Episode #306: Future-Focused Dental Sleep Medicine, with Dr. Steve Carstensen

Airway has a butterfly effect. If you don't breathe well, you don't sleep well. And we all know what poor sleep can do to physical and mental health! So, to stress the importance of treating obstructive sleep apnea early, Kirk Behrendt brings in Dr. Steve Carstensen to talk about the potential orthodontic and health disasters when left untreated. Help people breathe better, not just every night, but over their entire lives! To learn how to make the biggest difference in children, listen to Episode 306 of The Best Practices Show!

Main Takeaways:

• Dentists can make a difference in people’s health and lives from infancy to old age.
• Airway is managed differently for adults and children.
• We need to ask if children are sleeping well. There is an inadequate diagnosis for children.
• If a child isn’t sleeping well, it is likely because they aren’t breathing well.
• The new screener tool from the ADA will help identify more at-risk children.
• For adults, other countries are ahead in airway management; the U.S. is tied to CPAP.
• Only 18% of people who are supposed to be using their CPAP use it.
• About 32% of people don't bother with a diagnosis because they don't want to use a CPAP.  

Quotes:

• “My whole life is to make sure that people breathe better every night — and actually, over their whole lives. So, it’s kind of a 4D thing. It’s three dimensions of airway that we all learn about in anatomy class in dental school, plus the fourth dimension of how it affects their lives from their infancy all the way to their old age. And dentists have an amazing and really rewarding way to make a difference in all that.” (06:23—06:51)
• “If the American Dental Association is going to roll out a screener, instead of just making up five questions and thinking, ‘Okay, these must be important because we think they are,’ we’re actually going to have scientists, researchers, and there's a periodontist with a PhD in medical science informatics who is going to help us, and we’re going to make this an unkillable tool for anybody to use. So, the ADA will now have the world’s best tool for identifying children at risk for breathing problems. That's a powerful thing because it takes that out of the hands of, ‘Well, I think they breathe okay,’ into something that's really important.” (12:49—13:31)
• “There're 163,000 practicing dentists. There're only a few thousand practicing physicians, and out of those few thousand practicing sleep physicians, there're only a few hundred, maybe not even 200, that are practicing pediatric sleep medicine, because the biggest difference is we manage airway completely differently for adults and kids.” (14:17—14:41)
• “Sleep physicians don't really have a ton of tools to work with little kids. Plus, the problems are different. So, our screener tool is going to be aimed at identifying those problems, what's going south about these kids’ health and behavior and issues every day, every night, that we can intervene as dentists. Because actually, we’re the ones who are going to be in charge of fixing the problems that we are identifying.” (14:43—15:08)
• “If we can identify a four-year-old whose maxilla isn't growing correctly because they don't swallow right because they don't breathe right, then know that by the time they're 12, they're going to be an orthodontic mess. What if we can fix it when they're five? We can make them breathe better and have a better bite.” (15:37—15:53)
• “If we’re thinking about adults, then other countries are ahead of us [in airway management], because we in the United States are tied down to CPAP. If you go to get a diagnosis, then you're going to get a CPAP from most sleep physicians. And the sleep physicians are kind of just zeroed in on that.” (16:13—16:33)
• “In 2021, Phillips, one of two giant companies making CPAPs, produced a very cool infographic for World Sleep Day on March 21st. What they came up with is they interviewed 13,000 adults in 13 countries, so 1,000 per country, and it was scary numbers on some of these things. And a couple of big numbers that popped out is, only 18% of the people that are supposed to be using their CPAP were actually using their CPAP. Another big scary number was, 32% of the people said, ‘You know what? I'm not even going to go get a diagnosis because I don't want to use a CPAP.’ So, are other countries ahead of us? Yes.” (16:36—17:28)
• “I read the paper this morning, and there was an article there about a new drug for ADHD. And it talked in there about 30% of kids are getting some kind of medication for ADHD. I was like, ‘Oh my God.’ Because why would a child’s brain not be ready for the day? Why do they need ADHD medications to get their way through a day with reasonable behavior? It’s because they're not sleeping well. There’re experts in sleep medicine who tell us this, who've told us this for decades. Yet, the pattern in the United States is to give kids a pill.” (18:42—19:20)
• “What we have to do is look at, ‘Well, are the kids sleeping well?’ And the only reason for a child not to sleep well is because they can't breathe well. Now, of course there are outliers. But if we talk about the majority of children who aren't getting a good day at school, it’s because they didn't get a good night’s sleep. And why can't they do that? Because their structure isn't there to breathe well. And dentists have a massive ability to make a difference in that, because there's inadequate diagnosis across the board, but there's really inadequate diagnosis of children.” (19:24—19:59)
