S5 E08: Pediatric Sleep Medicine for Dental Practices

Wright: [00:00:00] Sleep is a vital part of overall health, especially during a child's crucial years of growth and development. Hey, hey, everyone. I'm Dr. ArNelle Wright.

Ioannidou: [00:00:09] And I'm Dr. Effie Ioannidou and today we are talking about why understanding sleep and airway health is so essential for pediatric dentists and more.

Announcer: [00:00:23] From the American Dental Association.

This is Dental Sound Bites created for dentists by dentists. Ready? Let's dive right into real talk on dentistry's daily wins.

Wright: [00:00:40] Well, hey, hey friends, we have a really good show for you today, but first, if you want to be a part of our growing dental soundbites family, please take a moment to subscribe wherever you listen. So you don't miss any new episodes.

Ioannidou: [00:00:54] And don't forget, now you can also watch every episode on the ADA's YouTube channel. I know, it's exciting. They can also see us.

Wright: [00:01:04] I know, which is why I ran and put on some lipstick.

So, we all know that sleep is important and it's really not just any sleep, but quality sleep, and especially for our kiddos today. Joining us on the episode, we have Dr. Loria Nahatis, a pediatric dentist, to teach us more about her sleep medicine journey. Specifically, we're going to be discussing what dentists need to know about sleep and airway health.

Good afternoon or hello, Dr. Nahatis.

Nahatis: [00:01:35] Hi there. How are you?

Wright: [00:01:37] Good.

Ioannidou: [00:01:38] Hello, hello, Dr. Nahatis.

Nahatis: [00:01:41] Hello, Dr. Effie. I'm really happy to be here and I was so thrilled when I received an email asking if I would like to come chat with you ladies. So thank you so much for having me today.

Ioannidou: [00:01:52] It's our pleasure.

Wright: [00:01:53] We're so glad to have you.

Ioannidou: [00:01:54] So Dr. Nahatis, welcome and we are very excited to have you obviously, on the podcast. Tell us a little bit about your background and how and why you got into this sleep medicine thing.

Nahatis: [00:02:05] Yeah. So I am a pediatric dentist, board certified and I practice in Dallas, Texas. I knew from a very young age, actually, Dr. Effie, my uncle in Greece is a dentist in Thessaloniki.

Ioannidou: [00:02:17] Oh, this is where I'm from.

Nahatis: [00:02:19] Oh, awesome. I used to go visit in the summers and I absolutely loved dentistry and then, you know, fast forward to high school, I went in and shadowed somebody and I didn't really love general dentistry as much in the states, at least in Texas. It wasn't like Greece and I just remember everything being so modern and so great. So I decided to be a pediatric dentist, did my residency and I knew. So I knew going into dental school, this is what I really, really wanted to do and I practiced, and I loved it so much. It was so fun and it is still so much fun. But then, one of my co-residents who we went to residency together. So I went to dental school back then, it was called Baylor in Dallas and now it's Texas A&M and then I went to the University of Maryland in Baltimore for my two-year residency in pediatrics. So, this is where I met this...

Ioannidou: [00:03:06] Very good school.

Nahatis: [00:03:07] Yeah, it was a great school.

And I met my friend Lauren Ballinger and she totally opened my eyes to this is 10 years later after residency. She saw a picture of my daughter Alice on Instagram and she said, Lauria, your daughter is so cute and beautiful. And she just turned four years old, and I was like, “oh, thank you.” And, you know, I had her dressed up in a unicorn outfit and I just thought she was, you know, and she is the most beautiful thing, and she said, but how does she sleep at night?

And I thought to myself, that's a weird question. She's like, I would love to share some things with you and, you know, when you go through dental school, you become very close with your dental school classmates and residency. You become very close. So we had a relationship, we still have a relationship where she said, “how is she sleeping? Is she sleeping with her mouth open at night?” And I was really a little offended. I was like, What, what do you mean? Is she sleeping with her mouth open? No, she's not like Napoleon Dynamite.

Like, look at her, she's a beautiful four-year-old, and so she said, “okay, go take a picture of her an hour after she falls asleep tonight”. So I went and took a picture and Lauren was right. So Alice was sleeping with her mouth open. What she saw in the picture, she could tell just by looking at her smile and looking at her face, that she probably wasn't sleeping well, that she wasn't sleeping with her lips together.

And I knew we needed early orthodontics at the time. Like, you know, back then we were trained, okay, early orthodontics, age seven, we send them to the orthodontist. And I knew that's when I would probably treat her. Then she's like, no, you can start with things actually, a little bit earlier and not necessarily orthodontics per se, but just trying, just teaching some good hygiene and breathing through the nose.

