By Gary M. DeWood, DDS, MS 

Whether you’re presenting research findings at a conference or sharing case studies with colleagues, your job is to craft and practice a presentation that informs, engages, and inspires. 

Key Strategies 

• Know Your Audience and Tailor Your Message: Understanding your audience is fundamental to effective communication. Consider their level of expertise, interests, and expectations. Tailor content and delivery style accordingly. For instance, when presenting to fellow dentists, you can delve deeper into technical details and use industry-specific terminology. Dentists like dental jargon. 

• Organize Your Presentation for Clarity: A well-structured presentation is easy to follow and more impactful. Consider using a clear outline that includes an introduction, body, and conclusion. Tell them what you’re going to tell them, tell them, and tell them what you told them. The introduction will briefly outline the main points of your presentation, while the body dives into the details. The conclusion will summarize the key takeaways and reinforce the message. 

• Leverage Visual Aids Effectively: Visual aids can enhance your presentation and help your audience retain information. Use high-quality images, diagrams, charts, and videos to illustrate your points, being careful to avoid overwhelming your audience with too much visual clutter. Keep your slides clean and easy to take in, allowing your visuals to speak for themselves. 

• Practice Makes Perfect: Rehearsal is essential for delivering a confident and engaging presentation. Practice your presentation aloud several times, paying attention to your pacing, tone, and body language. Consider recording yourself to identify areas for improvement, both audio and video. The more familiar you are with the content, the more comfortable and confident you will be when delivering that presentation. 

• Engage Your Audience: A successful presentation is not a one-way street. Encourage audience participation by posing questions, inviting discussions when appropriate, and including interactive elements. This not only keeps your audience engaged but also provides you with valuable feedback and insights. 

• Transparency: At the beginning of your presentation, disclose any financial relationships or conflicts of interest that may be relevant to your topic. This includes any payments, grants, or consulting fees received from companies that manufacture or sell products or services related to your presentation. 

Incorporate Dental Case Images Effectively 

• Choose high-quality images: Ensure images are clear, well-lit, and relevant to your topic. 

• Cite Sources: If you’ve used information or images from other sources, clearly cite them in your presentation. This demonstrates respect for intellectual property and enhances the credibility of your work. 

• Acknowledge Collaborators: If you’ve collaborated with colleagues or mentors on the research or case, acknowledge their contributions. This fosters a collaborative environment and recognizes the efforts of others. 

• Use images selectively: Avoid overwhelming your audience with too many images. 

• Provide context: Explain the relevance of each image and its connection to your narrative. 

• Tell a story: Use images to create a compelling narrative and engage your audience. 

• Maintain consistency: Use a consistent theme, typography, and color scheme throughout your slideshow. 

• Consider animation: Use subtle animations to highlight key points or transitions but avoid excessive use.  Audiences are distracted from the message when a lot of stuff is happening on your slides. 

• Practice and seek feedback: Rehearse your presentation and ask for input from colleagues or mentors. 

Consider Alternatives to Traditional Presentations 

While presentations are a powerful tool for communication, they may not always be the most effective approach. Sometimes, a more informal conversation or a collaborative workshop can be more engaging and productive. Consider the goals of your communication and choose the format that best suits your needs and the needs of each audience. 

Following these guidelines will help you create dental presentations that are informative, engaging, and impactful. Remember, the goal is not just to deliver information, but to inspire thought, discussion, and to foster a deeper consideration and understanding of your topic.  It’s also possible to have a lot of fun being the “expert.” (That’s anyone from out of town who brings slides.) 

By Paul Henny, DDS

Bob Barkley’s “learning ladder” concept, akin to Peter Senge’s “ladder of inference,” emphasizes understanding where individuals stand regarding their knowledge, beliefs, and motivations. When patients or dental professionals are “stuck” on this ladder, they tend to rely on outdated or incorrect mental maps, often described as deductive thinking.  

Inductive Thinking Is Double Loop Learning 

Progressing on the learning ladder requires engagement of inductive thinking or double-loop learning, which involves challenging existing mental models and the subsequent development of new and innovative solutions.

How I Facilitate Inductive Learning 

Here’s an example of how I facilitate inductive thinking which leads to more double-loop learning, the patient moving up the learning ladder, and ultimately better decision-making.  

