Missing the Forest for the Trees

Your dentist may just be the one who keeps you from having a heart attack in your sleep.

Wait, what?

You read that right. While your typical dental check-up will probably involve filling out forms, xrays, getting poked in the gums, a cleaning, and someone inevitably telling you that you should floss more, it might also save your life.

To which the typical response is, maybe even what you’re thinking right now: “C’mon Katie. Let’s not be dramatic. You’re a dentist . . . we get it, you’re a ‘doctor’ (picture me doing air quotes here) . . . but you do teeth. Not life and death.”

In the first ten years of my career, I generally would have had the same thoughts. Gums. Teeth. The occasional TMJ issue. These are the wheelhouses of the dental professional, and those were the lanes we were trained to stay in. Sure, I was taught in dental school about the proven relationship between gum disease and diabetes and premature births, so I knew that poor gum health could cause adverse health outcomes, but I had resolved to stay in my gum/tooth lane and leave those discussions primarily to my physician colleagues.

And then I fell down the rabbit hole. A very, deep, long, confronting rabbit hole.

As a general dentist, I’ve had the privilege to have spent my career treating both adults and children. I spent six years early in my career in a pediatric office (initially due to the opportunity for loan repayment) despite the fact that treating children generally terrified me during dental school and I had no intention of doing much of it once I graduated. As the universe would have it, I gained experience and skill in pediatric dentistry over those years not in a formal pediatric residency, but in a baptism by fire. I grew to love treating pediatric patients. And doing it four days a week for six years, I got pretty good at it. In my career since, a good portion of my practice has been dedicated to children and adolescents, including my current faculty position at my alma mater.

Even so, I spent the first ten years of my career ignorant to the epidemic issue that was sitting right in front of my face ten, fifteen, maybe twenty times a day. I can’t tell you how many times a parent would come in for their child’s checkup, and after the inevitable reassuring sigh that followed the news that their child was cavity-free, would say, “Actually, I have more question. He grinds his teeth at night SO BAD that we can hear him from our room. Is there anything we can do about that?”

And this is where “you don’t know what you don’t know” was on full display via the completely wrong, backwards, and unfortunate advice I gave to more parents that I care to count. “Oh no, don’t worry about that . . . he’ll grow out of that when his adult teeth come in.”

Now picture my teeth-clenched “yikes” face (you know the emoji I’m talking about—that one).

I. Was. Wrong.

Why was I telling this to parents? Well, the honest answer is because I had heard dentists with much more experienced than I, both in dental school and after graduation, say the exact same thing many times. So, like a parrot, I repeated it. Because they must know, right? To be fair, the dentists I heard that from were all excellent dentists. I would have trusted any of them with my own or my children’s care. But in hindsight, I realized that it’s an all-too-common occurrence that the people we look to as “experts” are often just quoting the previous “experts,” and in some cases, those experts didn’t know what they didn’t know either.

In 2020, I enrolled in a continuing education course that completely changed the way I practiced dentistry. Two of my close friends and colleagues, both of whom I still practice with today, were already fully committed to implementing complete health dentistry (i.e. your mouth is connected to the rest of your body and as dentists we should evaluate and treat patients accordingly). They had introduced me to many oral-systemic connection concepts, and as a health care provider, I decided I wanted to take a deeper dive into this pool of knowledge, particularly where it affected the children I was treating. The rabbit hole I jumped into was indeed long and deep. But it wasn’t dark. It was full of light. In actuality, it was one of the most glaringly bright moments of my life. It was one of those pivotal experiences where I felt like I had finally stepped far enough away from the trees to see the forest. And once you know there’s a forest, you see every tree differently.

So what was this mind-blowing discovery that changed the way I look at every patient, child and adult, to this day? It was the realization that a person’s ability to breathe properly, particularly during sleep, has a profound effect on almost every bodily function, including growth, development, immune response, hormone regulation, daytime performance, cardiovascular health, metabolism, mood, behavior, and yes, teeth too. As I listened to the presenters in this course make the case for early intervention in sleep disordered breathing, the onslaught of information became deeply personal. It wasn’t just that they had accurately described many of my patients and the multitude of dental and health complications I saw presenting in my dental chair every day. It was because they had described me. To a tee. I WAS this kid. Who grew into an adult who still struggled with mouth breathing at night. And allergies. And sinus infections. And had to have nasal surgery and orthodontics . . . twice. I suddenly had an explanation for my childhood restless sleep, mouth breathing, teeth grinding, asthma, night sweats, and persistent anxiety over not getting enough sleep. If only my parents had known. But they didn’t. Neither did I, even as my oldest son showed many of the same signs in his earliest years. Neither did the pediatricians at one of the biggest, most successful practices in my community. I know this, because in an effort to collaborate with more of my medical colleagues, I presented this information to them over a lunch at their office, and they flat out told me they had no training in this area during medical school. Neither did the couple who drove two hours to bring their daughter to me, after seeing some of my related posts on social media, EVEN THOUGH THEY WERE BOTH DENTISTS THEMSELVES.