So that's how my eyes opened and since then I have not looked back. Our practice focuses on early growth and development. Just, you know, babies even making sure they're feeding well, because that's so important that they're chewing their food, breathing through their nose, not drinking their vegetables, that they're actually chewing their vegetables.

You know, there are just so many little things that 10 years ago, perhaps I really didn't put as much emphasis on. My emphasis was more cavities and prevention, which is very important too, you know, but, but not so much what's going on at home and root causes of things.

Wright: [00:05:19] So, so excited.

Ioannidou: [00:05:22] Yeah, that's a very interesting story. Very interesting and really personal. So we appreciate the fact that you shared this with us, it's really, you know, it makes me think about how observant you have to be even in the, you know, family, personal level with our own kids as they grow up, right?

Nahatis: [00:05:42] Yes, yes, and sometimes it's hard to see things with your own children. You know, it's hard, but then once you see it with your children, then you start seeing it with every, it's like, Oh,

Ioannidou: [00:05:51] It's an alert, an aha moment, right?

Nahatis: [00:05:54] It is. Yes, yes.

Wright: [00:05:55] I was going to say the same thing as soon as, and some of our listeners, as soon as they become like aware of this, now they're not going to be able to, you know, turn a blind eye to it, hopefully.

Nahatis: [00:06:06] Yes.

Wright: [00:06:08] Yeah, for sure.

So, well, we know that quality sleep is the foundation for so many aspects of child health. We talked a little bit in the intro about what got you into sleep and airway medicine, especially for pediatric. Not just for kids, but we want you to go a little bit deeper about why sleep quality is important for overall well-being.

Nahatis: [00:06:31] Just that's our whole rest and digest, like everything throughout the day. That's when we're able to clean our, you know, our brain that goes through the glymphatic system, which is something I've learned about in the brain, which cleans out all the quote trash and that's when we get to that deep sleep and we're able to wake up feeling rested.

I mean, think about how you and I are, if we don't have a good night's sleep. The next day, we're very irritable, we're very short with our peers. We're very short with patients, you know, we can't handle things, sometimes that you just have a shorter, just able to tolerate things, you know, from people.

So think about with children. With them, that's the thing is, and I know you were asking about just overall, but it's just even more important with kids who are developing with their brains and the synapses. I've just learned so many things, which I probably maybe learned a little bit about here and there in my pediatric residency, but the most, all the synapses keep connecting between ages four and five, that is when they're the highest. You have the most that have connected in the brain, that's the highest you'll ever have. So imagine if these kids aren't sleeping well, how is that for their brain? It's not good. And then you hear about something that really opened my eyes is that a lot of kids are diagnosed with ADD and ADHD, but in reality, they're just not sleeping well at night, and it's really hard to tell the difference clinically unless you have a sleep study of true ADHD versus having sleep apnea or sleep related breathing disorder.

So yeah, it's just, this is just what I live for now is just making sure because I feel like the kids are the future and it sounds so cliche, but it's. That's the truth. Like you see it with, you know, I see it with my family, I see it with my patients and this is who we have to make sure that we give them the best and the best quality sleep too. It's not just quantity of sleep, it's also the quality of sleep.

So yes, you know, some parents will say, yeah, they're sleeping because I noticed some things now when they come in for comprehensive care and I'll say, you know, how's your child sleeping? Oh, they sleep 10 hours and that's the answer. I'm like, okay, but 10 hours, are they still, are they tired? Are they moving around? Are they wetting in the bed still at age seven, eight years old? Are they waking up just really restless? Are they waking, are they restless during sleep? Are they waking up just exhausted? Is it really hard to wake them up in the morning? So there are different things that you can ask and then they're like, oh, well, actually, yes, their sheets are off the bed and, you know, they come to my bed two to three times every night and, you know, so they don't take that into account. So yeah, it's just so important to ask the right types of questions, you know?

Ioannidou: [00:09:08] Oh my God. Yeah. This is so interesting.

It makes me think that, you know, you mentioned sleep apnea and any sleep disorders, but nowadays, it's not only this, it's the way that parents, us as parents and our patients as parents handle the social media and the electronic addiction, right? So kids may be trying to fall asleep, but the phone will ring, the, you know, message will come.

I know, especially when in, you know, older age groups like teenagers, right? I know how much I struggled with my daughters when they were teenagers. Especially during the pandemic and these, you know, go to bed at 10 p.m. because it's a school night and you have to wake up early, but the phone and the communication with the friends would keep them up until midnight and then, you know, obviously, as you said, the entire story is lost because you cannot really have a well-rested sleep. So it's so complicated and so important.

Nahatis: [00:10:11] So important to me. I feel like it's the most important thing how we're breathing and how we're sleeping.

