Latest / The DOC Podcast / The Truth About Mouth Breathing, Sleep, & Sleep Medicine (w/Dr. Funke Brown) [Ep.170]

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The Truth About Mouth Breathing, Sleep, & Sleep Medicine (w/Dr. Funke Brown) [Ep.170] · The DOC Podcast

• riverside_mike_deluke_raw-video-cfr_the_doc podcast stu_0092 [00:00:00] Cold open Dr. Brown: Primary snoring changes the trajectory of a child. It's not benign. I love the polysomnogram. That's what I do for a living. But it is flawed, a flawed way of diagnosing a condition when we know there's night-to-night variability. Do not make a full diagnosis of ADHD in a child when you're doing the evaluation without doing a complete and thorough sleep assessment and making sure that you address the underlying sleep issues. The American Academy of Sleep Medicine, I think the last time they made updates in the guidelines was over a decade ago. If there's anything you're gonna leave with, noisy breathing while awake or while asleep, is not normal. Podcast welcome Speaker 2: Hello and welcome to The Doc Podcast. I'm your host, Dr. Mike Deluc, and it's my mission to help you lead a happier, healthier, and more prosperous life, both personally and [00:01:00] professionally Guest introduction Speaker 4: Hello and welcome to this episode of The Doc Podcast. Today, I have the pleasure of being joined by Dr. Funke Afolabi Brown. Dr. Brown is a triple board-certified sleep physician, the founder of Restful Sleep MD, and the best-selling author of Beyond Tired: A Sleep Physician's Guide to Solving Your Child's Sleep Problems For Good. As both a sleep physician and the mother of two children, Dr. Brown understands firsthand the profound impact that sleep has on every aspect of our health. Through her clinical practice, research, writing, and speaking, she has made it her mission to help children and adults achieve healthier, more restorative sleep so they can truly thrive. Dr. Brown is an internationally recognized speaker and consultant who has lectured on regional, national, and international stages, authored numerous peer-reviewed publications on sleep disorders, and works with healthcare organizations and businesses to incorporate healthy sleep into their wellness [00:02:00] initiatives. In today's conversation, Dr. Brown and I go far beyond simply talking about sleep. We explore what truly defines healthy sleep and how to recognize when sleep has become a problem. We discuss why sleep medicine remains one of the least understood areas of healthcare, why both physicians and dentists often receive remarkably little formal education in sleep despite its enormous impact on overall health, and why that must change. She and I also examine the spectrum of sleep-disordered breathing and why it is about so much more than just obstructive sleep apnea or a score on the apnea-hypopnea index. We discuss the strengths and limitations of in-laboratory polysomnography versus home sleep testing, why symptoms and clinical judgment are just as important as test results, and why focusing solely on the AHI can cause clinicians to overlook patients who are genuinely struggling. I think one of the most powerful parts of our discussion centers on the far-reaching consequences of [00:03:00] poor sleep, particularly in children. Dr. Brown and I explore how inadequate or disruptive sleep can profoundly affect neurocognitive development, behavior, emotional regulation, learning, academic performance, attention, and overall quality of life, and why sleep disorders can so easily masquerade as conditions like ADHD while their true underlying etiology remains unrecognized. And in this packed episode, we also find time to discuss why snoring and chronic mouth breathing should never be considered normal, the critical need for collaboration among sleep physicians, pediatricians, ENTs, dentists, orthodontists, myofunctional therapists, and other healthcare providers, and why an interdisciplinary approach is essential if we hope to improve patient outcomes. Dr. Brown is also going to share why she is incredibly optimistic about the future of sleep medicine, as the growing awareness surrounding sleep health is contributing to a new generation of collaborative healthcare [00:04:00] professionals who have the opportunity to fundamentally transform the lives of millions of our patients. So without further ado, let's get on to today's episode and my discussion with Dr. Funke Ofolabi Brown. Enjoy the show, everybody. Interview begins Dr. Mike: Welcome to Doc Podcast, Funke Dr. Brown: Thank you so much for having me. I have been so excited and so looking forward to this episode Dr. Mike: Same with me. Ever since we met, uh, just a little background into how we, got to know one another initially. We were both speaking, or both speakers, at Jerry Simmons' Sleep Consortium, which he does an amazing job with in Houston, and we were sitting at lunch. We just happened to sit down next to one another and got chatting and talk. Actually, we were in line first, and we got talking when we were in line for the food, and then we sat down with one another and got talking for quite a while, and I just really enjoyed hearing your perspective, and There were some things I was talking about, too, of the challenges I face from the dental orthodontic side that seemed to be somewhat surprising to you when we were [00:05:00] talking about it. So I feel like these are the types of conversations we need to have, these interdisciplinary conversations, because there's so much you do that I have no idea about, and obviously a lot of the things in the dental world that happen that the medical world doesn't know about. And, um, that's really one of my missions for this show is, is to help educate people on these topics that we just don't get to talk about or hear about. So, uh, I'm really looking forward to this conversation. Before we get into the technical side of things, if you don't mind, one of the things I love to do on this show is have the guests just talk a little bit about who they are, what your story is your past, your history, and how you got to be to the point that you are today. Dr. Brown's background Dr. Brown: Yeah, absolutely. So I'm a sleep medicine physician, and I have a background in pediatrics and pediatric pulmonology. Sh- so I, you know, I, I did my training in pediatrics, then did a fellowship in peds pulm. And I really... That was when I started to hear a lot around breathing, sleep issues in kids, and [00:06:00] really wanted to do a deeper dive into it. And then I did a sleep fellowship at Penn, and the rest, as they say, is history. That was where I realized it's beyond sleep apnea, it's sleep health. Sleep health, um, in the sense of both optimizing the quality of sleep, the quantity and timing of sleep. So I do a lot of work now in my practice and out there on the media and, and, and other platforms where I talk around changing that narrative that we have around sleep, both in kids as