Today I interviewed Dr. Shereen Lim!
Dr. Shereen Lim is a Perth-based dentist with a postgraduate diploma in dental sleep medicine from the University of Western Australia.
She has been involved in the team management of snoring and obstructive sleep apnoea since 2011.
Dr. Lim is dedicated to promoting airway health from infancy as an alternative approach to minimize the development of these problems, and is the author of the book “Breathe, Sleep, Thrive: Discover How Airway Health Can Unlock Your Child’s Greater Health, Learning, and Potential.”
I am so excited that she is here with us today to share her expertise and her book. It is amazing and I really think it’s going to help so many people. We talk about why she wrote the book and what she would like parents to know. The book is divided into three main sections: Part I sleep and airway health, Part II What to look at for early intervention, and then Part III What to do to restore health if we didn’t repair in early intervention.
I love how simple this book is to follow and the information you share.
Dr. Lim: Thanks for having me, Sheree. I really appreciate this opportunity. Why I wrote the book is I basically got involved in gentle sleep medicine about 12 years ago. It was prompted by my husband snoring, really frustrating. So I decided that I was going to learn more about how to help manage the dental appliances so that I could help other spouses that were in the same frustrating situation. That’s when I enrolled in a graduate diploma in Dental Sleep Medicine. I became able to accept referrals from sleep physicians to manage this problem. I started to notice with these patients, It’s not just storing, a lot of them have significant health conditions and poor quality of life without refreshing sleep brain fog depression, and anxiety too. We are really treating a craniofacial problem.
It’s a problem of poor jaw development. And people have suffered for decades, and we’ve missed that opportunity to grow the jaws properly in the first place. So that’s why I wanted to write this book to help parents understand that these problems are developed, they have their developmental origins from infancy and if we know what to look for, we can actually make a difference and ultra that trajectory of development.
Sheree: I’m glad that you start with that because, in the dental hygiene world in the dental field, many professionals tell parents to wait until they lose out their baby teeth to see an orthodontist when they’re seven or eight, but we’ve missed that growth potential when we do that.
Can you tell us a little bit about when you think parents should start looking at this and when to assess it and then who they can look for to get help not all dentists are knowledgeable on this subject? So you need to find someone that incorporates the airway.
Dr. Lim: Yeah, so the traditional age for early interceptive orthodontics is around age seven to eight years. And you know, when I was doing my Dental Sleep Medicine course, I found research to support that part expansion could improve breathing and sleep apnea. And in practice, we know that when we refer patients for early interceptive orthodontics around the age of eight years, quite often, even then the approach is to just watch and wait just wait till the child is 12 years old, that growth is 90% complete if we’re going to get a more predictable outcome and more efficiently and sometimes we have to take out seek to alleviate dental crowding. However, we haven’t really been able to address the underlying jaw problem. And since her eight years when I met Dr. Christian Guilleminault, one of the pioneers of Sleep Medicine in 2014, I was telling him how his work had really inspired me to learn more about early interceptive orthodontics so I could offer it to children in my practice. And he said to me, if you’re doing palatal expansion, you are too late. I really didn’t know what that meant at that time. But I now understand that what he’s trying to say is that sleep apnea, it’s really a deep jaw problem, and the jaw spawns the framework for our collapsible upper airway and if they’re not formed properly, we’re going to have a deficiency in our breathing or our airway support and the jaws and growing most early in the zero to six years of life.
That’s when we had the most significant jaw development. 60% of treatment is attending those first six years. So that’s really the time that we need to be looking at the problems and when we have poor jaw development, it’s really a reflection of poor muscle function. So the way that the mouth is working, and the tongue in particular has a very important role in sculpting or developing the palate.
So we really need to pay attention to this very early on in life and in so in terms of what to look for and how we optimize that function that provides a stimulus for the jaw development, starting with breastfeeding in the first year of life, that most rapid window of jaw development we want to have optimal breastfeeding, because that’s the one modifiable factor that’s most important, and so we need to have good tongues option with breastfeeding to recognize the mechanical benefits of breastfeeding over bottle feeding because breastfeeding requires tongue suction to tongue lifting up to the roof of the mouth, and then as it pulls it creates a vacuum and that’s how milk is transferred efficiently. And so we want to make sure that we have really good breastfeeding and looking at the compensations such as you know, pain or weight or overuse of lips and cheeks, whether there are any reflux-like symptoms which could reflect or swallowing, suboptimal feeding and poor use of the tongue, what else to look for. So breastfeeding is really important to look for then we want to minimize pacifier use and nasal breathing as well.
