EP 15: 5 Clues Your Child’s Behavior Is Breath-Related

0:00 Are your kids acting out or silently struggling to breathe? I brought in Dr Michael DeLuke because he's going to address these issues that are going unseen. For example, is your child snoring, bedwetting, way past, beyond the years that they should be? Are they having behavioral issues? Are they struggling paying attention at school? Now, this was my son and I've gone through that road and I knew how hard it was to diagnose, to get to the root cause of the issues, and a lot of it was his sleep and also the airway obstruction. So it's not talked a lot enough.

0:41 Dr DeLuke is an orthodontist. He will give you guidelines and questions to ask orthodontists, who to see, and questions to ask and notice about your own kids. This hour can change your child's life. Well, welcome, dr DeLuke. I'm such a pleasure and an honor to have you on here. Thank you very much. Thanks so much for having me. Melissa, Really excited to be here with you.

1:21 Yes, and I have so many questions, so I'm just going to dive right in and let's start with airway obstruction. Can you just explain what is airway obstruction, and especially related with kids as well? Yeah, it's a tough question to answer succinctly, because airway obstruction can be due to different things and I'm guessing you're asking it in the context of, say, let's sleep, disordered breathing or potentially obstructive sleep apnea, is that? the general gist of it. So when, when you have a child, that we'll talk about children out. It is different for children and adults. So, specifically now we'll reference this with this discussion, we referencing children right now. Um there, they should be nose breathers.

2:03 We should be breathing through our noses and there are many reasons for that. The nose people have described it as the gatekeeper to the body. It purifies and moisturizes air. The nose actually has antimicrobial properties through nitric oxide. So when we breathe through the paranasal sinuses, as they enhance the oxygen uptake by up to 20% because they incorporate nitric oxide, which is a profound vasodilator, so our lungs get more oxygen to them, which then allows our bodies to get more oxygen to our peripheral tissues. It also there's these little things in the nose called turbinates, and they're like a conch shell Some call them conch or concha and they have that swirled shape to them and they have a really important function to humidify the air.

2:50 They clean the air, they slow the air, they pressurize the air. So when we breathe through our noses, it really not only purifies and moisturizes the air, it also allows us to uptake more oxygen in our lungs. So you say, well, okay, why would that be a big deal? Well, so many things can obstruct the ability to breathe through the nose. And again, speaking with children, when children are born they're obligate nasal breathers. They have to be able to breathe while they're feeding, right as an infant. They then are able to breathe through their mouths. That is not.

3:33 Yes, we can get oxygen in. We can survive that way. It is not the ideal way to thrive. So what can obstruct the airflow? Well, we could have enlargement of those turbinates. I talked about those swirly things that are bones covered by soft tissue in our nose. If those get enlarged, as what happens with allergic rhinitis and there are estimates, some estimates from the American Institute of Allergy that they say that up to 40% of kids American Institute for Allergy and Asthma say up to 40% of kids are suffering from allergic rhinitis. And when suffering from allergic rhinitis and when you have allergic rhinitis, which we think of as kind of like a stuffy, runny nose related to allergies, those patients are more likely to have and it's kind of a fancy phrase of it, but it's called turbinate hypertrophy.

4:16 Hypertrophy just means that enlargement of the tissue, so those turbinates that are covered in tissue get large and swollen. They swell up, and there was a 2019 article in the Journal of Oral Science, which stated that they looked at 544 children, the ages three to 10 years old, and they found that there was evidence of turbinate hypertrophy in 81% of the patients who had allergic rhinitis. So just think of it like four out of five patients who have allergic rhinitis have this swelling in their nose. So if almost half kids have some sort of allergic rhinitis, some reaction in their nasal passageways, and then four out of five of them have swelling that is going to restrict their ability to breathe through their nose and I see this all the time in young patients and then let's just take it back from there.

5:07 Let's say the turbinates are fine and the nasal passageways are fine. Well, if you go back in through the nose and get back up toward the back of the nose before it turns down toward the throat, we start into what's called the pharynx. People probably heard of the pharynx, but there's the main, two main areas where we can get obstruction. It's called the nasopharynx, which is at the back of the nose before we get to the back of the throat, and then what's called the oropharynx, which is like at the back of the mouth and the throat when someone opens and says, ah, you're looking at their oropharynx. You can't really see without imaging or using an endoscope at the ENT, the nasopharynx. So when we go up into that area of the nasopharynx there's something called the adenoids and a lot of people have probably heard of the adenoids.

5:50 It's a common thing to heard of. It's a type of tonsil, it's a lymphoid tissue and it's a reactive tissue. So when we breathe through our mouths we are taking all that unfiltered air in and there are theories that that unfiltered air in and there are theories that that unfiltered air hits that reactive tissue and causes it to enlarge. That's just one of the reasons there are many why that tissue can be enlarged so that can obstruct airflow. Then we go down a little further into the oropharynx and that's where we have our tonsils, or technically called our palatine tonsils, but what people just call tonsils. Again, lymphoid tissue can get swollen and inflamed and further restrict the airflow. Then that patient, if they are not breathing well through their nose, that changes the way the shape of the face grows.

6:37 So if we are nose breathers our faces will grow differently than if we are mouth breathers and that's been shown. We've known that for many, many decades. It was a really famous group of set of studies done, published by a gentleman named Harvold, in the seventies into the early eighties, where he looked at rhesus monkeys and he plugged their noses with silicone and he studied how they grew. And they all grew with these longer faces, narrower dental arches, lack of tongue space and crowded teeth and bad bites or malocclusion resulted. So it's this negative cascade of events because then, when you're growing more narrow, so to speak, because you can't breathe through your nose, you have obstructed breathing you open your mouth more, because that's your lifeline, you have to get air in to survive.

7:25 So you habitually open your mouth more, because that's your lifeline, you have to get air in to survive. So you habitually open your mouth more. Well, what happens when you open your mouth more? Your cheeks stretch and that inward pressure of the musculature further constricts the arch and it makes the palate narrow and high and vaulted. And what's on the opposite side of the palate, above the palate, is the floor of the nose. So that's all getting squished in. So you can see you start to have this really negative cascade of events can be caused by a myriad of factors, and now your tongue doesn't have room. So now when you lie supine at night. Your tongue doesn't have room. Your tongue is supposed to rest at the roof of your mouth very easily and not fall back to your throat and block your ability to breathe.

8:05 But when a lot of these kiddos are narrow and their faces and jaws are so narrow, they lie back, the tongue falls back, so that's another way that obstructs, so they have to open their mouth further. And a gentleman who is a physician, who's a world famous he's passed since passed, but he really is kind of known as the founding father of sleep medicine, modern day sleep medicine Christian Gimeno. He talked about this as this evolving cycle of what's called facial dysmorphism. So the more you have obstructed nasal breathing, the more it changes the shape of the face and the way your face grows, and the more that negative cycle continues, face grows and the more that negative cycle continues, and so that's really where the overall obstruction of breathing through our nose becomes an issue.