I purchased my practice in 1994 from a retiring dentist, who was competent and capable relative to the state board defined standard of care. He had achieved MAGD status and served in several professional leadership positions. He also had a very confident and caring demeanor, and his patients loved him and believed in his leadership skills. However, he wasn’t comprehensive in his practice philosophy, and subsequently did not spend a lot of time investigating root causes.  

The result was that he was tooth-centered and focused on solving or stabilizing current problems, one at a time. His failure to plan for the future dental health of his patients led to many chronic, slightly-below-the-radar problems that were never diagnosed.  

For instance, many patients had progressive destruction of their anterior guidance, loss of vertical dimension due to accelerated posterior attrition, and then were fracturing posterior teeth. They had significant occlusal disorders that were causing occlusal disease and the self-destruction of their dentition. 

The challenge: How could I get these patients to better understand why their posterior teeth, restorations, or even the roots of their teeth were fracturing when the apparent problem was in the back of their mouth, and the unknown driver of their problem(s) was in the front of the mouth?  

The solution: We made study models and took occlusal records. and photographs. We then scheduled each patient for an appointment with me that was specifically intended to allow them the opportunity to learn more about their situation, understand why destructive trends were happening, and allow them the opportunity to choose whether or not they wanted to continue in that direction or alternatively engage in a comprehensive restorative process that would render out optimal form, function, and esthetics.  

This type of process creates the opportunity for more double-loop learning, and therefore better decision-making and long-term stability and health in my patient base. 

By David R. Rice, DDS 

Overcoming Initial Challenges 

Dr. Emily had always dreamed of owning her own dental practice. However, the path to achieving this goal was not without its challenges. After years of working as an associate dentist, she decided to purchase a practice from a retiring dentist in her community. 

Securing funding was one of the biggest hurdles she faced. She had to navigate the complex world of loans and financing, working with banks and lenders to secure the necessary capital. Once she had the funding in place, she faced the daunting task of transitioning the practice smoothly. 

Pleasing the existing patients was another priority. She knew that many of them had been loyal to the practice for years and were concerned about the changes that would come with a new owner. Dr. Emily worked hard to reassure patients and maintain continuity of care. She met with each patient personally, listened to their concerns, and assured them that she was committed to providing the same high-quality care they had come to expect. 

Working with the legacy team also presented its challenges. Some team members were resistant to change and unsure about the new direction of the practice. Dr. Emily recognized the importance of building trust and creating a positive work environment. She took the time to get to know each team member individually, understand their concerns, and address their needs. 

Building a Supportive Team Culture 

As Dr. Emily settled into her new practice, she quickly realized that building a strong and supportive team was not as easy as she had anticipated. Her initial team consisted of a few experienced dental assistants and a hygienist, but they seemed to be struggling to work together cohesively. There were frequent disagreements, low morale, and a lack of motivation. Dr. Emily knew that she needed to take action to address these issues and create a positive and productive work environment. 

She started by taking the time to get to know each team member individually. She learned about their strengths, weaknesses, and career goals. This helped her understand their unique perspectives and identify potential areas for growth. 

Dr. Emily also implemented several strategies to foster teamwork and improve communication. She held regular team meetings to discuss challenges, share ideas, and celebrate successes. She encouraged open and honest communication and created a safe space for team members to express their thoughts and concerns without fear of judgment. 

Addressing Conflict and Building Trust 

One of the biggest challenges Dr. Emily faced was managing conflict. She learned that it was important to address disagreements promptly and respectfully. She would often facilitate constructive conversations between team members, helping them to find common ground and resolve their differences. 

Building trust was also essential for creating a positive and supportive team environment. Dr. Emily demonstrated her commitment to her team by being transparent, honest, and supportive. She showed that she valued their contributions and was invested in their success. 

The Rewards of a Strong Team 

As Dr. Emily continued to invest time and effort into building a strong team, she began to see positive changes. Morale improved, productivity increased, and the overall atmosphere in the office became more positive. The team members started to work together more effectively and support one another. 

Dr. Emily realized that building a strong team was an ongoing process. It required constant effort, patience, and a commitment to creating a positive work environment. However, the rewards were well worth it. A strong and supportive team could help her achieve her practice goals, provide exceptional patient care, and create a fulfilling career. 

By Deborah E. Bush, MA 

This blog draws on insights from Dr. Michael Melkers’s 2022 Pankey Webinar, “Managing New Patients in Challenging Times.” While the blog offers a unique perspective, it is informed by the valuable strategies and experiences shared by various dentists during the webinar. For a more comprehensive exploration of these approaches, I recommend watching the full webinar on YouTube. 

