club topics are always very interesting.

Mason’s mouth breathing was a function of his airway problems. With the tonsils growing, making it even harder to breathe through the nose, mouth breathing was also the cause of his decay. Oral breathing changes the oral pH,6 and an acidic environment changes the behavior of a biofilm, stimulating its growth. Mason isn’t a pain—he’s a child trying to survive with improper breathing apparatus.

Here’s Mason’s dental hygiene treatment plan with some orofacial myofunctional therapy thrown in:

1. Use topical fluoride varnish.

2. Use xylitol nasal spray (Xlear) at bedtime.

3. Use fluoride toothpaste at home with the no-rinsing technique.

4. Chew xylitol gum, one piece on each side, for a total of an hour a day to stimulate maxillary growth.7

5. Use MI Paste (GC America) before bed after brushing.

To improve nasal breathing during the night, all three were taught the Buteyko sinus-clearing techniques. We also went over nose blowing before using the xylitol nasal spray to improve the nasal airway before bed. The sequence can help improve nasal breathing for the night.

He also has referrals to an orthodontist, an ENT, an orofacial myofunctional therapist, and a pediatric sleep physician. The dental treatment plan is for bitewing x-rays and a glass ionomer tooth prosthesis with ozone gas applications before placement.

Michael Gelb, DDS, MS, an airway dentist in Manhattan and a second-generation dentist, created a sleep appliance for adults. He says he’s now of the mindset that the primary function of teeth is to hold the airway open, so he calls for orthodontists to see children as young as one to help improve brain development by way of arch expansion to improve the sinus airway.

Shirley Gutkowski, RDH, BSDH, is a practicing dental hygienist and orofacial myofunctional therapist. Her practice, Primal Air, focuses on the prevention and treatments of orofacial myofunctional disorders, such as snoring and immobilized tongues. She can be reached at [email protected].


1. Chang SJ, Chae KY. Obstructive sleep apnea syndrome in children: Epidemiology, pathophysiology, diagnosis and sequelae. Korean J Pediatr. 2010;53(10):863-871.

2. Huang YS, Guilleminault C. Pediatric obstructive sleep apnea and the critical role of oral-facial growth: Evidences. Front Neurol. 2012;3:184.

3.Grippaudo C, Paolantonio EG, Antonini G, Saulle R, La Torre G, Deli R. Association between oral habits, mouth breathing, and malocclusion. Acta Otorhinolaryngol Ital. 2016;36(5):386-394.

4. Hyla-Klekot L, Truszel M, Paradysz A, Postek-Stefańska L, Życzkowski M. Influence of orthodontic rapid maxillary expansion on nocturnal enuresis in children. BioMed Res Int. 2015;2015:1-7. Accessed September 27, 2017.

5. Guilleminault C, Huang YS, Monteyrol PJ, Sato R, Quo S, Lin CH. Critical role of myofascial reeducation in pediatric sleep-disordered breathing. Sleep Med. 2013;14(6):518-525.

6. Choi JE, Waddell JN, Lyons KM, Kieser JA. Intraoral pH and temperature during sleep with and without mouth breathing. J Oral Rehabil. 2016;43(5):356-363.

7. Chew gum for an hour? Dr. Mike Mew [radio broadcast]. Cross Link Radio. Cross Link Radio website. November 23, 2015.