One of my eight year old patients came in for his routine checkup, and upon noticing his evolving bite issues, I of course discussed the need for orthodontics with his mom. But with my newfound forest vs. trees perspective, I also presented her with a questionnaire that screened for signs of sleep disordered breathing, as I now knew that his ill-developing bite was possibly just one of many manifestations of a larger problem. This mom, like most parents, was a little confused at first as to why the dentist was inquiring about symptoms like ADHD, restless sleep, bedwetting, night sweats, snoring, mouth breathing, and behavior issues. But her confusion was quickly replaced with a pleading, hopeful look, as she then began to explain that her son suffered from severe night sweats. So bad in fact, that she had to wash the bedding every night because he completely soaked his clothes and sheets. Every. Single. Night. She then went on to explain that the pediatrician couldn’t find any explanation and had referred them to a pediatric endocrinologist, who tested for diabetes among other possible causes. Everything came back “normal,” and this mom was told that he was “fine” and that “he would probably outgrow it at some point.” Her mom intuition knew that he was not indeed fine, but with the experts telling her that he was, she was starting to lose hope that she would find a solution for her son. Having heard this mom’s desperation and knowing based on the answers on her questionnaire that there was likely a root cause related to sleep disordered breathing, we decided to try a new approach. Her son started sleeping in a removable habit appliance (we call it a mouth guard with the kids), and within seven days, this eight year old’s night sweats had stopped completely and never came back.

That case alone was enough for me to commit to helping as many kids as early as possible who showed similar signs and symptoms, including my own three boys. But in four years, I’ve lost count of the children who have had significant improvement in their quality of life, health, and well-being, simply because they can breathe better. Some of the results are dramatic, like the night sweats case above. And some are more subtle, but still improved. In any case, treating the root cause of a problem is at the core of our practice philosophy, and we began to actively seek out professional colleagues in the medical and therapeutic space who shared that philosophy. We now have a pretty kickass collaboration between primary care physicians, ENTs, myofunctional therapists, orthodontists, functional nutrition docs, and chiropractors who we trust to help us get our patients well. And every single one of those folks understands that none of us has all of the answers. It’s the commitment to treating the root cause, collaboration, and open-mindedness that actually improves a patient’s health instead of simply masking their symptoms.

So what does this all have to do with keeping you from dying in your sleep? Well, as it turns out, the majority of children who present with sleep disordered breathing don’t grow out of it. They grow into it. And in turn, they become adults with many of the same issues, only now their body has been doing its best to compensate for decades. So many of the adults that we screen for sleep apnea based on their health histories combined with the obvious signs in their mouths report that they’ve experienced many of those symptoms since childhood. But because there was never any “emergency,” they just learned to live with it and never thought much more about it.

Simplified, sleep apnea is basically a diagnosis of the brain being starved for oxygen. And let me tell you, NOTHING in your body is working the way it should when your brain doesn’t have enough oxygen. In order for your body to restore and recover every night, you must get the required amount of deep sleep. Deep sleep is when all of the reset, cleanup, priming, and readying happens so your body can perform at its full potential. Deep sleep directly influences the quality of your immune system, metabolism, hormone regulation, memory, and cognitive function, just to name a few. If your brain has to wake you up constantly during the night just to breathe (which you may or may not be aware of by the way), then you aren’t getting deep sleep. And if your brain needs more oxygen, it will employ all measures to do so, including raising your blood pressure and heartrate to pump more blood to itself in order to save itself, sometimes past the point that your cardiovascular system can handle. This is precisely why people with untreated sleep apnea are 140% more likely to die of heart failure.

So yes, in our practice, if we see the signs in your mouth that identify you as a high risk patient for sleep disordered breathing, we are going to have that conversation. And no, you telling me that you “think you sleep fine,” unfortunately isn’t very reliable information. I’ve had too many patients say those exact words, only to take a sleep test and find out that they had severe sleep apnea. Most of whom, when I ask them if anyone talked to them about potential sleep apnea before the dentist, reply that they had no idea.

When you’re at high risk of an airway disorder, getting tested is simple and potentially life-saving. It’s routine for people to have bloodwork and blood pressure checked. A sleep test is no different. It’s information. What you choose to do with that information is still up to you. All things considered, avoiding a heart attack is a pretty good reason to take action, and it might actually be the difference between life and death.

And yes, your dentist might just be the one that talks to you about it first.