well as in adults. So yes, I have a practice, a sleep medicine practice in Horsham, Pennsylvania. We see kids and adults with sleep, a wide variety of sleep disorders. Dr. Mike: That's so cool to hear the journey you've been on to go, um, on to help so many people. And that's really, I, I think maybe just to start with talking a little bit about the medical profession and where it stands from a sleep perspective. I've had a bunch of physicians on the show. I find that one of the things that has surprised me probably the most is how little you all get in [00:07:00] sleep. Uh, and sometimes even in some of your ... And we were talking a little bit about this when we met in person in Houston, but even sometimes in the fellowship training and, and the advanced training, you're not getting as much as we may think. So talk about that a, a little bit, if you would. Sleep education gaps Dr. Brown: Yeah, I, exactly. And I think this is a, this is a real problem. This is a, not just a problem, it's a crisis. So, uh, you know, even though I did pediatrics training and I was teaching parents about the importance of sleep, and I did a pulmonary fellowship where, again, you know, we're treating patients with, you know, sleep apnea and asthma, breathing issues. The level of sleep education I had up until when I did my sleep fellowship was very minimal. In fact, there've been a few, you know, studies looking at essential surveys, looking at essentially how much, uh, education physicians get throughout their training on sleep medicine, and on average it's about maybe two hours' worth. And when we talk about sleep education, we're talking about the whole thing. [00:08:00] So everything between sleep apnea, very rarely do you hear about other disorders like circadian rhythm disorders, narcolepsy, things like that. So it's a true crisis because here's something that every single person on earth that does every single day is sleep. And so to think that the information we have is so minimal is a real problem. And now to layer on some of the work, you know, I'm really seeing as I work with quite a number of dentists and orthodontists, that's c- that's like no man's land. Like, there's really very few people seeing things in this way. So, um, and I would say for me, it's, it's personal too, because even though I kept telling people, especially during my, you know, my journey, my career and having kids and, and seeing them and wanting to help them, there were things that I didn't know from my training. There were things I needed to learn on my own as well. So, uh, yeah, it's a, it's a real problem. So to tell you I'm excited about this [00:09:00] conversation, hopefully you get it. Dr. Mike: Yeah, that's why, uh, we hit it off instantly because we both are so passionate about this, and I think instantly recognized in speaking with one another that there is this huge gap. We were talking about, about the silos that exist and, um, how little we each get exposed to each other's fields, and it's just so sad. And I, I mean, you, you said one thing there, too, that, just to swing, to touch back on, um, how it's something we do every night, right? We h- hopefully, all of us are, are doing that. And yet it gets so little attention until it's a problem. And even when it's a problem, we don't even know that that's the etiology of the problem. So if, you don't mind, take a moment to just talk a little bit about what good sleep is. How do we define that? You know, people will wake up, and you'll say, I mean, I say it to my girls, or my wife, "How'd you sleep last night? Did you sleep okay?" But we don't really know... It's kinda subjective, right? Like, w- I think. You know what I mean? So, uh, and we might know more than we used to, or we do know more than we used to with wearables and all those other things that [00:10:00] can... And we can talk a little bit more about the role that those could play, too, now and in the future. But just for the audience listening, and it's, I mean, the audience is medical, dental providers, uh, professionals as well as laypersons. So what should we all know about sleep? And, and you can kind of divide it into pediatrics or adult or both, whatever's easier for you in terms of breaking that down. Defining good sleep Dr. Brown: Yes. So when I, when, when, when I think about this kind of question, what good sleep, sleep is, one of the things about-- I, I think about is, you know, restful sleep. What does that even mean? There is the objective piece of this, and then there's the subjective, which is so critical. And I think while I love the wearables and the data, sometimes it overwhelms the person, the, what that person is feeling, right? If your data shows that you barely got enough deep sleep, yet you feel awesome or vice versa, right? So when we think about good sleep, we're really thinking, talking about, one, the tiny, the, the... Usually, I'll talk about the quantity of sleep. That's [00:11:00] important, you know? And that quantity varies based on age. So for kids, we know that depending on how old they, depending on how old they are, the older they get, the less. So a newborn needs anywhere from fourteen to seventeen hours. That's incredible. They spend a l- they pretty much their entire day sleeping. Why? Because sleep is so critical to their development, their brain development, their growth and ev- and emotion regulation and things like that. So when you get to school-aged kids, maybe they sleep anywhere from nine to eleven hours, or teenagers eight to ten, and adults seven to nine That's just quantity, and that's just a piece of the puzzle. And this is why even if you're getting, as an adult, seven or eight hours of sleep, you still feel crappy. It's not about the quantity. There's more to it. That takes us to the second piece of it, which is the quality of sleep. And so the quality of sleep really speaks to the restorative nature of sleep. Sleep is meant to be restorative. People talk about sleep being a very sort of passive process. And I [00:12:00] dare to say sleep is actually pretty active because if you think about emotion regulation, you think about, uh, memory consolidation, the development, um, you know, so many aspects, your immune system being mediated and regulated, all of that is occurring during sleep. Growth hormone release. So all of that occurs based on how good the quality of sleep is. And when we talk about quality, there's so many things that can disrupt that quality. The end result is you get sleep that does not feel refreshing. You wake up in the morning, and you feel exhausted already. Or you have that child who is hyperactive, irritable versus being the pleasant person they usually, they usually are. So that's really the quality. And then the third piece, which we often don't pay as much attention to, is the timing of sleep. We all have this circadian rhythm that regulates our sleep-wake cycle. And everybody has, uh, you know, sort of what we call chronotypes. So you may