Ioannidou: [00:10:16] Yeah, and it's very much undervalued in this culture. Super valued in the Mediterranean culture where you know, as I mentioned earlier, you know, we had to go to sleep between 3 and 5 p.m. As kids It was part of the routine. We had to close our eyes and sleep. I mean, siesta was a part of and it's so valuable, but, you know, it's between countries.

There are so many differences, but how can a dentist, Dr Nahatis, identify sleep and airway issues? Are there specific signs that we have to look for? I know you touched a little bit on them, but let's be a little bit more descriptive.

Nahatis: [00:10:59] Yes. So you can look if a child or anybody really is sitting in your chair and they are sitting there waiting for you to do their exam and their mouths are open, even just a little bit and or their lips are together. Are they breathing through the nose?

So that's one thing you can look at and there's actually something, there's a validated screening tool that anybody can download. It's called the Fairest6 and it's a little screening tool that you can look at for sleep disorder, breathing and children.

We can share that later on too, but the first thing is breathing through the nose. Then you can look at when they have, when you have them have their lips together, do they have a lot of dimpling on their chin? Mentalis strain is what it's called, so if they have the strain like this, that means usually their mouths are open because they have to use this extra perioral muscle to help keep the lips together.

So when you're seeing that, you know that usually they’re mouth breathing, which is not great. Then the next thing you can look at is tonsils. So as dentists, and that's something that we should be assessing anyways, the tonsil or pillar area. You can see, are the tonsils are covering over 50 percent of the airway? So they are Brodsky three or four. That's something else that can tell you that, you know what, they're probably not breathing well, there may be mouth breathing. They may, I mean, yes, they may be inflamed because they are just getting over a sickness or something like that, but you know, a lot of times it can be chronic and, you know, that can cause mouth breathing and not sleeping well.

Another thing you can look at is narrow palates. Are the teeth, like with baby teeth, ideally, you want there to be spaces in between all of the primary teeth, especially in the anterior area. If there aren't spaces, then usually that means everything is deficient, like the space is deficient. The palate transversely there's not enough room for the tongue to fit in the mouth. So you think about when the palate is very narrow, where's the tongue going to fit? It can't fit in, because if it fits in the roof of the mouth and they keep their lips together, it's actually going to close off the airway in the back, so they keep their mouth open and the tongue down and low and that helps, you know, that continues with like low tongue tone and all of this. It's kind of like a cycle.

You can look at grinding like signs of grinding a lot of times when you see a lot of wear in little children. So that's something. When I first got out of residency, the answer was, oh, they'll grow out of it. Wait till they're six-years-old, the six-year molars will come in and it'll be okay. But research has come out to say that when kids grind as if it could be a few things that could be big tonsils, it could be nasal obstruction and nasal obstruction can be even inflammation from allergies or, you know, a large adenoid to anything in, in the nose, and then also tongue tie may be a part of it. So that's something that we didn't really learn a lot about in my residency. And this was residency, I say I graduated my residency, by the way, in 2006. So it's been a, it's been a while and I think more residents are now learning a little bit more about this because really moms are asking more of these questions.

So those are some things that anybody can look at. I feel like pediatricians can look at that, dentists can look at that. Primary care dentists, that's what we call general dentists, primary care dentists, because they're the primary care providers of the mouth and you know, they can see these things and when sometimes when the parents out and you see the child sitting there with their mouth wide open, you can ask the questions, “hey, I noticed that little Johnny, oh, they're so cute, I noticed the lips are apart. Are they always like that?” And they're like, “yeah, why do you ask?” And just say, “oh, you know, cause that could be associated with this.” And that's how you gently bring up the conversation. You know, that's something I've learned just throughout practicing and learning. Cause once I learned all of this, I wanted to like go around and tell everybody, “hey, your child shouldn't be doing that.” It’s your child and nobody wants to hear there's something wrong with their child. Nobody wants to hear that. I mean, I was even defensive myself and I'm very open to criticism, being Greek. My father, everything was like, [laughter] they're not criticism, constructive. Any who, there are other ways to, you know, bring this up, but yeah, those are just some main things to answer your question, that you can look at and not have to take specific measurements or anything like that.

Wright: [00:15:04] Yeah. That's so good. I remember going to like a CE course in 2021. And I think that's when I was introduced to airway and...

Ioannidou: [00:15:12] You are both babies. 2021, the other one 2006.

[Laughter]

Wright: [00:15:23] ...But at the CE course, that's when I learned about airway and then I was, once you go down the bunny trail, they say, you're on an Island. And so, then I started following all of the airway people, the myofunctional therapists on Instagram. I'm like, I just want to know cause I have my kids keep their mouth closed.