Interestingly, the challenges and strategies discussed in the webinar are reflected in a broader industry trend.  

Mature Dental Practices Often Become Overwhelmed with New Patient Requests 

A year ago, I conducted a dental marketing survey for Alatus Solutions, which provided revealing statistics about how independent private dentists seek and manage requests for new patient appointments.  

• Responding to the survey were 474 dentists aspiring to be 100% fee-for-service.  

• We found that 5% were so booked that they couldn’t make new patient appointments for more than 30 days. 

• 15% had new patients waiting more than two weeks.  

• The 5% had stopped paid marketing because they didn’t want more new patients, overloading their schedules, exhausting themselves and their team, and negatively affecting the care they provide. 

Multiple Strategies Are Possible to Control New Patient Flow 

One strategy to control the number of new patient calls tying up the front desk is to stop all paid marketing and rely solely on referrals from patients who truly appreciate your comprehensive care. Another response (which happens frequently) is to screen calls and do callbacks. That’s something I do not recommend as you will see in my “Do and Do Not” section below. Alternatively, some dentists expand the practice by bringing on a new associate or refer new patient inquiries to a like-minded dentist who is growing their practice.  

Dr. Melkers’s online seminar emphasized the effectiveness of prescreening potential patients during live calls and having knowledgeable front desk staff act as gatekeepers. This concept is discussed in more detail below as an effective strategy for managing this challenge.  

Do and Do Not 

• Even when you are overwhelmed with patients, I do not recommend frustrating your loyal patients by screening calls and relying on voicemail to call them back. Do pick up as many calls live as possible. 
• You can turn off your paid ads, but don’t ignore your website or your Google business page. Your digital presence is necessary to sustain your practice. And the referred prospective patients (who are most likely to be prequalified for comprehensive care) will be curious to see your persona, credentialed expertise, and reviews before reaching out for an appointment.  
• Do keep your website and Google listing frequently SEO-refreshed and up to date with your services. The current Google algorithm prioritizes Quality Content, Mobile Utility, and Local SEO (location, business hours and contact information visible and consistent across all platforms). 

The New Patient Funnel 

The new patient funnel is a metaphor for a potential patient’s journey from initial contact to becoming a regular patient. The stages include: 

• Awareness: The patient learns about your practice through marketing, referrals, or online research. 

• Consideration: The patient evaluates your practice and decides whether to call to discuss scheduling an appointment. 

• Conversion: The patient schedules and completes a new patient exam. 

• Retention: The patient becomes a regular and ongoing part of your practice. 

The funnel helps us conceptualize the flow of interactions we can control. When you have a “leaky” funnel, potential patients fall out near the top of the funnel before being qualified. This can occur if the front desk does not answer calls live or fails to return messages. A lack of training in optimal call handling contributes to this failure. 

​​​In ideal scenarios, receptionists are initiative-taking and well-trained in moving new patients through the funnel or onto a more suitable path for finding the type of dental care they want. However, according to Patient Prism’s AI evaluation of over 50 million new patient calls over the past nine years, more than 80% of the U.S. dental practices participating in Patient Prism’s AI evaluation do not benefit from such attentive phone handling until their performance is tracked and new behaviors coached.  

Prescreening Patients: Identifying High-Quality Candidates 

Prescreening is an effective strategy for managing the new patient funnel. By asking targeted questions during initial contact, your team can determine which patients fit your practice well.  

My Notes for Call Receptionists: 

• Understand Their Needs: Ask, “How may I assist you?” and engage in a conversation to understand the patient’s dental needs and expectations. 

• Set Expectations: Explain the benefits of a thorough examination, the process, the time involved, and the fees. Assess the patient’s willingness to commit to a comprehensive exam, consultation, and finding solutions for their current problems. 

• Note Previous Dental Experiences: The caller’s freely offered comments about their dental history, health history, or concerns about dental care are revealing, but be careful of assumptions based on your biases. Stay in the conversation long enough to understand the person on the other end of the phone. It’s okay to simply say, “Please tell me more.” And, if the caller seeks a “Pankey dentist” because they are accustomed to the highest level of comprehensive care, note that this person has prequalified themselves for your practice. 

• What to Do When in Doubt: If you are unsure, saying, “Our schedule is full right now,” is okay and not impolite. Continue with, “I need to consult with my supervisor to determine if we can fit you in. May I put you on a brief hold or call you back in a few minutes?”  