With nasal breathing, we have the mouth closed, we have the tongue suction to the roof of the mouth, and that provides the proper stimulus for jaw development.
If the mouth is hanging open, the tongue is more likely to sit low, and we’re not going to get the stimulus. So really, overall, what I really want people to recognize it’s the function, the way that the muscles rest and function that actually determines the jaw growth and we can look at this very, very early on and when we have problems with muscle function, such as speech problems, or difficulties chewing and swallowing, they’re all signs of the muscles not working well. And they’re not going to be providing the proper stimulus for the jaws to grow well.
We really should be looking at it in infancy and how we’re feeding.
Sheree: So what do you recommend for parents that maybe can’t nurse as far as bottles because all bottles aren’t treated the same as well? What should they look for if they’re not able to nurse?
Dr. Lim: Yeah, if people aren’t able to nurse Well, one of the very first things we want to do is to rule out his tongue tie, obviously, which restricts normal tongue elevation. It’s a very hidden and underdiagnosed problem that can contribute to feeding issues. So it’s always good to get that checked out.
In terms of bottles. I’m not really the best expert on that. But I think we want to make sure that we’re using paste feeding or not allowing babies to get the milk out too easily, sort of having the more upright but I think in terms of the bottle selection, it’s not something that I necessarily go into with parents and parents missed that opportunity to do breastfeeding. To really recognize there are many other opportunities along the way as long as we recognize that when we use the bottle we start introducing compensations for the tongue and the other muscles juggle work as well. So a lactation consultant, a feeding specialist, and a myofunctional therapist should all be on the team at the start to help with proper jaw growth.
If that does not happen, there are many opportunities to get that back on track early on in life. So that brings us to the thing we weren’t taught: so we didn’t know that.
What do we do to get on track?
Once we’ve noticed that people are having some of these open mouth postures, weaknesses in the muscles and they’re not able to nasal breathe. The next opportunity really is at the age of six months. Chewing! Chewing is really great, especially for our lower jaw development and to build the tone of all our jaw muscles. I am a really a big advocate for the use of baby munchee or the munchee for babies because what that does, it actually helps provide that increased sensory input that babies need plus that functional stimulus of the jaw so getting them to chew and filling their lip seal promoting nasal breathing and proper swallowing so deactivating some of the facial muscles that may have been overworking through the use of the bottle and just introducing more texture in the first not ever during the purees because that involves a lot of sucking and we want to have more chewing and more use of the jaw muscles.
In terms of the question, what can I do if we missed that boat?
I think chewing is the next most significant thing and really trying to make sure that children have nasal breathing, having a clear nasal airway. So if there is no congestion, do nasal rinses and keep the nose clear. I definitely think that’s good.
We used to be hunter-gatherers and we had different food and now the foods are a lot softer, so we’re mashing them and sucking more than chewing.
Do you notice the mouth breathing? What signs to look for, like Bedwetting, dark circles under their eyes, and things like that? The next most common problem is going to be enlarged adenoids and tonsils around the age of two to three years. The size can cause disruptive sleep and breathing. So the symptoms that you described are symptoms of poor sleep and breathing and looking out for snoring or any sounds that a child makes with their breathing. Breathing should be quiet and breathing to sleep should be still and so any restlessness tossing and turning any unusual sleep positions. Like neck hyperextension and stomach sleeping which could be compensations to improve the airway.
If the child has a restriction such as teeth grinding, bedwetting, or unexplained awakenings, some of these children that come into a mum or dad’s room in the middle of the night because they don’t want to be on their own. Those are the other types of symptoms that we look out for that could indicate that the child is not breathing well.
Sheree: Do you recommend that parents videotape their kids at night when they sleep? Do you recommend sleep studies? Because I know that some of the times that we recommend sleep studies, they come back and they say that the child is not having any issues. So can you talk a little bit about that and what you recommend in that realm?
Dr. Lim: In relation to the video. I think it’s always helpful when parents have concerns or they notice unusual things like a lot of tossing and turning or gasping or snoring to record a video because that’s how you can get taken more seriously and have your concerns validated. But in terms of sleep studies, it’s not something that I refer to regularly, and many of my patients are having these sleep disruptions. The problem with sleep studies is that they are very focused on obstructive sleep apnea, or the more severe reading disruptions to get counted as obstructive sleep apnea, you have to have as a child a minimum of one apnea hypopnea per hour of sleep. So that’s a 10-second pause or restriction in airflow to get counted as obstructive sleep apnea every hour. If that’s nine seconds. Or if it’s eight seconds, it’s not counted. And a lot of the time when you get a sleep study report, they weren’t recognized that a child had one of these events per hour to get counted as obstructive sleep apnea.