8:51 And we can, if you want, let me know we can talk about the negative sequelae and the negative things that happen beyond just pure, beyond, I'd love to dive into because I got into that, because my son Mateus, we went through that when he. I noticed it. You know I'm a dental hygienist. I noticed it when he was about three years old. You know that. I'd love to dive into the behavioral. You know, things that I saw like for him, the sluggishness, uh, the anger temperament there was, uh, you know, the bedwetting way past the years that you know that was appropriate there was. Also, I did a few times he would, you know we'd share a bed and whatnot. I would document the times he had sleep apnea.

9:31 So that makes sense when you say the tongue, you know, and he was. And then he had the allergies. I remember he, the first year he was born, I remember in the spring, he had those allergies and the red eyes and the stuffy nose. He went through everything you just mentioned. So I've, that's why, you know, at our dental office we dove into, you know, healthy start and trying the expander for him. So I'd love for you to share that because I went down that road with Mateus and other patients that we had at our office as well. Yeah, absolutely. And for parents out there, if you see this in your child, like Melissa did with Mateus, videotape it Videotape.

10:13 Take your phone out and videotape record. Show my age right. Record it video. Take a video of it. And that's what happens when it gets to be my age. That's something my children, my teenage girls, would laugh if I said that. But record it, take your phone out, record it right and just take that recording. It's invaluable because when you take that to a physician or if you need to see a sleep physician or the orthodontist or the dentist and say this is how my child is breathing, I'll answer your question in a second. The importance of that is it's hard for them to deny that that's a problem and if you just give a verbal recount, they can be like well, you know, you know kids, and I will state this, and I've had on my podcast a gentleman named Jerry Simmons who's an amazing, brilliant sleep physician, and he said unequivocally children should not snore.

11:04 He said unequivocally children should not snore. And absent, obviously, if they have a cold and their noses are plugged up, right, I mean those isolated instances, but on the daily or on the nightly, so to speak, children should not snore. Say that all the time to parents. I say your kids shouldn't be snoring, yeah. And if they are, there's a problem and that needs to be addressed. And we can talk more about this later, about how to address that and what to do and how parents need to sometimes advocate for themselves. But yes, there are significant behavioral and neurocognitive deficits that can result from patients who aren't breathing properly or who are mouth breathing and or snoring. So before I dive into that, I want to just state for the audience the problem.

11:49 A lot of times and this is orthodontists, unfortunately have done a really poor job of educating ourselves or our residents and the public on this. But we talk about this a lot of times as OSA or obstructive sleep apnea, and there's something called a sleep study, called them with polysomnography that measures that If you ask sleep physicians or pediatric ENTs, they will be the first ones to tell you that pediatric polysomnography. When you look at a, when you take a child for a sleep study, that child could have a zero on the apnea hypopnea index, which was, incidentally, developed many decades ago by Dr Gimeno and is not based off of any data, any randomized clinical trials, any studies.

12:32 They literally took the adult data which was made in the 70s looking at asymptomatic 40 to 60 year olds. They took that subset of data and they literally took a third of it and made that for the kids. So the scale in and of itself is very flawed and Dr Gimeno recognized that later in his life. I did not know him but I have gotten to be very friendly with people who did and they've been on my show and they've said on my podcast like that was one of Dr Gimeno's biggest regrets was making that scale, especially for children, because now that is what everything is judged by what insurance companies judge reimbursement by. It's become a big problem and the orthodontists unfortunately look at it and say, well, if they don't have obstructive sleep apnea, then they're fine. That is not the case.

13:13 Obstructive sleep apnea. What's important for the audience to do is think about sleep disordered breathing or sleep-related breathing disorders as this spectrum of disease. Okay, so it's a spectrum of disease that goes from snoring to something called upper airway resistance syndrome, to something called obstructive hypoventilation, to end-stage disease essentially, which is obstructive sleep apnea. So a child can have all these breathing problems and not have obstructive sleep apnea. They can have, as you said with Matthias, apneas, meaning they can have periods where they are not breathing right. No breath apnea.

13:54 They can have hypopneas, which are insufficient breathing or less breathing, going on, breathing going on. But you are not necessarily having them for the duration that you need to have or the frequency to qualify as having obstructive sleep apnea. So you have to. To qualify as having OSA, a child would have to have an incidence of apnea or hypopnea or adult for that matter of 10 or greater seconds. Well, children have faster respiratory rates. They have more active sympathetic nervous systems. They are less likely to suffer from apneas or hypopneas of that duration.

14:35 They tend to become hyper aroused prior to that. So in 2007, american american academy of sleep Medicine added to it well, it can be an apnea or a hypopnea of two successive breaths duration. It doesn't have to be 10 or more seconds. But here's the catch Not every sleep lab uses that criteria. It's just a recommendation, so a lot of sleep labs don't use that. Some sleep labs use that up to the age of six. Some use it up to the age of 18. It's very, very randomized on how these sleep labs operate these studies. My point of telling you that is you could have a child like Mateus and you take him for a sleep study and it comes back with a zero on the apnea hypopnea index and you take that to the dentist, orthodontist, physician, ent and they look at it and say he's fine, he doesn't have a problem.

15:22 That is not true. If you talk to the sleep physicians they will be the first to tell you just because they don't score on an apnea hypopnea index doesn't mean your child is healthy from an airway perspective. So, getting to the neurocognitive and behavioral deficits, as well as the craniofacial growth that I was talking about a moment ago, you don't have to be diagnosed with obstructive sleep apnea for that to be the case. You can just have some level of sleep disordered, breathing on that spectrum which starts with snoring, and still have behavioral and neurocognitive deficits much like you just spoke of.

16:04 There are tons of them Hyperactivity and ADHD is a very common one. Yeah, do you find like a lot of kids are being misdiagnosed when it's actually a sleep disorder? Yeah, well, yes, so ADHD, the diagnosis is a symptom-based diagnosis as well, and that's the tough part is sleep-disordered breathing is a symptom-based diagnosis. It's based off of patient history and clinical symptoms. It's not like a scale. That's why we like the apnea hypopnea index for diagnosing obstructive sleep apnea, because it's a number, it's much easier to quantify and certainly as well for reimbursement purposes for insurance companies. It's a number, and so, with the randomness of the subjective, the subjectivity of the diagnosis I should say random the subjectivity of the diagnosis for sleep disordered breathing also is the case for ADHD, meaning it is, I believe it's two.