• Complimentary Consultations: Offering complimentary consultations is a common practice for implant and clear aligner services, but the front desk of a busy practice must prequalify patients for those appointments, or the dentist will spend a lot of unpaid time prequalifying the patients herself or himself. 

Make Room for the New Patients You Want 

Even highly qualified patients may become frustrated if they wait more than a week for an appointment. Consider reserving one extra patient slot per week for the type of new patient you want. If no such patient calls early in the week, use the slot for an existing patient who needs attention. You can also modify your new patient protocol to offer this person a shorter appointment to get started–with the recognition that there will be more than one appointment to complete the new patient process. 

Coach Your Front Desk 

If you have an inexperienced or new receptionist answering your phone, it’s important to discuss with them the types of high-value patients they should prioritize for you. Additionally, provide guidance on how to nurture these new patient leads, so they are more willing to wait for an available appointment. This is a Team Meeting Topic every fee-for-service dental practice should discuss periodically. A high-value patient to you is likely one who wants the highest-level of comprehensive care, appreciates your approach to patient-centered care, and eagerly wants you. 

Lee Ann Brady, DMD 

The origin of a patient’s dental wear may be deceiving. Is it physiological or pathological? This minor difference could spell major consequences for the lifetime oral health of your patients. We care about understanding the differences and how to manage them for the benefit of our patients. 

What is the amount of normal tooth wear? 

To understand normal tooth wear, let’s compare the size of teeth at age 10 to their size at age 70. Based on extensive research, we’ve found that the average loss of tooth structure over this 60-year period is approximately: 

• 1.74 millimeters on posterior teeth (first molars) 

• 1.01 millimeters on upper anterior teeth (centrals and laterals) 

This equates to roughly 15-26 microns of wear per year, depending on the tooth type. 

It’s important to note that this includes all forms of wear, such as attrition, erosion, and abrasion. Even with this normal wear, most people should still have a layer of enamel on their teeth at age 70. In fact, you might expect to retain at least half of the original enamel thickness on your incisal edges and cusps. 

While a certain amount of tooth wear is a normal part of aging, it’s important to distinguish between physiologic wear and pathologic wear. Physiologic wear is a natural part of aging and includes abrasion, erosion, and attrition. It occurs at a predictable rate and typically does not result in significant tooth structure loss. If you notice excessive tooth wear beyond the expected range of 15-26 microns of wear per year, it may be a sign of an underlying issue that requires further evaluation. 

What is the patient-centered approach to discussing wear and understanding the cause of tooth wear? 

When discussing tooth wear with patients, it’s essential to approach the conversation with empathy and understanding. By using a patient-centered approach, you can foster open communication and encourage patients to take an active role in their oral health care. 

• Open-Ended Questions: Ask open-ended questions to encourage patients to share their observations and experiences. For example, you might say, “I’ve noticed some wear on your teeth. Have you noticed any changes in how your teeth feel or look?” 
• Avoid Assumptions: Don’t jump to conclusions about the cause of tooth wear. Instead, ask questions to gather more information and explore potential contributing factors. 
• Emphasize Collaboration: Emphasize that you’re working together to identify the cause of tooth wear and develop a treatment plan. This fosters a sense of partnership and encourages patient involvement. 
• Avoid Blame: Avoid blaming the patient for tooth wear. Instead, focus on identifying the underlying causes and developing strategies for prevention and treatment. 

What do I say to my patients? 

I always start from a place of curiosity. I might say, “When I examine your teeth, I notice some wear that seems more than what’s typical for your age. I’m curious if you’ve noticed any changes in how your teeth feel or look. Sometimes, unusual wear can be a sign of underlying issues like teeth grinding, acid reflux, or other factors.” 

Many times, patients will then say to me, “I don’t know. Do you think I grind my teeth?” or “I don’t know. I do have acid reflux.” If the patient says, “Gosh, I don’t know what that’s about,” the next piece of the puzzle is to take my curiosity and help them understand what we would do diagnostically to figure that out and potentially what we would do to manage that. 

If I think the wear is erosive, the conversation can turn to acid reflux or an acidic diet or abrasive toothpaste. If I think it’s erosive, the conversation leads to “seeing if we can learn what your teeth are doing when you sleep at night. If you’re grinding your teeth, that is something we can manage.” 