have somebody who is more of a, uh, you know, a night owl, and you [00:13:00] have somebody else who's more of a morning or who's more of a morning lark. All that to say your circadian rhythm regulates your sleep-wake cycle. It also regulates physiological processes, other systems in your body, your hormones, the timing, and things like that. So when you have the three, good quantity, good quality, and good timing that aligns best with your circadian rhythm, that is literally s- good quality sleep or, you know, good sleep in that sense. Dr. Mike: Yeah, it's funny you say that about the wearables too, because I know they're not super, and actually Jerry was talking about this in the, um, in the consortium, but breaking down how they're, they're... Most wearables, the more I'm talking about the normal watches and rings that people will use, they're sampling not very frequently, right? That, that's the difference between those and the more high-quality rings or rings you might get through a sleep physician that are gonna be sampling much more frequently, um, per milliseconds versus every few seconds, so to speak. Again, correct me if I'm wrong on that, but, uh, it's, it's a, a different, uh, frequency of [00:14:00] sampling, and I find that people do get tied to those numbers. And, you know, they wake up and they look, and they'll be like, "Well, I feel like I slept well, but oh my gosh, it says my sleep score was a 78. Like, what am I doing wrong?" And, um, well, it can be very helpful too to kind of dial in, like, "Oh, geez, I notice the days I have coffee at 5:00 PM, you know, I'm not getting the same sleep." So i- it's this kind of, to me, double-edged sword. It's, it's got a lot of good information, right? But people get obsessed by it. Um, so what is your experience with, uh, with your patients? What, what, how, what role do wearables, if, if any, play? And what about in kiddos? I know most products, they're not recommending them, for the younger kids. So why is that, and, and is that gonna, going to change soon? Wearables and orthosomnia Dr. Brown: Great question. So we've actually now seen that, you know, the wearables are getting a bit more accurate in that sense. For me, I see it in terms of the trends. The utility is in the trends and the story it's telling us rather than the day-to-day, um, insights that [00:15:00] you're getting. In fact, we now have a condition called orthosomnia, which is that excessive obsession with your sleep data to the point where it's impacting your sleep itself because now it becomes sleep-related performance, which now triggers this anxiety around how well did I do? Did I do well or not? Listen to your body. Your body will tell you. And so when it comes to how I use it, and many of my colleagues in the field, we let it tell us a story. Like you said, you're somebody who is just looking to optimize your sleep. You're somebody who's making better sleep habits. You finally decided you wanna put the phone away right before bed, and you wanna make that bedroom cool. Well, maybe you wanna see what does this do for trends? Or you're someone who takes a-- who gets a nightcap, you know, a, you know, a glass of wine every evening. Now you're cutting back on that. You wanna see what story is that telling me based on the data. I think there's some utility in that. But the issue now becomes when it becomes this obsession around [00:16:00] did I get a good sleep score or a bad sleep score? That's where I start to get concerned. The other piece is we now have some that are detecting, you know, fluctuations in your oxygen. And like you said, the sl- sampling frequency is not frequent enough. But if I have somebody who says, "Oh yeah, my..." You know, give an example, "My Oura Ring said I'm having some breathing irregularities," um, I will, I will take that to heart and say, "Okay, you know what? Let's dig deeper." But I'm not gonna make a diagnosis based on that. Then we're gonna get a more, you know, more reliable testing, like a polysomnogram or a home sleep test to figure out what's going on. So it can tell a story, but it's just one piece of the puzzle. Um, the way I-- the, the kind of analogy I also give is, you know, you're trying to, you know, lose weight. You're trying to do something to improve your weight. So maybe you go exercising. You're checking out how much you're eating daily to make sure you're, um, within a certain range of calories. Obsessing [00:17:00] over the steps you're taking beyond saying, "Okay, am I making progress daily?" I think that's the same way I can you know, compare it and things like that. So it has a role to tell us a story, more useful when we talk about trends. Definitely, I do not go with the day-to-day variations. When it comes to kids- Like with so many other things, which is why we are so excited that you're in this space and doing the work we do, you do. There's just not enough. There's not enough data. Most of the u- most of these devices were not tested on kids or children below 18, so there's definitely a gap. I do see over time some of it extending to, you know, to children because when I think about sometimes parents, if you have a child that's 12 years old, and I ask you, "Does your child snore?" You might not know that. How will you know your-- you sleep trained your child to be able to sleep independently. So there may be some information that some of these wearables may [00:18:00] provide to us that can help us to really get better at understanding of what's happening to kids, but we're definitely not there yet. Dr. Mike: Yeah. Um, thank you for breaking that down and providing some clarity on that because, you know, it's, it's, orthosomnia, it's interesting how... I- and I'm not surprised. Actually, when that first started happening, I remember saying to my wife, I'm like, people are gonna get crazy with this." Because you, it's just one of those things you, you could literally, and I, full disclosure, I was like, "Ah, maybe I don't..." I, I, my personality tends to be a little more obsessive with things. I was like, "You know, I don't think I wanna..." You know, I don't want, I don't wanna have a score that's bad. And , I have pretty good, uh, mental strength and willpower I can fight through even if I don't think I had the best night sleep. But if I see that score, and I thought I had a decent night's sleep, I might, you know, subconsciously kind of look at it differently. So I hadn't done it, and then I did get one, a little while back, earlier in the year, and I was using it for a little while and, uh, maybe about a month. And I just, I found that I did start to look at it too much, and I'm like looking at it and I'm analyzing the sleep. And I'm like, "What am I doing?" This is, you know, stick to the principles like you said, right? You know, I tend to be more the [00:19:00] night owl than the early bird, for sure. Uh, my, I mean, it, it's just my chronotype is definitely more predisposed to that, always has been. But I was