16:54 You need two professionals involved in the child's life to fill out a form and document that this child is presenting with these certain symptoms and then that will give them a diagnosis of ADHD. They could behave in a manner that would qualify them as having ADHD just based on being sleep deprived and not getting deep, restful sleep because of the way they are breathing. There are some estimates that up to 50% or greater of children that have been diagnosed with ADHD have a sleep-related breathing disorder Asthma right, asthma. There's some estimates that up to 30% of children diagnosed with asthma have sleep-disordered breathing.

17:41 Well, why? Well, because they're breathing all that unfiltered air through their lungs. They're not doing the things we talked about before that the nose is meant to do purify and moisturize and humidify the air and it gets into the lungs and it irritates the lungs. So they have bronchoconstriction as a result and asthma. So it's not that sleep disordered breathing causes those things necessarily directly, but indirectly. The fact that you're not breathing the way we are designed to breathe is either exacerbating or causing those issues to present. And you mentioned bedwetting right, called nocturnal enuresis. That is extremely common, to go well beyond the normal age.

18:21 In patients who have sleep disordered breathing. There are all sorts of other mood disturbances depression, failure to thrive. If your child is tossing and turning like crazy at night, that is not normal. They shouldn't wake up upside down in the bed with the covers kicked off. If they're tough, if they are grouchy in the morning, tough to wake up, dragging to get to school in the morning, that is a sign that something is going on with the way they sleep. They have morning headaches. Sometimes it shows up as daytime sleepiness. Right, they could be hyperactive for a while and then they crash. It can be their relationships with their peers and the students that they're interacting with on a daily basis in school.

19:02 They could have trouble mixing in with other kids because of this and so this, all these things that were then unfortunately in our medical system. Throwing medications at and just trying to medicate a lot of these kids with essentially speed is what we're really giving them when they have ADHD. You're getting them on these heavy duty medications without looking at at and I'm not saying that it's always airway and sleep right, it can certainly have, you can certainly have asthma. You can certainly have ADHD and not at all be related to sleep. The problem is is it sometimes is related and when we're medicating them the same way, no matter what, and not looking at the etiology or the cause and just looking at the symptoms.

19:44 We have to get away from just treating those symptoms and look at why they are that way and make sure that we're not just sending for a sleep study, coming back at zero and saying, oh, the child is fine, and I face that all the time. Parents I'll send to ENTs and if it happens to be an ENT that I don't work with as often and they see that ENT and they take a sleep study. There's times I've had kids that are just suffocating themselves and they come back with a normal sleep study. I had one parent, melissa, that told me that I had prepped her that the sleep study may come back normal, even though she'd showed me the video of her child suffocating at night. And he's got the dark circles under his eyes and he's on multiple meds from the neurologist for his ADHD. And I was starting to diagnose this and figure out what was going on with him and refer him to other colleagues.

20:29 And mom said when she went for the sleep study they woke him up at 4am and ended the study. Yet he came back with a zero. And I'm like well, we know that in children the time that they show the most incidents of longer duration apnea and hypopnea is when they get in the deep REM cycles of sleep later in sleep. So who knows what time he actually fell asleep by the time he was tossing and turning and then they wake him up at 4 am. It's possible he hadn't got into the point of sleep yet that he would have had these apneas. And the last thing I'll say about that on the neurocognitive side, there are numerous studies in the medical literature. One which was kind of really a landmark study was by Karen Bonick, published in Pediatrics in 2012.

21:13 She looked at almost 10,000 kids between the ages of 4 and 7 years old and determined that early life sleep disorder breathing had strong, persistent and statistically significant detrimental effects on childhood behavior. Think about that On childhood behavior. And David Gozal, another physician. He published an article in 2016 where he found that snoring alone just snoring again not a diagnosis of OSA just snoring alone in children. He looked at 1,010 children ages five to seven years old. Found that snoring alone has a significant impact negative impact on neurocognitive development. So we know that there's this problem out there.

22:01 Isaiah and colleagues in 2021 in nature communications studied the MRIs. So they're studying the MRIs of the brains of over 10,000 children that were enrolled in this adolescent brain and cognitive development study. Found that children who snored or even gasped during sleep back to your son right and smaller volumes of gray matter in their frontal lobes. Wow, that's so fascinating because, yeah, I did a brain scan on Mateus too, and they had found Did you. Yeah, and they had found the inflammation was in the amygdala. So I'm kind of trying to get to the root cause as to why. But they also wanted to give a couple of medication. I'm like, no, no, I'm going to keep diving and seeing. Where is that inflammation all coming from?

22:43 And so I've been diving in and actually we got it. He got diagnosed he's had a parasite actually Giardia and mold and heavy metal, so that's causing all the inflammation. But I know with him we're still dealing, probably with the jaw structure from him earlier on, even though we had him on a Healthy Start appliance you know at three years old and hopefully that you know that helped a lot, but I'm wondering if that's still an issue. So I'd love I know you talk about when you're a podcast, that you even do surgery on three, four, five years old for the jaw right To open up that airway.

23:24 Is that correct, not surgery just jaw growth appliances, so expansion, yep, appliances to just help develop it, and people will. One big misconception is that, and sadly, just like in anything, there are people who take things and run with it. And so, yes, there are providers out there in the dental field who are saying, okay, every you know any patient with an airway problem, expand, expand, expand, which means widen everything out and they'll be fine. And that is not true in the sense that not every patient's obstruction or airway problem is due to narrow, deficient width in their arches. A lot are, but not all of them. It takes more diagnostic time to figure out where it's coming from, and that's a lot of what I teach, and I'm giving a lecture at the end of this week, actually at Florida Dental Association's convention on the team approach to this and how we have to work together and how, really, in my mind, the orthodontist can be the quarterback of all of this.

24:19 Even though we're not doing that quite yet, I really believe we need to be. So when you talk about treating younger patients, traditionally in orthodontics we think about the earliest a patient would ever be treated is six, seven years old, and for most people that's still earlier than they would treat most weight right. So when I would tell parents in my practice that we were going to start at five, six, seven years old, they're like well, I didn't get braces till I was 12. What's going on? So we have to change the mindset on how we think about this because and I'm going to come back to more directly answering that question but the indirect answer is, if we wait and don't do anything, young, it is a very reactive, symptom driven approach.

25:01 So the concept there is we can't change the way these patients grow. We can't really do much about it. All we can really do is straighten their teeth once they're crooked. So let's just kind of wait and watch. Maybe we have to pull some teeth because maybe their jaws are so narrow that the teeth don't have room, because rarely is crowding of teeth due to big teeth. It's not never, but it's almost never. It's almost always due to narrow jaws. So one of the reasons those jaws are narrow is again the way they're breathing. But if we're not looking at that as orthodontists and we see the patient at seven, eight years old and they're really crowded with narrow arches et cetera, we just say, well, there's not gonna be room for their teeth, mom or dad, we're gonna have to pull some teeth and we'll straighten them out when Johnny's 11 or 12 or 13.