I never start with “I think you grind your teeth,” or “I think you have acid reflux,” no matter how confident I am that that is the case. I don’t approach it that way for a couple of reasons. I need to give the patient a chance to process that information and come to terms with the fact that something may be going on that they weren’t aware of beforehand. There’s an emotional impact from hearing that information, so we want to deliver it in a gentle way. And I want the patient to become aware of what may be happening on their own. I want to create a co-discovery process.  

The general message is “We can work together to figure out what might be causing this. By understanding the cause, we can work together to determine the best course of action to protect your teeth and prevent further wear.” 

Paul A. Henny, DDS 

Charisma is the ability to attract and influence others with our ideas and communication style. There are many different types of charismatic styles, with no moral component associated with any of them, which means that some charismatic people are quiet, graceful, and principle-centered like Jackie Kennedy, while others are more extroverted, and self-centered like her husband JFK. In other words, some charismatic people are exuberant like Oprah Winfrey, while others are more introverted Elon Musk. 

Charisma is often said to be a “subjective ineffable quality,” something we either have or we don’t have, with attributes such as confidence, passion for a topic or a cause, optimism, a ready smile, expressive body language, and a friendly voice. In other words, the social characteristics of a charismatic person reflect feelings of someone with high self-regard. 

Is charisma an important attribute if we want to become a more successful, relationship-based, health-centered dentist?  

Simply answered —yes. 

But the basis of our charisma must originate from an “other-centered” world view, because if we use charisma as a strategy to simply get more of what we want out of others (act in a manipulative fashion), then it won’t work well for us long-term, because empathetic patients are able to detect insincerity very quickly, and the perception of insincerity will cause them to steer away from us. 

On the two-way street where relationship-based, health-centered practices live, both charisma and empathy are essential. Even if we’re introverted (most dentists are), we can still be charismatic if we present ourselves and our message in a fashion that’s “other-centered,” sincerely helping, and in an “I’m willing to give-before-I-receive” fashion.

L.D. Pankey, Bob Barkley, F. Harold Wirth, Peter Dawson, Mike Schuster, Richard A. Green, Frank Spear, John Kois, Lee Ann Brady, and other stars who shine in our dental firmament all had/have different personalities and communication styles. In common, they all shared/share their deep love for others and an insatiable desire to help others learn and become better at helping others. We know them because they have drawn us in. They have engaged our attention and inspired us to push our personal envelope and follow their lead.

by Lee Ann Brady 

Have you ever noticed a confused look on the face of an older dental patient when you tell them they have a cavity? Many people falsely assume that only small children develop cavities. When I let older adults know that they have one or more cavities, they say something like, “Wait, I thought only kids get cavities” or “I haven’t had a cavity in decades.”  

They honestly think we outgrow that, so I typically say to these patients, “I know you’re thinking that cavities are something that only kids get, and you’ve outgrown this. But that isn’t accurate. Yes, kids are often prone to getting cavities, but adults can get them for the same reasons.” 

Most of my older adults with cavities are doing a good job with their oral hygiene, so I will explain four things to them.  

1. As we age our saliva is no longer as protective. There are also lots of medications older adults take that diminish saliva production. But, even if our mouth does not feel dry, the saliva does not protect us against bacteria and plaque as well as when we were younger. 
2. As we age our taste buds change, and the foods that satisfy us the most are carbohydrates, so like children, older adults tend to eat more sugary foods. 
3. As we age, if we have gum recession, we have larger space between our teeth, and this tends to trap more food particles that feed bacteria.
    
4. After teeth are restored, normal function over time can introduce openings in the restoration, and bacteria can creep into those openings. 

After we talk about the various reasons that they and other older adults may get cavities, we talk about the fact that there are several preventive strategies and I suggest ones they might like to try.  

My patients enjoy our conversations because they know I really care about them, and I will happily spend time explaining why changes are occurring in their mouth. They appreciate hearing that their problem is not unusual and there are strategies to avoid cavities going forward. 

By Steve Carstensen, DDS 

The following four exercises will support your physiology. As you practice them during the day, your nighttime breathing will improve. These exercises are not a cure for snoring or sleep apnea but any improvement in respiratory patterns helps day and night. 

Light Breathing  

Our brains are sensitive to the oxygen and carbon dioxide balance in our blood. The buildup of CO2 triggers respiratory cycles. As we breathe lightly, we increase our brain’s CO2 tolerance. If we are sensitive to hypercapnia, we breathe faster. Quicker breaths lead us into poor gas balance.  