terrible on sleep early in, like in my career when I was practicing and my practice was super crazy. I was, not getting enough sleep at all, and it definitely affected me in ways I didn't even realize until after. And I started to get, you know, past few years was much better on my sleep and sleep hygiene. Uh, but yes, I, I think it plays a role, but at the same time, it's not practical that you're going to get a perfect night's sleep every night. And I think that's the other thing I wanna hear your thoughts on is, how do we judge that? Like, I've heard different people on podcasts and read different things where if you get one or two nights of disrupted sleep or bad sleep, it takes, you know, three or four days to recover. And I, I feel like there's so much, you know, and almost like we had no attention paid to sleep for, for so long, and now it's become this thing that everybody's out there talking about. Sadly, not the physicians and, and dentists enough, but in the lay population, uh, it's hard to find a, a podcast or a show [00:20:00] that's on health and wellness that doesn't have multiple episodes on sleep. So how do we judge our sleep? Is it, uh, when we have a bad night's sleep or two, or when you're a new parent, my goodness, when your kids are little, I mean, you're not getting good sleep. You survive. So how do we differentiate between a chronic problem and an acute problem? And how are those acute problems, how easy is it to recover from, from I guess either of those? Acute vs. chronic sleep problems Dr. Brown: Yeah. I love that question so much because this plays into a lot of the problems we have with people who have insomnia. Um, starting off, we know that your sleep will fluctuate. And this is why when I say, you know, when we look at data, we're not looking at the day-to-day because there will be fluctuations. I usually tend to take two-week blocks to say, "How are we doing over the last two weeks? You had a rough time. Your kid was sick. You had travel. You had stress at, at work. You should have about a week to, to recover and get back to baseline." And so when, for instance, for patients [00:21:00] who have chronic ins- or chron-chronic insomnia or even acute insomnia, when I'm, when I'm, when I'm taking care of them, that's one of the things we look at when it comes to our sleep diary. I'm not asking you to give me a report of how your night went from night to night. I wanna see over the last two weeks, we'll see trends. And here is the beautiful thing about when we do have seasons that we lose some sleep. Your body has its intrinsic way of making up. So for instance, you have, you know, you have a young child, you... or something is happening, you're not able to get seven hours of sleep, or you get very fragmented sleep because your child is waking you up multiple times at night. Here's what happens. We get a phenomenon which we actually call REM rebound. You get those stages you may have missed. You'll get it over the next, you know, few days as you give yourself more sleep opportunity. So again, understanding that nobody has perfect sleep. Even the best [00:22:00] sleepers have bad nights, but we're not gonna use that one night to define our whole trajectory. And this is really plays into how we define even insomnia, right? Chronic insomnia is when you have difficulties either falling asleep, staying asleep, or early m- morning wakefulness that's impacting your life. We don't really technically make that definition until these issues have been, you know, going on sustainably for some time. Usually, we'll say, sometimes some people say three months. I don't think you need to wait for three months before you fix insomnia if you know you have insomnia. But the reason why that is the case is because we know that your body does know how to self-adjust. So usually within a week or so, you should, um, be able to reset. Here's the thing, though. There are two con- there are two things when we think, when we think about this. When we think about insomnia, it's not the same thing as sleep deprivation. Sleep deprivation is when you chronically are not giving yourself the opportunity to get the [00:23:00] sleep you need. Well, until you make changes in your habits, you're gonna have to be playing catch up for a much longer time, and that duration is gonna be depending on you, on how willing you are to make behavioral changes to optimize. Insomnia, on the other hand, is you've given yourself enough opportunity, but maybe because your mind is racing or something else is going on, you're just not able to get it. And so the trajectory for that is completely different. Usually for somebody who has sleep deprivation or who's not giving themselves enough time to sleep, the recommendations are different. Set boundaries, put the phone away, get help if you have a little kid or get your spouse to kind of chip in or, or help out or whatever. If it's insomnia, we're saying try less. Don't give yourself so much of a hassle. Don't b- get bent over backwards because you're having a hard time. Because the harder you try to chase sleep if you have insomnia, the harder it is to get sleep. So it, it kinda is a little bit different. But again, we're looking back, [00:24:00] making those changes and then saying, "How are we doing over the last-- how have we done over the last two weeks?" I usually will say that's about the time I give. And then from there we can say, "What do we need to change from a behavioral standpoint, um, to optimize and improve?" Dr. Mike: Yeah, that makes complete sense, and I appreciate you breaking that down and separating that out. Um, and the more I learn about this and get into this space, it's so complicated. And I think that's why a lot of, at least speaking for my dental colleagues, why a lot of us don't get into it, because we're busy doing our work and doing our jobs, and we're like, "I can't now get into this whole thing," because it is a bit of a rabbit hole. Once you start learning more about sleep, you realize how little you know. It, it's the whole Dunning-Kruger curve. I mean, it's like you think, "Oh, yeah, I know it, right, get this," or go for a sleep study, which I'm gonna ask about in a second. Go for a sleep study, and if they're fine, they're fine, and, and that's the end of it. And the more you learn about this, you're like, oh, my goodness, even the sleep physicians argue about these things, and, and they're trying to figure out how to best adjust care for their patients and make these recommendations, which is, again, fascinating to me, and it's gr- so great we're having these conversations. But [00:25:00] on the sleep study note, the polysomnography note, you know, I was struck by the fact you said you, you wanna see a, a solid two weeks of data to really get a trend. And even good sleepers have bad nights, uh, and I'm sure probably even bad sleepers have good nights. So, uh, talk to me a little bit about in-lab polysomnography, uh, for everyone and then especially for children, which just for anyone who's not aware of it out there, is a one-night, typically, um, which is one of the problems, a one-night study in a laboratory hooked up to a bunch of different electrodes. And, uh, Fungai can explain it much better than I can, but it's, at a facility that you're going to this, and we're not talking about an at-home or a wearable, this is in a sleep lab. So if you could talk a little bit about that and the, the good and the bad, so to speak, of, that method of testing for sleep. Speaker: Hey everybody. 