We did mouth taping and stuff like that and so I was like, oh my gosh, this is a whole other world out here that, you know, I wasn't introduced to. I'm a general dentist or a primary care dentist and so, yeah, I'm so excited that we're talking about this cause I feel like our listeners, wherever they are in practice and if any patients run upon this, you know, they will be informed.

Ioannidou: [00:16:01] Can I interject something that you said that was very important? And I like what you said about you guide your kids to keep their lips together and their mouth closed, right? Oh, yeah. That's a good habit. They should keep it up forever, don't open your mouth.

Wright: [00:16:16] To breathe through their nose, my mom used to make us close our mouth. She'd be like, close your mouth, something's gonna fly in your mouth and she'd be like, close your mouth and breathe through your nose. And so now, I'm like, why are you breathing through your mouth? Close your mouth, breathe through your nose. So it's a cycle that I got used to growing up, but she had no idea that it was so good for us.

Ioannidou: [00:16:36] Yes, absolutely. So good, it's so important. You know, people know from life experience, but I think it's a good habit for all of them to stay with their mouth closed forever. I don't want to hear your voices, this is what I say to them.

Wright: [00:16:50] So we're helping them in one way or the other, right?

Ioannidou: [00:16:53] Keep your mouth closed. Don't talk to me.

Nahatis: [00:16:55] Well, that's something I talk about too. You know, it's just like the gentle reminders is what I tell parents. It's like gentle reminders. If you see them with their lips apart, because sometimes it's trained, like they maybe had a pacifier for too long and when they spit out their pacifier, they never close the lips together, the mouth just stayed the shape of the little pacifier nipple. So I told them, you know, once we stop the pacifier, we have to retrain those lips to be closed together and so just gentle reminders, breathe through your nose, lips together, always very kindly and nicely and that's what I explained to you. Like kids want to do what we like. They want to impress the adults, right? They want to be good. They want to, like that's in their heart. Especially when they're really young, when they're teenagers, it may be a little bit different story, but when they're younger, they do want to. So it's kind of like when you train, you know, you teach them, don't cross the street with a red light, look both ways, wear your seatbelt, breathe through your nose, lips together, it's just like that. So yeah. I think the sooner you start with that, the better, the easier, the less complex, I should say it is.

Wright: [00:17:52] We'll be right back.

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Ioannidou: [00:18:46] Welcome back to Dental Soundbites. We are having a conversation about sleep medicine and everything you need to know about sleep and airway health with Dr. Loria Nahatis.

Wright: [00:18:57] Well, I wanted to bring up some symptoms since we've been talking about those, or maybe also going deeper into how we can continue raising awareness about the importance of sleep, because we have three different practitioners here.

So I'm a primary care dentist, you are pediatrics, Dr. Effie is a periodontist, amazing academician in academia. So how can we continue to raise awareness for our patients or their, you know, their parents, whoever we're seeing in the practices.

Nahatis: [00:19:28] Well, what we use in our practice, we use something every new patient, whether they're coming in for airway issues, tongue tie, just regular comprehensive care, we give them something called a pediatric sleep questionnaire, and that's another validated tool that's 22 questions. They only fill it out the very first time they come in, just so we can see parents' awareness to how their sleep is. And that, you know, the questionnaire starts with, does your child snore more than half of the week? Does your child snore loudly? Do they have heavy breathing? Like the first few questions are about the quality and about how they're breathing. Then the next set of questions is about their quality of sleep. Are they moving around a lot? Are there teachers stating that they're tired throughout the day just about sleepiness and that, and then the next set of questions is more behavioral. So, is your child fidgety?

Now this is validated for ages two and up. So a two-year-old, once they check all the bottom behavioral questions, it's like, “well, gosh, what two year old can sit still and focus and not?” You know, all two-year-olds I feel like are fidgety, but if they're six, seven, eight years old, they should be able to sit still and focus and listen, you know, so those are some questions that we asked. So that's how we bring awareness, I guess, to parents. Bringing awareness to other practitioners, like when I learned as a dentist, that a policy came out from the ADA in 2017, the positions, the policy about how we should be screening for sleep disordered breathing.