For adult they need to have five of these events per hour to get diagnosed, but children only need one and sometimes they use the adult criteria or adult measurements we’ve missed a lot of children get told there are no problems or no obstructive sleep apnea, but that’s really not what we’re looking for. Because if there are more subtle breathing disturbances where their sympathetic nervous system is on high alert, and they’re really responsive to any restriction in airflow, they will actually have arousal from sleep and maybe even grind their teeth to keep their airway open. And so they won’t have these 10-second gaps or hypopneas.
What is still happening is they’re having very disturbed sleep and which can affect their daytime function and is an increased risk of behavioral and learning problems. Children, I think it is better if we can address the snoring or those symptoms rather than the numbers themselves because even snoring has been linked to so many problems in terms of ADHD symptoms, poor attention, concentration, and socio-emotional problems with these children that are having poor emotional regulation or tantrums, meltdowns, and it really affects their learning with you know, research showing that even snoring can alter the brain function or the brain structure. We really need to address that. So sleep studies I think can underscore the severity of the problems if we are looking at those final results and numbers and if I have a child that is having symptoms.
I want to address the risk factors. I don’t need to have a sleep study and a lot of EMTs surgeons are the same if there are enlarged adenoids and tonsils the child is snoring. They’re having difficult behaviors. We don’t necessarily need to have a sleep study.
Sheree: I love that answer because a lot of the doctors are having kids get a sleep study and this is getting missed. You mentioned ADHD and behavior. I think that’s a great segway into that before we put our kids on medications that they’re being diagnosed with ADHD we should look at sleep-disordered breathing.
Dr. Lim: Well, there’s very compelling evidence that there is a link between snoring and obstructive sleep apnea and ADHD symptoms, and that when children have the airway issues addressed specifically with tonsil removal, many children will have these symptoms improved. So I think before we medicate children, it’s really important that we actually investigate any of these underlying breathing disturbances during sleep. So parents need to be able to recognize that we don’t want children to snore and to recognize all those other symptoms we described earlier and get that investigated, and although research tells us that removal of adenoids and tonsils might improve the symptoms in these children, what hasn’t been studied or published as much is other interventions that improve children’s breathing as well. So we do know that pilot expansion is a very important intervention to improve nasal breathing and obstructive sleep apnea. In children.
There hasn’t been much research specifically about the reduction in ADHD symptoms, but it is actually something that I see in practice all the time when we can get a child better sleep, they are going to function better and their behavior is going to be easier to manage.
Sheree: I agree. I saw that with my daughter, which is why I’m into this now and that’s why I love your book because it explains everything that I couldn’t put into words and I didn’t know back then. That’s why I started the Healthy Mouth Movement because it was a way to reach parents and get this information. I’ve been a dental hygienist for over 30 years and I didn’t know how important your tongue was until my daughter started having issues.
So I figure if I’m in the dental field, and I didn’t know this, how many other people didn’t know this? So I am really grateful for doctors like you and people that are in this airway space and for sharing this information because we truly can make a difference and not watch our children suffer as I did. I couldn’t explain that to my daughter. And even me I had my tonsils taken out and removed when I was 16 but still a mouth breather and didn’t know anything about myofunctional therapy and my tongue. So that’s another thing that people can address was myofunctional therapy and you also incorporate that in your practice as well, correct?
Dr. Lim: That’s correct. Because a lot of the time when people have the adenoids and tonsils removed, children will have an improvement in symptoms, but then there are many children that will still have persistent symptoms as well. So a lot of the time parents will say oh, the sleep is much better, but there’s still teeth grinding or bedwetting and snoring and those types of things as well. And so it’s we need to promote more awareness to parents that when children have these types of surgeries, the ultimate goal is really to restore nasal breathing, and obviously color expansion has a really important role in that because the palate is the floor of the nose and when it is narrow expansion is really well supported to expand that nasal floor and improve the nasal airway and improve nasal airflow.
But in addition to that, we need to restore the muscles because a child who has been chronically mouth breathing will have changes in the way that the muscles work to compensate for that obstructive breathing and the open mouth posture, the facet lips, and the facet jaws and we’ve got to really work together to get the muscles working well and that’s where my functional therapy comes through. To get the muscles working well and get the tunnel working well. He’s telling us the most important upper airway, dilated muscle or Virginia bosses step onto the bulk of the town and that means it helps to keep the airway open during sleep. And so we need to get that working well and myofunctional therapy also has a really important role in addressing the underlying dysfunctions that are created for jaw development. So it’s really important to address those to get the stability of the results of any orthodontic treatment we do.