25:44 And that's the traditional approach to orthodontics. I actually call it. If anybody out there has read Peter Attia's book Outlive I call he talks about medicine 2.0 versus 3.0. I call that orthodontics 2.0, which is very siloed, it's very reactive, it's very tooth based. It's not looking at the overall patient and their health. We're just there to be these two straighteners that have learned how to use biomechanics in the mouth in a way that others don't know how. So we're the best at moving teeth around. I like to do to practice what I call orthodontics 3.0, which is and I this is a lot of what I teach as well is we need to start thinking about treating patients earlier, much earlier. Patients earlier, much earlier, and being more proactive in helping guide the growth and development of the jaws, the craniofacial complex or the craniofacial respiratory complex, and helping them not need as much treatment later on.

26:37 So when you talk about these things we can do young. The hard part of this is because most parents will hear this and say why the heck aren't the orthodontist doing this right? I mean, it makes total sense. Again, not to be overly skeptical, but insurance doesn't reimburse it. The same way, our office practice systems aren't set up to do this we. When you're an orthodontist and you're seeing 75 to a hundred patients a day straightening teeth, it is a major overhaul to start thinking and you're treating mostly teenagers and adults right. It is a major overhaul to start thinking about treating even six and seven year olds in mass, let alone three, four, five year olds. It's a whole different level of behavior, behavior management, patient management, parent management, team training.

27:25 I mean it's another world. And so and we're not taught to do this in our residencies. Honestly, melissa and I've taught in multiple residencies throughout the US orthodontic residencies. Most of them are three years long, some are two and a half. There's a couple out there that are two, but for the most part they're three years. So you go to four years of college, four years of dental school, and then you have to be well towards the top of your class to get into an orthodontic residency and then you go to another about three years. In that time you may very well treat no patients orthodontically under the age of 10 years old. You may. If you're lucky and you're in a really good program you may get a few.

28:06 If you're in a good orthodontic residency you may get a few patients that are younger. There's a couple spectacular programs that they're treating a bunch of patients in that 6-7 window. I don't know any right now. I'm sure there's maybe one or two out there that are treating patients younger than that, because it's just not what we historically have done, it's not what we're taught to do, it's not what we know how to do. So we not only, unfortunately, don't know how to do it, we say, well, for all those reasons I gave, it would change everything in your practice. Right, and you're not trained to do it. And you're not trained to do it and you're busy, you're successful, you're doing what you're doing in your practice. You're making patients still look better. I mean they still look better after your treatment, even if you haven't necessarily had a whole health approach.

28:49 So it's really hard to convince my orthodontic colleagues like you should think this way, because there's no real incentive to. It's not like the other way is directly harming the patient. Now, indirectly, you could make the case that by ignoring the narrowness and the airway and all that, you are setting that patient up to have very severe health problems down the road. Yeah, like core mortalities, right? I mean that could lead to countless of things as they grow older. Yes, so yeah, it's very important to address those earlier on. So you're starting that movement, which I love, because I know, actually, my husband went to their dental office.

29:30 He was starting as well. He made sure he told all the hygienists to start talking about this with parents and ask them questions. You know I would ask them are they snoring, are they? You know, and I do feel there needs to be a questions. You know I would ask them are they snoring, are they? You know, and I do feel there needs to be a questionnaire. You know, a questionnaire for family, maybe even at school? You know, you know they do the ear and eyes test at schools. Well, why not? You know a sleep one as well, you know. Yeah, I can't believe you said that because that Jerry Simmons, with whom I was speaking on my podcast that I referenced before, who's the sleep physician in Texas he is working with actually he was on an episode together with Steve Karstensen, who's a dentist out in Seattle.

30:13 They're working on something called C gasp, which is the children's general airway screening protocol. I believe is what the acronym stands for, and it's to try to get it to the point where this could literally be like the nurse, just like you just said it was so insightful for you to say that would like they test eyes and ears, they would test, they would run. It's like a five question test that they would essentially put these kids through to try to figure out at some entry level of screening and get this into the hands of the pediatricians and the nurse practitioners. And they're trying to have to make it a validated questionnaire. They can't just create it and put it out there. There's a lot of data. There are a lot of data that have to be analyzed to make a questionnaire validated or to validate it.

30:56 So they're working on that now and gathering the data set. That is very exciting and the other part of it there is a questionnaire right now and people can Google it and find it. And if you want, I can. Yeah, we could put it in the show notes because I'm sure a lot of parents are listening and they're like, okay, what are those five questions that I can kind of ask myself or the kids, and then and then, and then, how do they find someone like you, orthodontist, that could help treat them and guide them along the way? That's the hard part. And one other thing on the questionnaire there's something called the Shervin Sleep Questionnaire Shervin's Pediatric Sleep Questionnaire.

31:36 Shervin was out of Michigan. It was published in the year 2000. It's a validated questionnaire. It was. Shervin was out of Michigan. It was published in the year 2000. It's a validated questionnaire 22 questions which ask about sleep behavioral issues. They really gives is a great easy tool for practices to implement into their intake process. Sadly, in the orthodontic arena to address what you were just asking about, finding an orthodontist Many people listening probably have been to the orthodontist with their child or themselves and the orthodontist walks in, does a little cursory exam, grabs a mirror, looks in the mouth, minute or two in the room right, the biggest thing is yes, are you ready for treatment? No, are you not? Are we going to pull any teeth or not pull any teeth?

32:16 And you want braces or alignersers? I mean, it's a pretty quick thing. They kick it off to their treatment coordinator to go over everything and the orthodontist goes back to the clinic to keep working and straightening teeth. And that's unfortunately how a lot of orthodontic practices are set up. And that's sad because you're not asking those other questions. We do a basic medical history, but unless something is like jumping off the page, some congenital heart defect that they might need prophylactic antibiotics for, or the history of childhood leukemia, or something that really stands out, we're just looking down through the systems like, yep, no, no, no, no, no, everything's good, healthy kid. It's not the case.

32:58 We don't ask the right questions. So the first way to answer that is find out, when you call an orthodontic office, if they do an airway screening. Now I will tell you the American Dental Association, the American Academy of Pediatric Dentistry and the American Association of Orthodontics all have publicly stated that every dentist should screen for airway compromise in children. So if you have a dentist or orthodontist who is not screening for it, you need to say to them why aren't you following those recommendations? They're not laws. It's just guidelines that our associations put out there, much like I referenced before the one from the American Academy of Sleep Medicine in 07.