Imagine there is a string in the top of your head pulling it towards the ceiling. Your posture is straight. Now close your lips so you are nose breathing. Breathe as lightly as you can so you barely feel the air moving through your nose for two minutes. Don’t concentrate on how deep you breathe. As you do this you will wish you could breathe a little more. That’s called “air hunger.” As you do this exercise more, the air hunger will fade. You are changing your body’s CO2 tolerance.  

Increasing the amount of CO2 our brain allows us to maintain helps our blood release more oxygen to our cells. Blowing off too much CO2 starves our cells of the oxygen they need for health.  

Deep Breathing  

The next exercise is called “Breathe Deep.” We have two different major muscle groups that fill our lungs. The primary one is the diaphragm, the secondary one is the intercostal muscles of our chest, between our ribs. Diaphragmatic breathing—breathing deep with your diaphragm, produces physiologic benefits. The increase in intra-abdominal pressure increases gut motility and activates the back and pelvic muscles to stabilize your core. This strengthens good posture.  

Sit up or stand straight. Place your hands on your sides so you feel your last two ribs. Breathe slowly and lightly. Feel those two ribs expanding. The diaphragm attaches above these ribs, so the muscles are not moving the ribs; the intra-abdominal pressure is pushing out on those ribs. Now breathe through your nose deeply so you can feel those ribs expand. Do this for two minutes. You might feel a bit of air hunger during this exercise as well.  

Slow Breathing  

The third exercise is “Breathe Slowly.” This is a cadence or timing exercise issue. As you breathe lightly and you breathe deeply, you breathe in for a count of four, hold it for a second, breathe out for a count of six, hold it for a second, and then repeat the cycle of in for four, hold for one, out for six, and hold for one. This will add up to six breaths per minute, which is the best for health because it calms the autonomic nervous system and sends the right signal to the vagus nerve and the rest of the nervous system. You can fit this into your day between patients to calm down and focus better.  

Control Pause Breathing  

The “Control Pause” breathing exercise measures the number of seconds you can comfortably hold your breath after exhaling and is an indicator of how well you breathe. Athletes can go as long as 40 seconds. You might be able to go 15, and that’s okay because this exercise, practiced over time, will improve your breathing volume.  

Breathe in through your nose, exhale, and then pinch your nose. Wait for your body to tell you when to breathe. This is not the very first indication, nor is it a ‘breath-holding contest.’  When you are aware of the signal, breathe normally again for ten seconds, pinch your nose again, and hold. By practicing this pattern for three minutes, over time, you will see you can pause your breathing longer and longer. The number doesn’t matter. The effect you have on the number with practice does matter. If you aim towards a pause of 30 to 40 seconds, you can achieve great breathing health and athletic fitness. It’s another way of increasing your CO2 tolerance, providing more oxygen to your cells.  

By Steve Carstensen, DDS 

Patients come to our dental offices with some common complaints related to poor breathing and oral inflammation…dry mouth…bad breath…gingivitis…excessive wear on teeth. They ask us to help them.  

One of the things we can do for our patients is to be curious about whether they have intermittent hypoxemia that is diagnosable and treatable. I caution us to be aware of having too narrow of a focus. When someone presents with jaw pain, wake-up headaches, and tooth wear, we tend to think they need a supporting nightguard. I think we should be curious about what else might be going on. 

I ask my patients about snoring. I ask them if they have been diagnosed with a breathing disorder. I wonder if they should be using CPAP before I make a bite splint. If you make a splint, they may come back and report they don’t like the splint, which may be because it interferes with their breathing. So, I recommend we stay curious, and when we do make a protective guard for their teeth, we ask more questions. Make sure the diagnosis we make not only correlates with the symptoms, but the patient responds well to the treatment we provide.  

How can we help our patients’ breathing physiology? We can help them be better breathers. There are oral appliances that keep the jaw from falling back and crowding the airway but what about the daytime? It turns out that people who breathe “badly” during the day develop breathing behaviors that the brain continues during the night, and these behaviors are inefficient for keeping the airway open during sleep. So, if we help our patients breathe better in the daytime, we set their brains to be more capable of handling airway disruptions during sleep.  

If you’ve read the book Breath by James Nestor, you will learn about the daytime problems translating into nighttime problems and that nose breathing is best for our physiology. I am a huge nose breathing fan. There are electrical signals that pass from specialized cells in the nose directly to the limbic system which influences our autonomic nervous system. It filters sensory signals from the rest of the body and sends proprioceptive signals into the cortex and down into the autonomic nervous system. None of these brain-signaling signals happen with mouth breathing. 

