The airways in our pediatric patients

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.