33:44 Not everybody follows it, but it is still a guideline that is based in science that they are putting out there to say this is something you should be looking at. There is no standardization or protocol for what that looks like and that's tough. There is no education a lot of times. So these organizations I've been critical of the American Association of Orthodontists because they've made that comment, but they don't provide any education on how to do it and they don't help our orthodontic residents implement that into their training programs. There's a lot of training programs I know of firsthand that I've tried to help implement these and they're like we don't want to do it, we don't want to do it. There's no need for that.

34:24 So that would be. The first question is to ask if they ask airway screening questions, if they screen for airway obstruction or compromise in children, you probably are going to get a lot of no's or um wells, you know, maybe we could um. So if they say yes, ask them what their protocol is. Ask what their protocol is, ask what they do. Do they use 3d imaging? Can I talk for a minute about the 3d imaging side? yeah, absolutely, yeah, absolutely so that's a big thing. There's all these articles. One just came out again recently, I don't think this one's in New York Times and it talks about that medical. It conflates medical CT scans with dental CBCT scans.

35:09 So it's the CB stands for cone beam, so it's a CT type scan, but it's done with a cone beam, so it is a fraction of the radiation. So, for example, like a CT scan of your head for valuation of your sinuses, right, medical CT scan, that's going to be like 2000,. What we call micro sieverts it's a way we measure effective dose of radiation. Just to give some context, like daily background radiation that you just get from just walking the face of the earth is like. The estimates are anywhere from like six to eight ish. You see five, ten, but about microsieverts. So you know you're talking magnitudes.

35:50 More than what you get in a day. A flight across the us, I think, is like 75 microsieverts of radiation. Yeah, I always say it's like five chest x-rays, One flight like a three-hour flight is the same amount of radiation than one chest x-ray. Yeah, so you get exposed to this background radiation just living. But obviously if you get a radiograph taken with ionizing radiation, which a CT scan is, you have an influx of it at that point, a cbct image, so a cone beam image which is a three full 3d of the skull. It lets you see everything in the skull, not in the detail necessarily that you can see with an actual ct.

36:35 You can't manipulate it quite as easily in terms of slicing it and everything. So that's why surgeons and they want the precise an ENT surgeon say, would want a precise CT scan. But for what we do from the dental standpoint, especially the orthodontic standpoint, a CT scan at the lowest level of radiation that machine can go, which there's two types of machines. There's a low dose machine, which is what I've always used, and then there's a regular dose machine. So let's just take the regular dose machine. If you do the regular dose machine at the lowest level it's about 50-ish micro sieverts right, about 50-ish. So it's at 140th of a head CT, a fraction right, less than a flight across the country.

37:16 If you get a low dose machine you can take that same image for like 13 to 17 microsieverts of radiation, so like twice a two days worth. Now I'm not being dismissive of radiation and like what's the big deal? Two days worth. But think of the diagnostic information we get. We get out of that right, it's so worth it. Whereas the traditional 2D x-rays just to put it in context, the 2D like the Panarex you know, the one that looks like kind of the jack-o'-lantern and the side Ceph, head view, the cephalometric view, called the lateral Ceph those combined with digital technology typically are about 25 to 35 microsieverts.

37:59 So, yes, you're splitting hairs, but the low-dose 3D image that my machine could take is less radiation than a 2D, panarex and CEF. Yet you'll hear a lot of orthodontists say well, we don't do 3D because the radiation is too high. It's not true. It's simply not true. When they first came out 20 years ago, yes, these CBCT images were in a couple hundred, you know, a couple hundred microsieverts. They were magnitudes more than routine 2D imaging. But that's not the case anymore. So with that 3D image, if that is a good sign, if the orthodontist you're going to uses a CBCT image, that is a good sign.

38:42 That means they're looking at more than just 2D of the teeth. Right, they're looking at things great, in a greater view. Now, not everybody who has one doesn't mean that they understand airway. There's just a good chance if you call and they do an airway screening and they're looking at these things and they have a 3D image, a CBCT machine. That orthodontist is probably looking more from the airway side of things. And then the last question would be is what do they do with patients when they detect an airway problem? And I would ask those questions when you call an orthodontic office. This movement, melissa, has to come from the parents, because I have. Yes, well, that's why I'm having this show, because I have so many, a circle of parents and I'm you know I'll be at a sporting event, you know, watch my son play soccer and I'm educating you know other moms and they're like, oh, I want to know more.

39:33 Send me some links. Who should I go see? I'm like, okay, I'm going to have a couple of podcasts, I'm going to have specialists, so then just listen to that. So I, you know, I do have to get to all the parents. You know they want to help their son. They see, you talk about, like, the allergies. I see so many kids dealing with allergies and the dark circles on their eyes and I see it. I'm like, oh my gosh, this is the sleep, the airway, and so now I just love that I'll have a podcast. I'll be like okay, you need to listen to this, you know, and, yes, you do have to start with the parents educating this. That's where we start the movement. Absolutely yeah, without a doubt. I am a ton of parents that listen to my podcast as well. I've been shocked at how many do, and it gets pretty technical.

40:14 But there's podcasts like Huberman out there today and you know people that are listening to medical-based podcasts, and so I have a lot of laypersons who listen and follow my content and they'll message me or email me on a show or comment on a show and say this is my child, how do I find someone to help them and what can we do about this? Because it is frustrating for parents, because a lot of parents will hear this type of thing. They will go to an orthodontist and I say this not as a criticism, just as the reality, because I don't want people to hear this and think that they're just going to be able to call an orthodontist and get in with one right away who thinks this way. You may not find one in your entire area, truthfully, and you know.

40:55 That's why the parents need to push the orthodontists to do better To make that shift. Yeah, we create that movement From the top down, exactly. Our organizations. Ada is great. I should say the ADA is amazing on this. They're really with guys like Steve Carstensen that I referenced before. They're really leading the charge. The AAO American Association of Orthodontists, american Academy of Pediatric Dentistry. They are not taking charge on this the way that they should. They are hiding behind obstructive sleep apnea. They're like well, unless a child has OSA, you know, it's nothing really and that's a physician's job. We're just there to kind of screen. It's really a cop out and I could you know beyond the scope of today to talk about why I think that is, but it is the reality that they are not doing their part.

41:36 I've had conversations with the president of the AAO in the past multiple of the presidents and past presidents about this, and I have challenged them to do better and nothing really changes. They don't. There's not a lot of talk about this at their meetings. If it is, they make sure they provide counter arguments to try to say why this isn't a thing. So I love my profession, I love my orthodontic colleagues and I mean that it's why I'm so passionate about trying to get them to change. I just am frustrated by how many of them refuse to, and I provide the literature and the data, and I can literally just have conversations on all the literature from the medical literature and dental literature, supporting everything I say, and they just say it's quackery, it's you know, it's, it's, it's no, no logic to it, there's nothing to it.