If you ask someone, “How is your nose breathing?” They will say, “Fine,” because you are the dentist, and they think that is a strange question. They also are accustomed to the amount of work it takes to breathe through their nose, so they don’t really know if they breathe through their nose well enough. The way to test is to ask them to close their lips and put their finger over their lips for two minutes and breathe calmly. With the finger over their lips, they are unlikely to have difficulty breathing through their nose but if they start breathing faster this is a sign of stress. If their heart rate goes up, if they know it was tough for them to do, there is something interfering with their nose breathing. It might be a deviated septum, allergies, a head cold or chronic rhinitis—but something is wrong.  

Knowing this is handy when we are planning to do restorations. You won’t use a rubber dam if they can’t breathe through their nose, or you will schedule to do the restorations after they’ve been medicated. I have found that Afrin is good for clearing the nasal passages before dental treatments. Short-term help is good but stay curious about how often they cannot breathe through their nose, and help them. 

By Steve Carstensen, DDS 

I want to share a clear example of how bad sleep directly affects the anatomical structures dentists pay a lot of attention to—the mandibular condyles.  

Sleep Disruption Disrupts Bone Regeneration 

We’ve all seen on X-rays condyles that do not look healthy. We wonder what causes so much degeneration. There are shelves of books and whole courses about what goes wrong but one of the things that affects condyles is a circadian rhythm disruption. Research* with rats has demonstrated that sleep disruption disrupts bone regeneration, causing thinning of the condyles. 

* Corrigendum: Circadian rhythm protein Bmal1 modulates cartilage gene expression in temporomandibular joint osteoarthritis via the MAPK/ERK pathway. Chen G, Zhao H, Ma S, Chen L, Wu G, Zhu Y, Zhu J, Ma C, Zhao H.Front Pharmacol. 2022 Sep 8;13:971840. doi: 10.3389/fphar.2022.971840. eCollection 2022.  

Rats were interrupted from their sleep cycles so they could not get through a normal night’s sleep. After eight weeks they took the disruptions away. During the first four weeks the cartilage layer over the condyles thinned, became really thin at six weeks, and stayed that way across eight weeks. After they returned the rats to undisrupted sleep for four weeks, the breaks in the normal covering of the condyles were still there.  

What do we take from that? The earlier in life that we establish healthy physiology that supports healthy sleep, the greater the chance children have of growing human condyles to withstand TMJ problems later.  

Disrupted Sleep Contributes to Multiple Health Issues 

There’s a lot of research that points to poor breathing contributing to pediatric and adolescent health issues. Among these issues are neurological deficits, behavioral problems, poor school performance, and pulmonary hypertension. A primary cause of poor-quality sleep among our youngest patients is enlarged tonsils and adenoids that obstruct their airway.  

Helping Children and Teens Breath and Sleep Better 

What can dentists do in daily practice with children and teens to help them breathe better and sleep better early in life?  

1. Educate our adult patients who are parents of children to be aware of signs and symptoms.  
2. Develop a culture within our practice of being a health consultant, so our adult patients feel welcome to easily engage in conversations about health issues that commonly affect children and teens.  
3. Introduce the parents to their own need for an open airway for healthy sleep to raise awareness.  
4. Assess all our patients for breathing issues and examine their airways for signs of obstruction.  
5. Provide guidance to our adult patients and to the parents of the young people in our care so they can choose appropriate care.  

Our Responsibility 

We need to start paying attention to these things as much as we do the health of the teeth and periodontium. As dentists, we are responsible for the entire cranial facial respiratory complex. My colleague, Dr. Kevin Boyd in Chicago, is a pediatric dentist who came up with that label a few years ago. I love that term, because it helps us focus on the whole person, structure and function! We can be proud when we help our patients with the respiratory part of the complex. 

As we take our place in medicine as being in charge of the cranial facial respiratory complex, we get to affect growth and development. We get to help train the body to swallow properly and grow good bone and good airway support. And that’s the major role I think dentists are going to have going forward in healthcare–identifying those children who have an underdeveloped cranial facial respiratory complex and influencing their care. Like other folks in medicine…an ENT doctor…a myofunctional therapist…a speech therapist, we help correct the things that we recognize that are going wrong.