• “When mom learns that their child has a pathway to breathe better, they're going to say, ‘Okay. What do I do? How do I make this happen? Money is not an issue. My child is going to breathe better if you do something. I'm in. I want to make sure they don't grow up like dad, who snores.’ I mean, all kinds of motivation. There’s going to be huge demand by moms. And when moms make demands, professionals listen.” (22:24—22:48)
• “If we think about diagnosing obstructive sleep apnea, the affliction that gets all the adults in trouble, kids don't have as much OSA. They have some, and we have to be cautious of that. But they respond quite differently, and sleep testing for kids is very challenging. One of the things we’re going to do with our validation study of our new screener tool is we’re going to actually test home sleep apnea tests for kids so we can see how those new tests run. One of them is a ring on a finger that's pretty powerful. And we think we have good hope for that one. But that hasn't been tested very well yet.” (25:45—26:20)
• “We can now intervene on that little soft maxilla and we can push that maxilla sideways with expanders. We can make more space. We can make that nose bigger. We can stretch that palate out so it’s not a bunched-up drape anymore. We can stimulate the lower jaw to come forward so we bring the base of the tongue forward off the back of the throat, all while the child is four, five, six years old. And so, now, we set that child up on a whole new pathway. And the only people that can do that is dentists.” (29:53—30:21)
• “We produce a chemical in our sinuses called nitric oxide that helps us process oxygen better in our lungs. But that's not the biggest thing in a four-year-old. The biggest thing is the fact that the maxilla is a plastic structure at that state; they're growing. It’s moving, it’s becoming influenced by these muscle forces. Not true in a 14-year-old or a 44-year-old, but it’s absolutely true in a four-year-old. So, we have one decade of opportunity from zero to nine to make a difference in how these structures grow up. And there's nobody that pays attention to zero through nine-year-olds better than pediatric dentists, orthodontists, and family dentists. And so, that's going to be the group that's going to make the giant differences going forward.” (31:18—32:05)
• “Think a little bit about getting nice straight teeth and a beautiful smile. Those are wonderful goals. But what we actually have to think about is why are those bones there. They're there to hold the teeth. They're also there to frame the airway.” (32:07—32:20)
• “I went to the Safeway here and looked at the children’s food aisle. And I found that kids don't eat food anymore. They squeeze food out of bags. And what Kevin Boyd’s theory is is that a few hundred years ago when we softened our food with cooking and grains and things like this, we stopped chewing. And then, parents apparently get very concerned about the possibility of children choking on eating a carrot, so they give them smushed up carrots in a bag. And so, the bones and muscles that are designed to chew through things to develop properly are not being asked to do that.” (32:56—33:32)
• “Everybody understands the value of exercise. But the jaw muscles need to exercise as well. The bones need to exercise. The teeth need to exercise. And so, we give little ones something to chew. Challenging food is what some of the experts say. Robert Lustig is a great writer about this. Give them challenging food, food that makes them work to eat — not dangerous food, but challenging food. Put the muscles and bones and teeth to work the way they're supposed to, and that'll help alleviate quite a bit of this growth and development issue.” (33:59—34:32)
• “The definition of dentistry says that we have responsibility for the oral cavity, the jaw joints. But the ADA definition also says that we have the ability to impact and pay attention to adjacent and associated structures and their impact on the rest of the human body. What's adjacent to the mouth? The nose. Why is that something that we should pay attention to? Well, it’s because as airway-oriented dentists, we can help move the posterior airway open by moving the jaw forward; that's true. But if they can't breathe well through their nose, there're lots of ramifications for that.” (42:41—43:23)
• “If we think just about obstructive sleep apnea in adults, if they can't breathe through their nose, well, then they must be a mouth-breather. What is that going to do? That's going to increase caries. That's going to increase periodontal disease and inflammation in the mouth. It’s going to make it much more likely to have TMD issues if they can't breathe well through their nose because of some ways that the body interprets the airflow. And if they can't breathe well through their nose, their lung function isn't going to be good enough. They're going to have intermittent hypoxemia, when their oxygen levels fluctuate up and down because they can't breathe through their nose, and their body hurts, and part of their jaws hurt.” (43:23—44:06)
• “When somebody comes back from oral appliance therapy and they say, ‘I can't believe sleeping is this good. I love my life,’ that is so heartwarming. When moms come back and say, ‘My son in school is a different kid. The teachers are calling in, ‘What happened?’ because they're just doing so much better.’ It doesn't take very many of those kinds of stories to make sure that you're going to be having energy, the time, the money, the resources, the effort, to listen to the podcasts, to attend the classes, to buy the books, to do all the things that we do as learners to impact our patients’ lives.” (50:40—51:22)