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Readers learn how to turn the tax code into their own generational wealth code by applying tax-smart strategies within each of these critical areas designed to maximize opportunities, minimize tax burdens, and build a long-lasting financial legacy. It's available now at Amazon, Barnes & Noble, and other major booksellers, and I'll put a link in the show notes as well, So don't delay. Get your copy and start learning how to unlock your generational wealth code. And now back to today's episode In-lab polysomnography Dr. Brown: Absolutely. So when we talk about polysomnography, it's polysomnogram. So you think about multiple channels to [00:27:00] observe sleep. That's it. That's the test. And right now, currently, it's technically the gold standard for detecting sleep disorders, certain sleep disorders. And you have... You can do it in children as well as in adults. When we talk about the, uh, the indications, there are different indications. There are respiratory indications, and then there are also non-respiratory indications. So for the respiratory indications, if you're looking to make a diagnosis of obstructive sleep apnea, central sleep apnea, it gives us the information to figure out nocturnal, what we call nocturnal hypoventilation. 'Cause you have some people who may not have very high or very bad sleep apnea, but their CO2 levels are just really, really high. So you can use your sleep study, your polysomnogram or PSG, that's the short form, to detect, to detect that. There's also things like if you wear on Continuous positive airway pressure, for instance, and you wanted to figure out how much [00:28:00] pressure do we need? Are we on the right settings? You can use a PSG for that. Sometimes we have patients who have a tracheostomy, meaning that for some reason or the other, they're not able to breathe through, um, their nose, and so they may have a tracheostomy, which is literally, um, an, a hole in their neck to help them breathe, and they may be attached to a ventilator. So sometimes we might use a polysomnogram to figure out what the right settings are for them to be able to breathe well. So those are respiratory indications. Now, we have non-respiratory indications. If you have people who, for instance, have also nocturnal seizures. These are pe- patients or kids and adults who may be having seizures which we're like, "Is it related to sleep? Is it not?" You can actually use a polysomnogram to figure that out. Now, if you have patients who have a disorder called periodic limb movement index or periodic limb movement disorder, this is a disorder where you have specific twitching movements in your lower legs. It's usually either related to kidney disease, sometimes iron deficiency, all that stuff. A PSG would be, [00:29:00] um, required. You can also use it for, um, to diagnose, or that's actually the way we diagnose narcolepsy, which is a chronic disorder of hypersom- somnolence, so you're excessively sleepy for no clear reason. So there's certain metrics that we would use to figure that out. So, um, you do the overnight study, and you do a daytime test, which is the multiple sleep latency test. So that's the broad definition, the indications of PSG. Now, what does it include? It includes a whole lot of leads, which we call EEG, because we wanna figure out what stage of sleep you're in, whether you're awake, you're in, um, slow-wave sleep, you're in light sleep, or you're in REM sleep, because different things happen then. We want to figure out also when you're in REM sleep, your eye movements tend to be frequent. So you have eye leads. You have chin leads to measure, um, to measure snoring. You have a nasal cannula that measures how air is flowing back and [00:30:00] forth. You have belts to measure how your chest is moving . You have limb leads to measure your movement. You have a pulse ox. You have, you also have a, um, a sticker that measures your s- the carbon dioxide level. So I'm sure as you guys are imagining, that's a whole lot of stickers, a whole lot of wires, a whole lot of technology, and you're in a room in either a hotel. Some people have a hot- uh, they use a hotel. Some sleep centers use a hotel. Some sleep centers have their own facility where you are in a bed. Everything is completely foreign, and oh, by the way, there's a camera that's watching you because they wanna see what you're doing, and you're to sleep. So this is hard for adults, let alone children. And it's, there are many pros in the terms, in terms of The accuracy of the data you're getting, if you're able to get that data, it tells a lot. It tells a story, right? You have all these channels, right? Telling a story. Now, the problem is if you get that data, because it's a, [00:31:00] it's a snapshot in time. So if you have a condition that no-- maybe does not occur to the same intensity every single night, we might miss it. And so then what do we do now, right? Since it's now considered the gold standard, right? So that's one. The other piece that we see that we struggle with a lot is access. As we know, there's a limit to the number of, sleep physicians in the US, in the world, and there's a significant limitation to the number of pediatric sleep physicians and sleep centers. So now you have this test that's considered the gold standard, where we're hoping that you actually do sleep, but unfortunately, you do not have access to get this test done for six months. Some people have a wait time of up to a year. Dr. Mike: Right Right Dr. Brown: uh, uh, w-- I'm, I'm just cringing right now as I'm s- as I'm saying this, right? And I told you, we have-- we're trying to figure out a problem that you're having every single night, [00:32:00] because you sleep every single night. And so this is just... Uh, uh, it needs to change. So that, I think that's a big limitation factor. The fact that it may not necessarily be a true reflection. You're in a different environment. You're being told, you're wired up and told to sleep as naturally as possible so that we can figure out what's going on. So I see a lot of children where they are snoring or they're having restless sleep, and we get a polysomnogram, and the sleep study says it's normal or there's no sleep apnea. And the reason why is, well, it turns out that child was awake most of the night because they were not comfortable, crying most of the night. And so as a result, the nasal cannula and the accuracy is questionable. Or they just happen to have a night that maybe their apnea was just not as bad, and so it didn't pick it up. And so this becomes a real problem because the child in front of us now, we're now making a decision as to do they need to be put on ADHD meds? Do they need to be pulled out of school because they're having such a hard time sitting [00:33:00] down and focusing and, and so many other things. So, um, you know, I could keep going on and on. I love the polysomnogram. That's what I do for a living. But it is flawed, a flawed way of diagnosing a condition when we know there's night-to-night variability. It occurs, you sleep every night and, you know, the-- it, it just keeps going on and on. Dr. Mike: Ah, I, I'm so glad to hear you explain it. You explained that really well, so thank you for breaking that down in, uh, probably one of the best ways I've heard it broken down from beginning to end, and all of the different aspects and the pros of polysomnography. 