Many of these issues have their roots in my functional disorders and so my functional therapy fills a really important void for those breathing concerns and orthodontic instability and many other issues too.
Sheree: Let’s talk a little bit about expanding the palate. So the Myo munchie is great to start chewing and then the tongue is great for the roof of your mouth because it acts as a natural palatal expander.
For people that aren’t in Australia and can’t see you, what do you recommend that they ask or they look for at the dentist for that early intervention to expand the palate beyond the Myo munchie and your tongue position being up?
Dr. Lim. So the traditional age to begin treatment is seven to eight years. But we don’t necessarily need to wait and I am beginning treatment as early as three to four years for children that are not sleeping well or not functioning well. And so sometimes it is really difficult to find people that will start that early, but generally speaking, if you can find someone that is starting a bit more early, they may be more on board with the airway aspect and sleep aspects.
What would they ask? There are a lot of dentists, especially in the United States that are not airway focused. So we’re trying to get this information out there. In terms of the briefing improvements, what we’re really looking for is any orthodontic expander or appliance that has a screw inside it because we’re looking for skeletal remodeling, which is basically when we can separate the suture the mid-palate suture or the joint between the two halves of the palate and slightly separate them. Then we can stimulate the new bone in the nasal four and then that’s the type of expansion that is proven to help obstructive sleep apnea snoring and more rapidly as well. So we’re trying to look for something along those lines that will actually produce that true bony expansion because there are other things that are promoted things like Myobrace and Healthy Start, I use those in my practice, then my functional training appliances, and they really actually guide the muscles or promote better muscle function so that we can guide better muscle or joint development. However, they’re not really expanders they don’t get the same nasal improvements, things like ours and things like Invisalign. They can actually be really effective at making more space for the total function.
If a child is not breathing really well, it’s ideal if we can get some sort of skeletal expansion where we’re getting that new bone for me. You really need to open the airway so that way the kids can breathe because if you don’t, then they end up usually having a CPAP machine when they get older because they can’t breathe because we didn’t correct these when they were younger.
Sheree: I had a question asked: If they have that done when they’re younger, do they necessarily need braces to straighten their teeth when they get older? if they intervene sooner?
Well, it’s not something that I actually guarantee in practice, so when I’m offering early interceptive orthodontics, I just let patients know that my primary aim is to improve jaw development to improve function. So I’m trying to improve my nasal breathing. I’m trying to improve tongue space and allow space to do myofunctional therapy and establish better function even including speech. So the other thing that I want to let patients know is that when we do this palatal expansion, we also need to address the underlying dysfunction. It needs to be combined with myofunctional therapy to get things working but only there is a tongue tie that needs to be addressed to get the muscles working better because we need that tunnel out the suction to the roof of the mouth. It’s a tongue that is the best orthodontic retainer because it provides support against the inward pressures of the lips and cheeks and so we need to make sure that’s done otherwise I cannot guarantee how stable those results and that is compliance based but in principle, the more we can show the grow the jaws the better space we have for the team to come through. I do think many children will be able to avoid orthodontic treatment or braces but it’s not something that I necessarily guarantee right up front and I’m pretty clear about that.
Thank you for answering that question. Then I had one more question that a parent had asked before we started talking today. What if they don’t want to do myofunctional therapy with a tongue tie? Let’s say we recommend myofunctional therapy with the release. And I’ve had several parents just want to go straight to the release and not do the therapy.
Why do we recommend that therapy and release go hand in hand?
If could tell us a little bit about why we recommend that and what can happen if they don’t do the myofunctional therapy along with the release? So my ultimate goal always is to get the tongue lightly suctioned to the roof of the mouth. It’s the best for breathing and orthodontic stability. And if we don’t do the therapy with the tongue are never going to be able to do that because where is that tongue? We introduced compensations and overuse of the muscles and the tongue doesn’t actually ever get used. It doesn’t develop that tone or coordination necessarily. And so doing a tongue tie release without it may not necessarily change anything, and that means that we’re going to have an increased risk of reattachment or scarring because the tongue isn’t going to adopt new things, new ways of doing things, patterns. So reattachment is basically normal healing when the edges of a wound want to join back together again. And so if we don’t change muscle patterns, we’re not going to get the good healing, we’re going to get more scarring and reattachment and nothing will change so it becomes really pointless.