42:24 So it's a challenge. So if we get more, parents asking for the, then that's how the they won't have a choice. Oh, it's a supply and demand right, so they'll have to change, Do you? know. That's what orthodontists used to say about Invisalign and clear plastic aligners. I say Invisalign because they were the first one. We didn't embrace that concept. We shunned that concept that you could ever move teeth with plastic. And once the parents and the general dentist started doing it and the patients started the patients and the general dentist and the patient started demanding it. It was amazing how many orthodontists because I was just starting my career in the early 2000s when it came out and how many that and I was taught. Like you know, there's no way this can work. This is crazy. Well, once there was a market demand for it from the public, orthodontists all of a sudden started really figuring out that you could maybe you could straighten teeth with plastic and we became much more open to it.

43:13 So I think the same thing will be the case with this is once more, parents tell their orthodontists you need to to be looking at my child younger and you need to be screening for airway obstruction and you need to know what to do in the event that you find one. And some of that, melissa, isn't anything I do. It's working with my colleagues, my medical colleagues, my myofunctional therapy colleagues to get these patients the help that they need and deserve. And that's another big challenge is we are trained orthodontically like we don't do anything till the teeth are really crooked and then our job is to straighten teeth. I like to think of us as the conductor of this operation, where we have to tell the parents or teach our team, teach the parents, teach the patient, communicate with the ENT, communicate with the allergist, communicate with the pediatrician, communicate with the speech and myofunctional therapist.

44:07 It's challenging, it's it's. And I again, I grant a lot of grace to my ortho colleagues, because if you're busy straightening teeth all day and you're doing really well at it, why are you going to change the way you do everything? It has to become that purpose. You know purpose driven because you're seeing a significant change in kids behavior and health and so it has to become more. Yeah, that purpose driven, yeah, to help others and what have been yours. Have you noticed people being more open to it? yes, yes, because I talk about it and I talk about it just, you know, in related to even just my son and patients that we've had at our dental office. They are, they are seeking, and actually I've been, you know, I still temp and I now I only want to temp where they have their.

44:54 They do airway, the biological dentistry. I'm really really leaning towards that, because you're talking about the scans and even taking drops of iodine before you take the x-rays, like using ozone, like just really getting to the root cause, not just saying, okay, I see some grinding, here's a night guard, let's what's causing the grinding? Like okay, let's, let's do some stress management, like let's start incorporating some stress management tools, breath work, meditations, let's get to that root cause. You know, and for me too, I see, for mouth breathing, sometimes I'll see them oh, you were just in, like just three months ago, but you have all that buildup because you know your mouth breathing is that dry air constantly on their mouth.

45:38 So it's causing all that calculus to build up so quickly and and so I'm, I'm just seeing it and uh, yes, people are driving, you know, longer. They're like, okay, because I'll say, well, only know two. Actually I recommend a lot of people to Dr Trevor Nichols because you introduced me to him, and actually I'm having him next ina couple of weeks here. And um, I recommend you know people to go to him, and then I I tell people to go to the offices that I've been temping at, because it is really really hard to find and I'm really particular and picky now where where I work too, because I want patients to be well treated.

46:20 But I do feel patients that are open to that are open to paying for it Because, like you said, insurance won't cover a lot of these things and but they're seeing the value. You know the long term value, because this will save them from the core mortalities and chronic health issues. As and and I'm also, you know, been diving into a lot of correlating, you know your gut health to the oral biome as well. You know getting what, what bacteria is in there. You know or and uh, so they are. They are very open, everyone that I've talked to. They just don't know where to start, they don't know which question to ask and they don't hear much about it.

47:01 So that's why I really wanted to have this and to hear you know your expertise on it, ask the questions and then guide them along. Now, for adults that are dealing with sleep apnea, what do you have for you know? What do you recommend for them. You know, treatment wise. Now, that's new, that's out there, you know. Yeah, it gets to be pretty involved with adults. I actually just had Dr Dave McCarty on my show. He's amazing. He's a sleep physician out and internist in Denver and he's starting a new much, very progressive, much needed platform where it's kind of again that Peter Atiyah 3.0 concept where he's putting a lot of specialists under one roof and really trying to get at the cause of why these patients are suffering with airway problems and how to deal with it.

47:51 So it is he actually I can give you a link to that episode for the show notes too, if you want, because he just taught he's so smart and he really breaks down a lot of what this whole challenge of sleep apnea is in adults. I would say from the dental orthodontic perspective. Again, our job is to recognize it, detect it. I'm ashamed of the number of times over my career before I understood this, how many patients I can look back at and I can remember them and sometimes I show them in my lectures that I didn't detect this in and they were. You know, say, a female in her mid-40s comes in and she's on SSRIs and having depression issues and maybe going through a divorce and having issues with children or children and all sorts of other issues and they sent.

48:40 She sent to me because her teeth are broken down, as you said, right, a bruxer. She's clenching, she's grinding and her teeth are so broken down. The dentist sends her to me to try to rebuild the bite. So, because the dentist can't put even bonding or veneers or anything on the teeth because that she's just going to break it. Well, bruxing and clenching, grinding, but especially bruxing, is directly related to an airway problem. So, instead of just making these patients a night guard, as you accurately said, which is totally treating the symptom and not saying that's not valid, I mean you got to protect the teeth. So, until you get this under control, like you got to protect those teeth, so there's certainly a place for a night guard. It shouldn't stop there. We need to figure out why is this patient grinding?

49:20 I had someone on my show a while back. She's a general dentist in Texas and she said that she has every patient who is a severe Brux or she has sent for a sleep study. Again, sleep studies in adults are different. There is more accuracy In an adult patient. There's still issues, but it's better. Has come back with some level of sleep apnea. Okay, have you ever heard? I've heard, I'm starting to hear this a little bit, but I don't have all the facts but have you ever heard? Bruxism due to parasites? Due to parasites. Not heard of it, but I wouldn't deny it. I've had it come up a few times saying uh, you know, I've worked at different dental offices and they're like oh, did you know that that could be a correlation?

50:02 But I I just starting to dive into it and I'd love to see if there is some truth to it well, yeah, the concept is that you're in again sympathetic overdrive. You know, when you're sleeping you're supposed to be in a parasympathetic state. Your nervous system is supposed to be calmed down and relaxed. Well, the bruxing is a very. You're using your skeletal muscle pretty aggressively to generate force and so that is that sympathetic overdrive and that hyperactivity that you're doing when you're sleeping, which, if you're in a deep, restful sleep you're not doing. So if you have a parasite, say, that puts you into this sympathetic overdrive. That could, I mean. I'm not saying that as a scientific reason, but just logistically thinking.