'Cause I think sometimes people... It gets a bad rap, and people are like, "Well, there's no value in a sleep, in a sleep test." And there is, and there's a lot of value if it's, if it's done properly . If, you know, if for a child, like you said, if the electrodes aren't getting pulled off or ripped off, or the cannula, nasal cannula is coming out, or the tech is going in to readjust things because the, you know, the, the cannula's been pulled out or isn't, uh, in the right position, or the child moves a lot. And that's another thing we know with children, is a lot of children with sleep-disordered breathing are [00:34:00] very active and hyperactive at night. So they're tossing and turning and flipping, and they're pulling these electrodes off. And so there's just so many issues there. Uh, and it's interesting because still a lot of people in the dental world, especially in the orthodontic world... And actually recently in the AAO White Paper update, which was what I spoke about it at the consortium, and I've since put out a 90-minute, I'll put a link to it in the show notes, a 90-minute breakdown of that American Association of Orthodontists White Paper update on sleep-disordered breathing, which came out in, April of '26. In that edition, in the, editorial, the editor talked about the fact that essentially you need to send every patient to a sleep physician who you detect may have sleep-disordered breathing. You need to send them all to a sleep physician. They all should have polysomnography. And then the editor in his editorial in that same journal said that all those patients, when they're completed with treatment, you should send them back and have PSG-confirmed resolution of the pediatric sleep-disordered breathing. And I'm like, w- how are [00:35:00] they this far out of touch with the reality of everything you just mentioned that they're still relying on it, and they quote how it's the gold standard? Just like you said, okay, yes, point conceded. I get it. It still is, quote unquote, the gold standard. But even the references they cited in that document went on to talk about the fact, one was a consensus statement on obstructive sleep apnea, and in that very document they said that even though it's the, quote unquote, gold standard, it is very flawed in a lot of ways, and you should use symptoms, and you have to evaluate your patient and use more, uh, time points of data than just this one night in a sleep lab. And I'll add to the point you said about some patients having, uh, zero, uh, coming up as zero and not showing up as in, with, on the apnea-hypopnea index, and therefore people thinking, "Oh, well, they went for a sleep study and their AHI was zero, so they're fine." I've had times where I had patients where they were woken up at, 4:30 in the morning and they stopped the test and they sent them home. And I say to the parents, like, "If they're going to have," especially with children with their more rapid respiratory rates, [00:36:00] typically, if they're going to have these episodes, the longer duration apneas or hypopneas or two successive breaths, which not every lab even uses that, to my understanding, uh, but if they're going to have these, th- they usually happen later in the night in the deeper stages of REM sleep, right? So i- if, if they wake the kid up at 4:30 and send them home, it's possible Johnny never even got into the, the depth of sleep to have it, correct? Dr. Brown: Yeah. Yeah. Absolutely. Absolutely. And when I read polysomnograms, that's always something I put as a caveat, that even if this study did not reflect, um, significant obstructive sleep apnea, we're also looking at a few things differently. This is something that because I know how flawed it is, I want to help and support whoever is requesting that study, right? Um, looking at what was the patient's respiratory rate? What was the patient's work of breathing? How much REM sleep did we get from this study, right? What were, were there flow limitations which were, [00:37:00] you know, unscoreable, which is what we call them, meaning they may not have met a 3% desat, but maybe a in-increase intensity in snoring that im-- that caused an arousal. So there are some non-scorable events. So you, you really have to take it very comprehensively. But unfortunately, many, and of my-- and I love my esteemed colleagues, many are not really looking into as much granular detail. And then this is where we have to really face the fact that we need alternatives. Sleep-disordered breathing spectrum Dr. Brown: This, this is not working. If you think about the prevalence of sleep-disordered breathing, and when I use the term sleep-disordered breathing, this is not just sleep apnea. And a lot of people change that, and this is something I wanna Dr. Mike: Yeah. Could you explain that? Yeah, yeah, please. Thank Dr. Brown: when you hear this term sleep-disordered breathing, this is a big umbrella term. Sleep-disordered breathing is really a way to describe an alteration in a patient's breathing. Snoring in and of itself is a version of sleep-disordered breathing because we know that snoring is not normal. When [00:38:00] you're snoring, that means there's some limitation in airflow, and that's causing vibrations of a-- of your upper airway structures. That's not normal. Air is not meant to be turbulent as it's making its way down to your lungs. It's meant to just be smooth, right? So snoring is a version of sleep-disordered breathing. Um, obstructive sleep apnea, which is-- which tends to be what people think is sleep-disordered breathing, is a version. It's actually on the, on the end of the spectrum. Um, upper airway resistance syndrome is also a version of sleep-disordered breathing. Then we think about things like central apneas, which is a-also a version. Usually, you see central apneas for a patient who maybe has a brain, uh, some s-central nervous system problem that's really not helping them to take those breaths