Dr David McIntosh
Samantha was noted to snore a lot at the age of three, so her family took her to see a general ENT surgeon on the advice of their GP. The surgeon suggested a nasal steroid spray to try and improve her breathing, and advised the family not to worry. They used the spray for a few months and noticed that, while it helped, it did not stop the problem entirely. However, they decided not to worry, as the surgeon had assured them that the breathing issues would sort themselves out over time.
Things were left until Samantha turned seven, when the family were prompted to follow up the issue after her teacher noticed she was struggling to focus in class. At first, it was thought to be related to her vision, and glasses seemed to improve things slightly. However, six months later her mum noticed she was having problems following verbal instructions, so Samantha was sent for a hearing test. It was a standard test, and the results came back as normal.
Since the first ENT review, Samantha had continued to snore. She was also sleep talking, grinding her teeth in her sleep and sometimes having night terrors. She slept with her mouth open, and her head arched back.
From the age of nine, Samantha’s school work deteriorated and her new teacher expressed concerns about her performance. She was referred to an educational psychologist, who identified some difficulties in literacy and numeracy. It was noted that she came across as being lazy, easily distracted, and had a poor ability to focus on tasks. Her temper was also becoming an issue, and she started having problems controlling her emotions.
Samantha was also advised to see an orthodontist by her regular dentist. She had developed a malocclusion with a narrow maxilla and had an expansion. The expansion went quite well at the time, but after it was removed a retainer was not advised, and so the teeth started to drift crooked again. The orthodontist reassured Samantha’s family that this was okay, and that braces would be required later down the line.
Around this time, Samantha’s regular dentist sold the clinic to a new practitioner. The new dentist assessed Samantha and her history of mouth breathing, snoring and orthodontic issues, also noting that she had generalised gingivitis. Considering also her poor school performance, the dentist queried if an ENT review had been undertaken. Samantha’s mum explained that this had been done at age three, and that they were told not to worry about the snoring. The new dentist strongly advised seeking a new opinion from a paediatric ENT that specialised in airway problems and that worked closely with dentists.
Samantha’s mum drove her daughter three hours to see the specialist, who took into account Samantha’s history so far, and then proceeded to examine her. The ears were normal, and the tongue and tonsils were also okay; however, examination of the nose from the front showed large inferior nasal turbinates, causing near total blockage of the nasal passages. The specialist then proceeded to use a nasal telescope to fully examine the upper airway, and in doing so found the adenoids to be enlarged to the point of causing about 75% obstruction of the back of the nose. With these findings, and the history of long standing problems, the specialist recommended surgery to remove the adenoids and to reduce the size of the nasal turbinates.
The procedure was carried out as a day stay operation under general anaesthesia. Samantha was initially a bit congested from the swelling of surgery, but once this passed, Samantha, as well as her family and teachers, noticed a marked improvement in her ability to concentrate and focus on tasks.
She was less anxious, less prone to being emotional, and had no further issues with outbursts of anger. Her teeth grinding stopped, she slept with her mouth closed, and the sleep talking dissipated. Whilst she still ended up needing braces, her dentist noticed that her gingival inflammation was much better when she stopped having to rely on mouth breathing. The family were extremely grateful that the new dentist had looked at things from a thorough perspective of dealing with breathing problems.
The Dentolegal Adviser's perspective
Dr Mike Rutherford, Brisbane Office
The relationship between breathing obstruction and associated mood and learning difficulties has only recently gained widespread acceptance by psychologists and ENTs. This relationship has traditionally not been taught in dental schools and is poorly understood in the Australian dental community.
Dentists are well placed to examine oral abnormalities and initiate the referral process to an ENT. This article, by case example, seeks to prompt dentists to consider these possibilities when examining children and to widen the scope of questions to parents. It is hoped to develop an interest and lead to some reading in this area.
This article links to a lecture to be presented by Dr McIntosh at YDC. Younger practitioners are more likely to accept new ideas and continue further education in this area.