It was like, oh my gosh, I haven't, cause I'm such a rule follower. I didn't know. So this was like a year after my friend, Lauren was like, you know, we're supposed to be screening for this now? And so I started, I mean, every patient gets, you know, we're asking about this and when parents ask when I first started asking this sleep questionnaire, I had a dad who was very upset and he said, “why are you asking me these questions? You know, you're not a doctor.” And I remember it really hurt my feelings because in my mind, I'm just like, gosh, you know, we're just trying to help. Actually, he didn't say that to me, he said that to my assistant and so I went up and I said, you know, I gave him a brochure because there's actually a brochure from the ADA and it's called Children's Airways. I gave him this brochure and I said, you know, sir, we're asking these questions because we care about your child's growth and development. The ADA actually recommends that we do screen for this and as a doctor of the mouth, this is something I can look for some signs that there may be some issues and if it goes along with symptoms that I'm seeing, but it's okay, you don't have to fill it out. This is just something that I'm doing as a service.

Ioannidou: [00:22:03] That's so good. I love this.

Nahatis: [00:22:05] Well, that was something I learned too from a mentor of mine and he's like, we're doctors of the mouth. Like that's the thing, we can see so many things, you know? As you both know, you're seeing adults, there's so many things that we can catch that start in the mouth that tell a bigger story, maybe something else that's going on in the body.

Ioannidou: [00:22:22] I don't know if you can see the poster behind me with this woman looking. Do you see the woman with, you know, can you read what it says? Probably you cannot, but I will tell you what it says. It says “woman searches for where the men get their audacity.”

So, it's interesting that, you know, how the father's perception, right, of your clinical assessment and the reaction to this, like it's really interesting for me to see someone that probably doesn't have medical background, but questions the validity of your diagnosis.

Wright: [00:23:09] Yes, or just your screening and your evaluation to even begin, you know what I mean?

Ioannidou: [00:23:14] Yeah, yeah, yeah.

Nahatis: [00:23:15] I think he was just mad because he had to fill out another piece of paperwork, I guess. You know, sometimes they don't like doing that, but it's life, you know.

Ioannidou: [00:23:24] It's interesting. I just find it very, but you know, as we discussed the symptoms and the significance of the screening, what are the next steps? What do you think dentists can do to help their patients in the levels of prevention, but also in the levels of, you know, improvement of the sleep quality.

Nahatis: [00:23:46] Yeah. So I think it depends on the age.

So if you see babies or toddlers, you know, you see, how are they feeding? How are they sleeping? Because usually a lot of times if they're not sleeping well, they're probably also not eating well. Their speech may be a little bit behind. So we refer them to lactation consultants, to occupational therapists who are trained in infant feeding.

You can refer to OTPT. They're just different providers that you can refer to because like I said, the younger they are, the less complex it is. So just changing patterns and changing, you know, what they're eating, how they're feeding them. Then as they get a little bit older than you notice the big tonsils.

Then, you know, sometimes you can refer to a pediatrician if you have a good relationship with a pediatrician, just stating, I noticed this, this and that, you know, the big tonsils, narrow palate, they stated the child isn't sleeping well at night, they're snoring more than half the time, and then the pediatrician can make the referral to the ENT. Or if you have a relationship with ENTs, you can refer straight to the ENTs, but I have a reason why, you know, not just, oh, cause the ENTs are very busy, you know, they can't just see somebody just cause they’re mouth breathing. Like they'll think you're crazy, but it's like, oh, they're snoring all the time, they're wetting the bed, you know, they're doing all of these things and you see the big tonsils too, then, you know.

Then also in our practice, we have a little CBCT, like it's an ultra low dose, sometimes when it's indicated, like when that pediatric sleep questionnaire is very high, like if it's, you know, usually if it's over 33 percent of the questions, so that's usually 8 or more of the questions are answered yes. Then that's indicated we could take a CBCT. We send it off for a radiology report so a separate radiologist looks at it. We have a full-page report that we can also send to the ENT as well. So it just gives parents an additional piece of information. They're not going to diagnose sleep apnea from a radiology report, because you know the gold standard is the polysomnogram, but it's just another tool.

Some ENTs like that, some ENTs say it's trash and they don't care about it. So I've asked too, I've, you know, cause I've made connections, I said, you know, do you like this information? And I feel like the younger doctors are like, yes, it's a great tool. Like it's a great additional piece of information. I said, well, what are your thoughts on? Cause I've had a couple ENTs that kind of just kind of smirk at it or I've heard parents say like, they just said, oh, that doesn't mean anything with what the x-ray showed with the CBCT and the...I'll never forget this one lady, she, an ENT, she said, they just don't know how to read them. They just don't know, you know.

Ioannidou: [00:26:15] What kind of information do you get from the CBCT? Like, what are you looking for to be able to connect it with your clinical findings?

Nahatis: [00:26:23] Yeah, so I look at, they grade the tonsils, they grade the adenoid tissue. So that's just, I mean, I did look at tonsils in the mouth, but it also is nice to have somebody else look at it and grade them like a three plus or whatever they think they are.