enough. Hypoventilation, where you're breathing okay, but maybe you're just not taking big enough breaths, is a version of sleep-disordered breathing. So you can see there's like five or six other things [00:39:00] under that umbrella term. So when we talk about, um, a normal AHI, what does that mean? Is there a primary snoring? Is there upper airway resistance syndrome? Is there sleep-related hypoventilation? Is there central apnea? Even if the AHI, the apnea-hypopnea index, is low, right? So again, this is why we need more tools, we need more, more data, we need more research looking at alternative ways to assess these kids especially, and adults as well, because this literally changes the trajectory of their entire life. These disorders we're talking about, primary snoring changes the trajectory of a child. It's not benign, you know? So, um, definitely something that people have to understand Dr. Mike: Yeah, I, uh, actually I love that you went to that point with it because I would love- I wanna go a little further in that with the primary snoring side and where this all begins. One of the things I teach a lot when I go and lecture on this, uh, give presentations, as well as in docs I coach [00:40:00] and, uh, r- with residents that I teach, I'm trying to explain to them exactly what you just explained so beautifully, which is the, is spectrum of disease that this is, and that, um, you know, just a, a zero on the AHI for, especially for a child, uh, because of the lack of sensitivity, the high number of, false negatives that we get, especially for those ones that are kinda borderline, right? That are not, you know, may, may not be that severe, but may, if we got them on the right night for the right duration, it would show up. So I talk a lot about that, and then I, the question I, I end up having from a lot of people, and I try to teach this, but, but you're clearly much more the expert than I am in this. What are some of the things that we can then do? And I guess not only what the p- physicians and dentists can do, but the parents to start to recognize this. So you said, you know, primary snoring, even just primary snoring or child snoring is not okay. Maybe go into that a little bit more, and if, a parent sees a child snoring or if a provider has a parent video f- film their child and, and they show them snoring or, you know, they go away on [00:41:00] vacations or trips or whatever it is and no one wants to sleep in the room with that kiddo because they're keeping everyone up for snoring. Talk a little bit about that. Why is that something that we should be concerned about? Primary snoring Dr. Brown: Yes. So like I said, when you are snoring, when you're making sounds when you br- when you're breathing, either while awake or while asleep, that's not meant to be. Breathing is meant to be quiet. So when there's a sound, the sound, the way that sound is generated is based on the fact that there is a limitation in air that's flowing. That limitation in airflow can be complete, like when you have an apnea, or can be maybe partial as to maybe you just have some structures in there that are vibrating. And this can be anywhere from the tip of the nose all the way down where there could be issues. And this is why, as parents, snoring is not cute. Snoring is not a sign of... 'Cause some people [00:42:00] see snoring and they're like, "Oh, yeah, he was in such deep, he slept really hard." Dr. Mike: Yeah, I hear parents say that all the time. Yeah. Dr. Brown: He slept really hard and you're happy that, yeah, your child slept so hard they snored. Dr. Mike: out cold. They're like, "Oh, they were out cold. They were snoring." It's like, "No." Dr. Brown: So no, no, no, no. So now here, let me just clarify something. When we talk about primary snoring, we're not just talking about that occasional snoring your child has because they have a cold, and so maybe they snore for three days and then they're done. No, we're talking about snoring at least three to five nights a week that is habitual. This is going on whether they have a cold or they don't have a cold. And there are different things that can cause it. When you talk about if you have your child snoring, I need you to ask for help. I need you to detect, realize. Let's start with that awareness, and I think that's the power of conversations like this. We're creating an awareness. If there's anything you're gonna leave with, noisy breathing while awake or while asleep is not normal. [00:43:00] So ask for help and keep asking for help until you get the answer. Because you might go to their pediatrician or t- talk to somebody and they're like, "Yeah, they'll outgrow it." But outgrow it at what expense, right? So that's something you wanna be aware of. So reach out for help. Ask either to be referred to an airway informed orthodontist or a sleep doctor or an ENT doctor. There's so many resources out there. Because what we will then do is figure out, well, where is the snoring coming from? It could be allergies. Guess what? There's ways to address allergies. That's the beauty of this. Do we need, um, you know, some nasal hygiene done? Do we need to, uh, put in some remediation strategies for allergens that could be in your home? That tells you something. It could be that they have big adenoids and big tonsils that have now, you know, crowded that airway, right? And there are treatments for that. It could be that maybe they've had the snoring for a long time, [00:44:00] that it's essentially they've become dependent on breathing through their mouth, and that has literally reshaped their face. Guess what? There's tools for that with, um, seeing an orthodontist or, you know, myofunctional therapy. There's so many resources. But the first is the awareness, not taking no for an answer. So I think I got off onto a soapbox, but I hope I answered your question. Dr. Mike: You, you completely answered it, and thank you. And actually many of the things you just said on that soapbox I'm gonna come back to, because they were things I wanted to talk to you about anyway. So thank you for, for touching on them there. Um, absolutely. No, you go any direction you wanna go. I'm absolutely loving th- this conversation, because these are a lot of the things that a lot of my dental colleagues, and a lot of parents really, when we, when we see, whether it's in the residency or patients I see and, docs I coach, these are the things that they're all saying, like, "How do we get some clarity on this?" So I thank you for taking that time. And I'm so glad you mentioned the allergy side, because that's something I find even people who are airway aware in the dental and medical [00:45:00] field, they seem to go right to tonsils and adenoids and lymphoid tissue obstruction, which are certainly important and relevant. Uh, they seem to bypass the allergies. And actually I'll. See cases where they're doing a, a MRB or a MASB or, doing the skeletal, anchorage for expansion in patients, and they're really