50:42 That could certainly make sense. And we see the bruxing in these patients that come in all the time in the orthodontic office and we just think, well, geez, I got to rebuild the bite and it's going to be a tough one because they've got strong jaws and they're grinding their teeth and clenching, and so we treat the teeth. And I think back to some of these cases and I'm like, oh my gosh, I look back at this is before. I had 3D, look back even at their 2D images and I can just see in the lateral view. I'm like, oh my gosh, their oropharyngeal airway was so small and their tongue space was so restricted and a lot of these patients did have teeth pulled as kids. And it's not that pulling teeth causes the airway problem. It's that the air, the teeth were crowded because a lot of times the way the patient was breathing was causing them to have narrow jaws and those narrow jaws don't have room to accommodate the teeth.

51:29 So orthodontically you remove the teeth to be able to give them straight teeth. So people say, oh, extracting teeth causes the airway problem. Really the way to look at it is the airway problem is there. Extracting the teeth is treating the symptom of the crooked teeth. It's not getting at the cause. So a lot of orthodontists, I think, don't want to admit that we weren't doing it right with extracting so many teeth all these years because they're worried about liability. A lot of times make the patient. Sometimes you can make them narrower, but if they're really severely crowded you're not even making them more narrow. You're just basically taking four teeth out to make enough room for the teeth that you have there and straightening them out. So I'm not doing this to indict the orthodontist and be like, oh, you should never pull these teeth on these patients, you didn't know better and you treated the symptom right.

52:17 You waited until the teeth came in crooked. You pulled teeth along the way and then you straighten them out. A lot of these patients and I'm sure you've seen this, melissa, in your practices that you've been involved in, a lot of these patients who are bruxing, who have airway problems as adults did, have teeth pulled when they were, when they were kids. Again, not that the teeth pulling caused it. It's that these patients were airway patients way back then and no one recognized it. No one detected it because their teeth, they just treated their teeth and then again take it beyond the dental arena. Then they go to the physician and they're having psychological issues, right, depression issues, anxiety disorders. Throw medication at them yeah, not getting at the cause of it. Then the general dentist Now they're in their 20s or 30s.

52:59 They notice they're clenching and grinding their teeth all the time. Make them a night guard, right and the jaw joints start to hurt. Make them a night, a bruxing appliance or a night guard, and then they start to have hypertension and maybe elevated blood glucose or type 2 diabetes. Put them on the physician put them on a medication. That's that 2.0 concept that peter atia talks about treating the symptoms instead of saying what is going on with this patient. So that is, to me, again, the primary role of the dental professional in adults. Then, once you have that, that is where you need to onboard a sleep physician much more quickly in an adult patient and get them evaluated, because there's something.

53:41 There's obstructive sleep apnea, which is typically what it is in kids. It's very rarely central sleep apnea in children. It can be, but it's very rare. The converse is true in adults, or I shouldn't say that, actually the the adults it can be either, and so you can have central sleep apnea and or obstructive sleep apnea, and if it's central and it's more neurologic, there's relieving. The obstruction isn't necessarily going to help that patient, so it can get very, very complicated, and that's what, uh, dave mccarty is talking about in that episode as well, as does Jerry Simmons and Steve Carson said in the other one I've been referencing. So then, what the dentist or orthodontist can do is there are things that can help. So there's something called the mandibular advancement device and that is something that patient wears to bed and it helps posture the lower jaw forward to bring the tongue away from the airway to help it stop it from falling back and obstructing the airway at night, and that can help CPAP obviously, uh, for patients, but some patients are CPAP intolerant or they don't want to wear it.

54:41 Um, but that's trying to force positive pressure down the nose into the lungs to get by, to push that obstruction aside. Um, and then there's something called MMA surgery or maxillomandibular advancement, which is jaw surgery, where you take the upper and lower jaw and you surgically bring them forward to again try to open up that respiratory complex and get the patient more ability to breathe air in through their nose. There's also something done now, often called Marpie, which is essentially you use these little anchors, these mini anchors, like little screws that go up, and you use what people think of as a traditional expander, like the thing you turn and crank, and it's screwed into the palate instead of anchored on the teeth.

55:26 And we're finding now that you can use these and actually split your upper jawbone. It sounds horrific, but the upper jawbone. It sounds horrific, but the upper jawbone is like a zipper in the middle of it and that zipper, when you're a kid, is like totally separate. There's space in between and that's where they grow from. It's like the soft spots kind of in a child's head. Right the bones are separate so that they can grow. As you stop growing those bones come together and they don't technically really fuse, they interdigitate. So it's like a zipper that's locked and you can, if you apply the force properly. We now know you can split that, and so that can sometimes be done with an addition of a little cut in the middle of the palate, in the middle of the roof of the mouth, to like cut the suture up a little bit, free it up, and then you put that anchor in and turn it and try to get that expansion again, not just to expand the mouth but to expand the nasal cavity as well and help facilitate nasal breathing.

56:22 So there's a lot going on now that the dentist and orthodontist can be involved in from the sleep and airway perspective. But again, in both cases, but especially, especially with adults, you're not treating your dental provider, isn't treating the airway. In that sense they are trying to help you manage the problem in the adult or provide treatment to what I like to call normalize the anatomy, meaning the more normal we can get your anatomy, the better the chance you are going to be a nasal breather Right, and so in a child, people are like well, the orthodontist job isn't to treat airway, that's the physician's job. Great, I agree. My job is to normalize the craniofacial growth and development, though, and we know that patients who have more normal craniofacial growth and development breathe through their noses more easily.

57:09 So, especially if you've gotten them to the allergist and ENT, et cetera, to free up any obstructions. So that's my objective In adults. That's the concept of what you're doing with that MARPI, what you're doing with the maxillum endibular advancement, what you're doing just when they wear that appliance at night to bring the jaw forward. You're trying to normalize the anatomy so that they can become a nasal breather. Nasal breather. I love that you explained that and this will be so good for people listening. I have this question all the time. You know a lot of people now are, you know, talk about the mouth taping and utilizing that and they're always oh, which one should I use? You know, but I don't like to have the taping. Some of them say, oh, I've got my lotion on, is there anything else?

57:59 So what? What do you recommend? Like? What's your thoughts about the mouth taping? Or, if somebody didn't like the mouth taping, what's another option if they want to get started with practicing nose breathing? I feel that to do that, people should really get a workup first from their dental professional physician, both to know why they are not breathing properly. Because if you have and I've had people, multiple people on my show, talk about this as well If you have obstruction of your nasal passageways from like chronic, you know, allergic rhinitis or turbulent, turbulent inflammation, turbulent hypertrophy or obstructive adenoids, and you tape your mouth your mouth's how you survive. So you're going to put tremendous strain on your system when you do that, because you physically can't get air in through your nose, right?