The adenoid tissue they grade, they can look at, there's a septum deviation. You would be surprised how many septum deviations are in five year olds. They can look at the sinuses, they can see if they have mucus in the sinuses. Now I know that can change like day to day, but just say the parents will say, oh yeah, they're always congested, you know, and maybe they need to go also see an allergist too, because that could be a piece of the puzzle.

Then it could, we also can see, I mean, you can look at all of the teeth that are there, how big the teeth are, the transverse, the palate. I mean, it's just gives so much information and to me, it's just, when I first saw, so that's when I flew my daughter, when my friend told me about Alice, so we'll go back to my first story that I was telling you about Alice.

I flew her to Massachusetts to be evaluated by my friend and she took a CBCT and at that time she had a very raspy voice. I was nervous. Somebody put in my head that, oh, maybe she has polyps on her vocal cords, and you know, so I was going to go down that rabbit hole with the ENT. I took her to the ENT, they wanted to put her under anesthesia just to do a scope just to see if she had polyps, just to evaluate and see. So me being, you know, at that time, I was like, okay, sure, I'll sign her up and then I went home and my husband and I talked about it and in talking, my husband was like, Loria, I don't feel comfortable putting Alice under general anesthesia. Just to take a look at something that we don't even know, that really is a, because she was only almost four at the time. So she was really little, you know, so I flew my daughter, Alice, out to the Berkshires to Massachusetts and Lauren took the CBCT and I'll never forget when I saw that and she explained everything to me. I was like, oh my gosh, this is amazing that you can have so much information just with this, you know, it's 12 to 16 micro sieverts, like the ultra low dose CBCT. So it's not a lot of radiation. When people think about CBCTs, they think about the medical CBCTs that are like 2,500 micro sieverts where this is, so, you know, we do take that and have that as well that we can share.

Wright: [00:28:36] Oh, this is so insightful. My gosh.

Ioannidou: [00:28:39] It's very insightful and I like the fact that when you send out your request for referral, it's so well, it's nicely packaged and well informed, right? So I cannot believe that there will be ENTs that won't like this, but whatever.

Nahatis: [00:28:54] Ah, yeah. There's many, like it's a small number that have said that. I think now even, and that was, so we opened this practice, so I was happy. I was an associate in the most beautiful practice for so many years.

Wright: [00:29:05] I was going to ask about your journey, I'm glad you're sharing that.

Nahatis: [00:29:09] Yeah. So I actually worked in my pediatric dentist office. So when I was in high, I mean, I can go way back where I was a dental assistant in the practice that I went to when I was younger. So that's where I decided for sure I want to be a pediatric dentist. Fast forward, I went back to that practice after my residency and practiced there for five years.

Things happened with my family. I decided to move to Dallas and that's where I started working as an associate for this amazing dentist and I loved working with her and just things change once I, my eyes open to all of this. It's kind of hard to open other people's eyes, you know, the eyes were opened.

It just wasn't the same. Like it just became my passion. So it was like, okay, I can't not say anything and I have to do something because I felt like it was my duty as a healthcare provider that we can make such a big change just because I saw the changes that were happening in my daughter with just teaching her to clear her nose every night.

Like we do this, we did the saline spray and then she would wear this like little mouthpiece that, you know, a little trainer just to get her lips a little bit stronger and her tongue positioned in the right spot and, you know, there were such big changes in just 18 months, just with that, no surgery or anything.

Ioannidou: [00:30:18] Oh, that's great. Yes. Now you're in your own practice, right? You started, that's great.

Nahatis: [00:30:23] Yes. Yes.

Wright: [00:30:24] Did you shift the majority of your focus like clinically to like sleep and airway or do you? Cause I remember you said some comprehensive care still.

Nahatis: [00:30:32] Okay. Yeah. So we do that. So of course, opening a practice.

So I have a partner, Carla Damon, we opened this practice beyond pediatric dentistry, and we had to have a way to have patients, you know, so patients don't, not everybody's looking for airway issues and all of this. So we started seeing comprehensive patients. Well, we both have gotten so, we're so busy. We have two associates that see, and they've learned everything that we know. So they know how to screen for all of this, but we're so busy treating all these kiddos for other things and we treat with, you know, different things. We do early expansion, tongue tie releases. Like I was trained by an ENT doctor, Zoggy in California for tongue tie releases. So I'm more focused on doing that where they can do all the comprehensive.

But at first we did everything and we learned, I mean, at first it was kind of out of my mouth, everything. I was like, your child has 10 cavities, they'll probably need sedation because they can't sit and I would start and I would give this like so much it was like, like diarrhea of the mouth and I learned it's very important to just plant seeds.