I try not to rush into some time release. Usually, when I have a child, I will probably do expansion first, because I think that helps restore the proper space for the tongue to kick well, and I think it’s often the most significant intervention out of politics, especially in ways to improve sleep and breathing. So I want to get that quick game and that buys us more time to be able to work with the therapy and do the tongue tie release.
Sheree: Again, another amazing, And there’s so much more in your book that just touched on a little bit as far as the process of what to look for from the beginning all the way up until when they may need an orthodontic evaluation because traditional orthodontics straighten the teeth and you’re looking at much more than that. And I think that this is the wave of the future and your book. As I said, it’s not only good for parents, it’s good for professionals that get a better picture as far as how you put everything together in this book.
What else would you recommend for parents in that age group that we haven’t discussed yet?
What else do we want to look for? For those under 12-year-olds? I think we want to let parents know that if there are any speech concerns or any sort of other mild functional disorders, really, it’s a sign that the muscles aren’t working well. And if they’re not working well for speech or for chewing, that means they’re not going to be working well for sleep as well. All the muscles of the tongue and the throat have a really important role in keeping the airway open during sleep. And so we need to get that working as well. So I’ll see many children that have speech problems that come in through a tongue tie consultation that really we can actually start to hear that they’re having significant problems during sleep and with their daytime function. And so all these things really go hand in hand. And we mustn’t treat things in isolation. So it’s not just a speech problem or a picky eating problem or a breastfeeding problem. It’s really how the muscles are working for sleep and how they’re going to fit the way that the jaws grow. And so we really need greater integration between professions and really trying to optimize those functions. When we say breastfeeding.
It’s not just about no pain and good weight gain. It’s really about making sure those muscles work. early on. And so really recognizing that everyone has their role in the bigger picture. And it’s not just little compartments that we’re working in. It’s putting it all together and connecting the dots and I think that that’s where healthcare right now is kind of failing us a little bit because we treat symptoms so a lot of times especially parents wait until there’s a problem, rather than looking to intervene early on.
I think we need to help people understand that these adult problems we really have this window of childhood to intervene and we want to try to address it early because it’s really hard to connect those dots hence the book, but at the same time I am seeing a few parents where they’re bringing in their children as toddlers are concerned about the mouth breathing and it can be very difficult age I think there is an age of zero to apart from optimizing breastfeeding, zero to three that’s really difficult, really challenging. I think it can create a lot of anxiety. So parents can’t find the right professionals to deal with these problems. And so I think it’s really important to recognize that we still have a window if we can identify really early it’s never going to be one quick fix. It’s all about how we can optimize the way that the muscles are working.
How can we optimize the way that the jaws are working?
Over that period of time, even if we get in before six? It’s still quite a good age to get in. And I think in the future, what I’d really love to see is for parents to have almost a library of things that they can do with their children to still get better muscle function. Things like you know, blowing into a straw blowing bubbles, or putting a pedal path between their lips to help promote lip seals or templates, and lip smacks, just all those little exercises that parents can do at home. It will be really great to see all of us collectively trying to put these resources together for parents so that for those types of age groups that are difficult to find providers, we can actually be helping them do something at home.
Knowledge is power and then we can make a difference and help our children that grow up to struggle and have other issues, even chronic illnesses because a lot of that stems from not getting enough oxygen to the brain because of breathing and sleeping and when you’re not breathing. You know, you don’t get that rest and restoration and that’s when our bodies repair when we sleep.
Absolutely. I think modern health care is really focused on medicating and even things like depression. It’s such a common issue. And one of my colleagues here in Perth did a fantastic study looking at adults with obstructive sleep apnea and seeing the high prevalence of depressive symptoms. And after treatment with the OSA, there were barely any people that had clinical depression. And in that study, 41 people had suicidal thoughts and after treatment, none of them had it and so we need to get away from medicating and get to the bottom of these issues and make sure that we can investigate sleep and really understand that airway health is a really key pillar of health and it’s important as diet or exercise and it’s really commonly overlooked. So we need to get more and more people on board with the importance of healthy breathing. And breathing through our nose and good jaw and airway development from infancy.
Recognizing that we need an integrative approach. And so when we’re coming to nasal breathing just as important as looking at an end to removing obstructions from our nose and throat, we really need to pay attention to the jaws that form the acid framework for the airway, the floor of the nose, the housing for the tongue and that support that collapsible upper airway and so really understanding the role of orthodontics and making sure that we address the poor muscles stimulus, the jaw development as early as possible. So addressing these mild functional disorders and getting the mouth working well as early as we can.
Thank you for sharing this. Thank you for writing the book and I just appreciate everything that you are putting out there and sharing with not only our community.
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