58:48 So if you block the mouth, you're creating another problem. So if you don't know what your obstruction is due to or what's being caused by, you have to be careful with that. Now, can it work in some patients? I'll admit I use mouth tape. I started a few months back, maybe six months ago and because I've had two sinus surgeries. I have terrible allergies and I had my first one in 06. I had another one in 2009. And I have to irrigate daily and I have all these other issues with my sinuses. So for me, I have been cleared out. My nasal passageways are clear, but I have narrow nasal passageways and something called my nasal valve, which is on the side when you breathe in like mine, go in.

59:31 They shouldn't go in. They shouldn't go in and collapse. So I'll use a breathe right strip to help keep the nasal, my nasal valves out and mouth tape to then force myself because I have the patency in my nose to breathe through my nose. I don't have obstructive sleep apnea. My tongue isn't falling back and blocking my airway. That works great for me. But I know my anatomy. I've been, I'm still, under the care of an ENT and an allergist, and I know from reading my own scans and having surgeries what my situation is. So for me it was just kind of opening my mouth when I slept, because it was easier to get air through my mouth, because my nose is narrower and I've had multiple and I have chronic allergies, but I'm you know that wasn.

1:00:14 But by doing this it helps me be an obligate nasal breather. That's different, though. If you did this to me before I had my surgeries 20 years ago, how would I breathe? So people need to be careful just throwing mouth tape on or a breathe right strip on, because you could be covering up the problem or making it worse if you don't really know what you're treating yeah, does that make sense? That's a good point. No, I like that. That's kind of like the patient's asking oh, teeth whitening, let's do that. I'm like well, let's take care of the decay or periodontal disease. That's more important, right, right, let's figure out what's going on. Yeah, what's going on first. Yeah, yeah. It can be great. It's just it might not be for, it's not for everybody, and you need to know if it's for you, which is really where your physician, your dentist and dentist coordinating with the physician in the case of adults should be should be involved in that decision-making process.

1:01:06 It means that a lot of those things are over the counter remedies that we all hear about and people try, but if you don't know why you're snoring, just taping your mouth shut isn't necessarily going to solve the problem. Yeah, keep asking questions, getting to the root cause and, yeah, then bypassing it. Yeah, I'm definitely very big at being my own advocate for my health and that's why I see so many specialists, even when it comes to my children, and sometimes it's overwhelming, you know. It's overwhelming for for parents and for people. So this is great to have these podcasts to talk about it and share the information for the root cause. So I really appreciate you taking the time to be on here today and, um, I know there's going to be a lot of parents listening and they're going to be well guided now and ask the right questions and what to look for.

1:01:55 So it's, it's always a relief, you know, when you're like, oh, this is why and there's, there's, you know I can help my child, you know, cause they see them struggling, you know, throughout the day, behaviorally or so. Parents know best. That's where I've had people say to me oh well, you know you need a sleep study on this child and I'll talk to them about the inaccuracies of sleep studies on children and say I will take a parent's recount of their child's issues, description of the child's issues in a video that that parent takes of that child any day over. What happens in a one night random sleep lab study that I don't even know the accuracy of, who did it, the reliability of the type of scoring they were using.

1:02:36 You know not that they're invalid, and there definitely are things you can, insights you can, there's, there are data there you can take from those studies. But as the end all be all, I'll take a mom and a mom's intuition that something is wrong with you, right, like I mean you were talking about it before. You knew that there was something not right. You knew he wasn't breathing properly. So if you're a mom out there or a dad but I feel like moms have a little more of that instinct and you see that happening fight for your child. Do not let your child continue to suffer being a snore or a mouth breather and let providers tell you that's okay, and that goes for medical providers, dental providers. It's not okay and our pediatricians need to do a better job on this, and I'm going to call out the pediatricians on this.

1:03:19 So often it's like, unless they get strep five times a year, unless they, pediatricians need to be more proactive as well. They need to start to ask airway questions and breathing questions and sleep questions of their patients. So that's another mission. Yes, because then the kids get these sinus infections or they'll get infected, so they're given all the antibiotics and that's goes down the whole rabbit hole I'm going into with the gut health, you know, and that creates a whole other mental health issues for kids to get issues. So so, yeah, no, I appreciate it so much. So how can people find you? Because you've got a fantastic podcast. I listen to it all the time and I learn so much, and then I can carry that on when I'm at work and educate people and tell them to listen to you and give them great advice.

1:04:04 So, yeah, tell our audience how to find you. Yeah, so people can email me if they would like. It's drmikeattheorthocoachcom. Um on um YouTube. That's at Duluc orthodontic coaching. That's where we post a lot. I don't do a ton, I just kind of post the podcasts on there. Uh, where the podcast typically gets listened to by most is on Apple or Spotify and if you just search for the doc podcast, so it's the, the T-H-E and then separate word D-O-C, doc stands for Duluth Orthodontic Coaching, and then podcast. That will come up on there. And yeah, it's been really exciting. I mean, the show has grown so much in the past six to nine months. I started it two years ago and it just kind of just an idea that really my wife had.

1:04:46 She was like she just podcast about this. How do you get cause? I didn't know how to get the content out, much like yourself. So how do I get the message out? And and it just led to that. And now the show has gotten really big. I just uh, this week I'm up in the pushing episode one 10. I'm up towards that range. Yeah, you're really good. You're really good at it, and I remember how I got introduced to you. I don't even remember how you had found me, but you had me as a guest on your podcast in September or October. Yeah, yeah, it was great having you on. I really that's been a really, really listened to episode by a lot of people. I've got a lot of amazing feedback for your, your story on that and Instagram. At the ortho coach, I'm working on my Instagram game. I need some help.

1:05:27 My daughters, my teenage daughters I'm always like, yeah, I got to get some help from you guys. Yeah, they're really good. My daughter is even better than I am sometimes, but I'm building that and try to put more and more content there. Okay, fantastic. Well, thank you for what you're doing. I really it's awesome that you're trying to get the message out and reaching the parents. It's so big and I really appreciate you having me on to try to spread that message. Absolutely Well. Thank you, it was my pleasure. Thanks, Melissa. I created this podcast because I know as a parent how hard it is to see your child struggle and you can't pinpoint what's the root cause. So I'm sharing my own journey with my son and airway obstruction and sleep disturbances, and that's why I wanted to have Dr DeLuke on.

1:06:11 So I hope this was helpful to nudge you in the right direction as well for your own children, and because, at the bottom of my heart, this is something that we need to create a movement, educate. So once you learn this as a parent, pass it on to other parents. I hope you enjoyed this and I do it just out of my passion for you to guide you the right direction for the health of your children. Just like Dr Mike said, don't be afraid to fight for your kids' health. Follow, like and subscribe. I can't wait to see you again.