So if you notice something is off and parents are coming to you because their child has a cavity, address the cavity first and plant a seed. Like, have you noticed this? Just like I said, I've become, I feel like, pretty good at doing this and then you start asking the questions and then at first they may deny, like what I did, and that's the thing.

I did the same thing and then they come back six months later and they'll say, you know, Dr. Loria, you mentioned this before. She is all over the place and she can't focus and, you know, it was just sometimes bringing that awareness and it's just so awesome that we can do that as dentists.

Ioannidou: [00:32:12] Oh, this is amazing. I love it. For sure.

Wright: [00:32:16] So, so good. So this has been so insightful and while we're talking about like all of the things that like your associates are learning or have learned there's one thing about, like, residents getting this information. Have you or are you aware or have any thoughts about residents and graduates being confident enough to treat these cases? So, like, sleep medicine is not that much covered in the dental residencies and just share with us a little bit about, you know, that direction about their confidence level.

Nahatis: [00:32:50] Yeah, yeah. So I wasn't taught any of this in my pediatric residency. It's really awesome. I feel like, and it's not that everybody, you know, you said to treat this, you don't have to really treat it. It's just bringing awareness and knowing where to refer to. So just when you see it, be able to intercept somehow, whether it is treating or referring to somebody who can treat. And what's really neat, is here in Dallas, Texas A&M, the dental school I went to for dental school, they've actually had me come the past two years to talk to their second-year residents about all of this and just like things that we can look for as pediatric dentists, because moms are coming asking for this. Like they come to our practice after going somewhere else and they'll say, nobody ever said that to me before. Why didn't they tell me? I said, you know. It's not that anybody was keeping information from you, they just didn't know yet. More and more dentists are learning about this, and I feel like when they go and ask, because I have even friends and colleagues who practice in other states, and at first they didn't really ask a lot to me, and now they'll call me and be like, “so what do I need to learn? Because these moms are asking me all these questions, and I don't know how to answer the questions and we want to have answers.” It's okay if we don't have the answers. It's okay, because we can just say, you know what, I will look into this, and I will get back to you or I will send you to somebody who probably could answer all of these questions better for you. You know, and so I feel like that's the direction I feel like it is going to change, you know, like, before Dr. Effie was mentioning CODA and things changing like sleep now, and I think that maybe last year that was just included where sleep passed out. I'm not 100 percent sure, but I've.

Ioannidou: [00:34:28] Yeah, it's something recent, but you're absolutely right. I see that things are changing. I can speak for UCSF. We have sleep clinics both in oral medicine, orofacial pain and orthodontics. The different residences started training, residents towards these directions. We, you know, there are faculty that have acquired as you did the training and the expertise to be able to pass it to the residents and train, you know, you teach one, no, you learn, but you see one, you do one, you teach one.

Loria, can I ask you a question? And I know it's something that perhaps we, I didn't have in my mind earlier on, but many of our listeners may think about this. How is this reimbursed is, in terms of insurance coverage? Like do you, how do you code this? Many people won't know. I mean, you have them inform, this is what I was thinking. Is it medical? Is it dental? Is it even reimbursed? Is it self-paid? Like based on your experience in Texas?

Wright: [00:35:41] That's a good question.

Nahatis: [00:35:43] So we are, we're a fee for service practice, but we're out-of-network provider. So we courtesy file for everybody.

So, let's say if a baby comes in, you know, and we usually don't just go in and do baby same day, if they need a tongue tie release, or if we believe that they would benefit from that. We send them off if they haven't seen lactation, do some like, you know, see a lactation consultant or a speech therapist who does infant feeding, then things might get better and they don't have to do anything, but then they come back and it's like, okay, we've tried all these things. Now let's do it. We do it and then they can code it through my practice manager. We always try to do it through their dental insurance first and if it's not covered by that, then they can go try to do it through the medical insurance and it's pretty interesting that this is covered. Then when we do early expansion, you know, an expansion and little kiddos, you can do, there's an interceptive ortho code, it's interceptive ortho for primary dentition, interceptive ortho for mixed dentition and that's as far as we go. Like I never use any other codes and you know, whatever fee that is, the patients and we have a payment plan in our office, so they usually pay like half of it and then they can pay it off, but in the meantime, we can submit it to their insurance and then it just depends on their insurance plan. So sometimes they cover, sometimes they'll cover 2000 of it. Sometimes they'll cover 1500 of it. Sometimes it's lifetime, sometimes it's not, you know, so that's something that, you know, we just work with. Especially if patients really, we feel like they would benefit from it and they need it. We work with however we can do it.