Snippets:

• Dr. Carstensen’s background. (03:14—06:59)
• Why dental sleep medicine is an important conversation. (07:27—09:02)
• CAST (Children’s Airway Screener Taskforce). (09:03—11:56)
• Why it’s been difficult to standardize screeners. (12:06—13:31)
• What percentage of dentists have incorporated DSM? (13:58—15:53)
• Is the U.S. leading the way in airway management? (16:10—17:53)
• There's an inadequate diagnosis in children. (18:41—20:52)
• How important is airway to the future? (21:20—22:49)
• How well has the orthodontic world adapted to this? (23:10—24:17)
• The future of technology in DSM. (24:52—26:34)
• Why are palates different now than 30 years ago? (27:04—30:21)
• Breathing through the mouth versus the nose. (31:11—32:20)
• Historical diets and development/inadequate development on airway structures. (32:34—34:49)
• Breastfeeding and palate development. (35:02—36:06)
• Current great textbooks on DSM. (36:49—39:14)
• The current reality of home sleep apnea tests. (39:16—42:08)
• Non-dental skills or support to help create an airway management center. (42:28—45:43)
• Last thoughts on the future of DSM. (46:06—48:19)
• Dr. Carstensen’s contact information and conclusion. (48:35—52:06)
• Articulating the value of airway to patients. (52:35—54:14)

Reach Out to Dr. Carstensen:

Seattle Sleep Education: https://seattlesleepeducation.com/

Dr. Carstensen’s email: [email protected] 

Dr. Carstensen’s Facebook: https://www.facebook.com/steve.carstensen.35

@swcdds

Further Reading:

Sleep Medicine for Dentists (Second Edition) by Gilles J. Lavigne: https://www.amazon.com/Sleep-Medicine-Dentists-Evidence-Based-Overview-ebook/dp/B085QKH9V7

The Clinician’s Handbook for Dental Sleep Medicine by Ken Berley: https://www.amazon.com/Clinicians-Handbook-Dental-Sleep-Medicine/dp/0867158131

Books by Robert Lustig: https://www.amazon.com/Books-Robert-H-Lustig/s?rh=n%3A283155%2Cp_27%3ARobert+H.+Lustig

American Academy of Physiological Medicine & Dentistry: https://www.aapmd.org/

American Academy for Oral Systemic Health: https://www.aaosh.org/

Collaboration Cures 2021 registration: https://www.aaosh.org/2021-scientific-session  

Foundation for Airway Health: https://www.airwayhealth.org/

ASAP Pathway: https://www.asappathway.com/

Dr. Steve Carstensen Bio:

After Dr. Carstensen graduated from Baylor College of Dentistry in 1983, he and his wife, Midge, a dental hygienist, started a private practice of general dentistry in Texas before moving to native Seattle in 1990.

In 1996, he achieved Fellowship in the Academy of General Dentists in recognition of over 3,000 hours of advanced education in dentistry, with an increasing amount of time in both practice and classwork devoted to sleep medicine. A lifelong educator himself, Dr. Steve is currently the Sleep Education Director for both Pankey Institute and Spear Education, recognized as among the finest places for dentists to further their education. As a volunteer leader for the American Dental Association, he was a Program Chairman and General Chairman for the Annual Session, the biggest educational event the Association sponsors.

He’s a Consultant to the American Dental Association for sleep-related breathing disorders and co-author of a textbook for dentists treating the disease.

For the American Academy of Dental Sleep Medicine, he’s been a Board Member, Secretary-Treasurer, and President-Elect. In 2006, he achieved Certification by the American Board of Dental Sleep Medicine.