Ioannidou: [00:37:14] But I think it's very important for our listeners to know that there are these options and there are the codes there and there are options in the, you know, dental or medical insurance reimbursement too, you know, for the practice managers to explore and understand a little bit better. So this is great information. Thank you for this and thank you for everything. Like this was a really enlightening moment, very informative. It was very useful for us and the listeners, our listeners to hear you and understand the, you know the significance of this and the, how important it can be for quality of life for our kids and adults, right?

Nahatis: [00:37:59] Yeah. Well, when their quality of life is poor, our quality of life is poor.

Ioannidou: [00:38:05] Is there anything else that we haven't covered and you might want to, bring up now or speak now or then?

Nahatis: [00:38:18] No, I just really, truly, I believe in a collaborative approach and that's how our practice is and I think it's so important. I feel, you know, that everybody's eyes are opening, not just dentists, but even ENTs even, I mean, every, all path, like all people that work in the head area, you know. It’s the roof of the mouth is the floor of the nose. So when you have that high narrow vaulted palate, you can have the septum deviation, which can cause, you know, there's no room for the tongue, you know, a speech like they've been in speech for seven years. Why are patients in speech for seven years? They should not be in speech for seven years straight.

Like you, speech therapy is a therapy, you get through it and then you keep going, but if there's an issue, why is there an issue? So maybe to look a little bit deeper. So I feel like for a kid to thrive, it's good to have that village, that collaborative team and it's really important to build that with your area to have that. And sometimes it takes five different lunches with different providers to find your one person. It could take 10, you know, it just depends on who you mesh with, who you have the same belief system as and, you know, it's really important not to just watch and wait and wait and see. Or wait and they'll grow out of it, see what's going on, intercept as early as possible, whatever you can do, or refer to somebody who you think could really help your patients and that way they can thrive. And it's just, I wish I had this when my babies were babies and that's why I'm so passionate about it and it's just really neat that we have these tools and we're able to guide parents and caregivers. So that way their children can have an optimal life and just be healthy.

Wright: [00:39:49] So good.

Announcer: [00:39:53] On the next Dental Sound Bites.

Ioannidou: [00:39:55] What's shaping the next era of dental care? Innovation strategist and bestselling author Shawn Kanungo is here to talk about dentistry at the intersection of creativity, business, and technology.

Oh, this is so great. Thank you so much.

Nahatis: [00:40:15] Yeah. You're so welcome.

Wright: [00:40:17] Yes. Thank you so much. Oh, these insights were so helpful. We are so glad that you are here with us today.

Nahatis: [00:40:25] Thank you for inviting me.

Wright: [00:40:26] Yeah. Can you please tell our listeners how they can find out more about you, where they can connect with you and learn more?

Nahatis: [00:40:33] Oh, sure. So you can check out our website beyondpediatricdentistry.com and our Instagram handle is the same @beyondpediatricdentistry and I have a Dr. Loria Instagram as well.

Wright: [00:40:47] That's the one I joined. I followed before the episode.

Ioannidou: [00:40:50] You should know that ArNelle is an Instagram queen. You know that, right?

Wright: [00:40:55] I was like, who are we interviewing? I was like, I want to know more about her.

Ioannidou: [00:40:58] And she's also a stalker. She's a stalker too.

Nahatis: [00:41:02] Oh, that's so nice. Yeah. So those are, that's more of my like personal professional where I share more about my CE, where I'm going and I do a lot of CE. So I think this year I have maybe like seven or eight things I'm going to.

I'm speaking at the ADA, actually, for everybody to know, they're having a children's airway conference this summer. So anybody that is interested in this, there's a conference I'm speaking at on Saturday for just one hour. Not just, I'm lucky to be there for the hour, but there are many wonderful people that are speaking at this. So I believe that's July, the last weekend of July, like July 24th and 25th, maybe 26th, so that's something that anybody can go to, anyone that sees families, children, or if you're interested for your own family, for your own children, nieces, nephews, grandkids.

Wright: [00:41:48] Well, we're going to make sure that we add those resources and links that, everything that you talked about to the show notes today, if you like this episode, everyone, please share it with a friend.

Ioannidou: [00:41:59] And be sure to subscribe to this podcast wherever you're listening so you can get the latest episode.

You can also rate it, write a review, should be good review, and follow us on social media. I don't want negativity.

Nahatis: [00:42:14] Yes, positive energy.

Wright: [00:42:16] Yes. Positive vibes only. Yes, and don't forget the conversation does continue with the bonus episodes on the ADA Member App and you can now watch this episode on our YouTube channel.

Nahatis: [00:42:30] Bye.

Announcer: [00:42:34] Thank you for joining us. Dental Sound Bites is an American Dental Association podcast. You can also find this show resources and more on the ADA Member App and online at ADA.org/podcast.