understanding the need to try to get additional nasal passageway volume in, in a good way. And then I'll look at their scans or it'll be someone I'm coaching and , working on a case, and I'll see the turbinate hypertrophy, and I'm like, "Have you sent them to the allergist?" And there's the mu- mucus rimming in the sinuses and mucus retention phenomenon. I'm like, "Have you sent them to an allergist?" At the... And they're like, "Oh, no." And, and I'm, I'm like, "Well, volume is volume." Whether you gain a millimeter in width or you shrink a millimeter of turbinate, like, you're gaining volume. This is still important. So I'm glad you mentioned that part because it really is, I think, an overlooked part of this. I mean, I rely heavily on my allergy colleagues. I think, you know, the, the, the turbinate hypertrophy that you see from chronic allergic rhinitis is just so [00:46:00] prevalent, um, especially in kiddos. Am I wrong in thinking that it's gotten worse l- i- and recently? I feel like maybe it's just 'cause I'm now in South Florida, I was in Upstate New York, but I feel like 75% of the kids that we're seeing in the residency have some form of nasal passageway obstruction. I, Allergies and nasal airway Dr. Brown: Yeah. I think you're, you're right. I think it's probably two things. It seems that we're, we're really detecting it more because we're looking. Because we're seeing what is the-- where is this coming from? What is the root cause of this? And so we're seeing it more. Uh, usually by the time I get to a child who's three, has these very prolonged colds, they're breathing, they have the allergic shiners, they're breathing with that open mouth posture. And then you're asking, they're like, "Yeah, they always have these itchy eyes, runny nose, but we put them on antibiotics." If, if your child is needing more than usual number of antibiotics, you, you need to request to say, "Let's just get allergy tested," because it might not be sinus, bacterial sinus infections. It might just be allergic rhinitis. So I think that plays a [00:47:00] big role because you can imagine now you have this child's airway and children's airway. Um, I love the CBCT scans you guys do. It's, it, it just sheds so much light. You can see the volume and already narrow airway because they're small, they're young, their airways are small. Now we have the burden of inflammation because of allergies or reflux. That's also another big one I see because if you do have esophageal reflux, sometimes you can get soiling of that laryngopharyngeal space, which can contribute to inflammation as well. So all of those things really then tell a story, and you can actually go to the root cause and address them really quickly. And then that kind of separates out who then needs further treatment, further advanced, um, strategies and interventions and things like that. So those are just really, really important. And then the other piece is, you know, the diet. That's also a lot of things we focus on as well. When it comes to airway health, a lot of [00:48:00] children are not eating diets that can... or foods that can-- that they actually chew. It's the suck, sucking the diet in the, in the pouches and things like that. So all of that, those are contributing factors for sure. Chronic mouth breathing debate Dr. Mike: On the breathing side, and you'd mentioned the chronic mouth breathing, uh, chronic open mouth posture, and I know there's a whole debate in the medical and dental literature on the fact that you can't really define what is chronic, how often d- is the mouth open. Yes, you can have your mouth open and breathe through your nose, and so there's all these debates. But I think people are getting a little bit down a rabbit hole on that when the fact that we know we are designed to breathe through our noses for, for a multitude of reasons: humidification, purification, pressurization, you filtration o- of the air. Um, we weren't designed to breathe through our mouths. And even if you have chronic open mouth posture, as you alluded to, that, because of the oral facial musculature becoming taut and tight, it squishes inward, the tongue drops, and you lose the ability or the, the purpose of that tongue to push up and out and help develop the maxilla, which is the floor [00:49:00] of the nasal cavity. S- I know, I feel we get really kind of prickly about this and, and all up in arms about this discussion of mouth breathing. I'd love to hear your thoughts because, uh, one of the articles I love to reference and I talk about when I speak is Howard Stupak's article in, uh, 2023 in the European Journal of Rhinology and Allergy. And he talks about this three-step process of mouth breathing, that, you know, it's ... The, the problem is that it's kind of the canary in the coal mine. It's the beginning stage of this problem where you, it starts this cascade, and everyone gets debating on whether it's part of the spectrum of sleep-disordered breathing or not, and it's this whole argument. And some people say it is, some say it isn't. But what, what Dr. Stupak says, and I love, is by unlocking that oral mouth closure clamp, you then get prolapse of that tongue into the soft palate and pharynx, and then this buildup of negative pressure within the pharynx distal to the site of obstruction. So it's not that if you open your mouth to breathe, which sometimes during heavy exercise or like you said, if you have a cold, you have to do, and we certainly can survive that way even though we're preferred nasal [00:50:00] breathers. The sequelae and the cascade of events that occur downstream from that, that to me is the concern, that why is Especially let's just go with a kiddo for a second. Why is this five-year-old kid sitting in front of me in the dental chair with their mouth wide open and their tongue down, and like that, why are they doing that? And to, to ignore that and say they're going to outgrow or it's not a big deal, I, I really don't understand. So I'd love to hear your thoughts on that whole debate or discussion. Dr. Brown: I, I agree. And honestly, let me tell you full, full disclosure, I did not learn this during my fellowship. I didn't, believe it or not. Dr. Mike: Interesting Dr. Brown: is really-- I mean, this is really the forefront because I've always wondered, even during my training, and this was really why I created a practice that looks at this very holistically, is why is this happening? Because there are those kids that have snoring, mouth breathing. They go to e- [00:51:00] maybe they even get a sleep study, and they happen to sleep well that night, and it shows mild sleep apnea. And they go to see our ear, nose, and throat colleagues, and they don't have very large tonsils. They don't, they don't have like, maybe they have, they may have, you know, mo- mild, moderate sized adenoids. So yeah. Or we get the adenoids out, we get the tonsils out, Dr. Mike: Mm-hmm Dr. Brown: there's still mouth breathing. There's still, this, this phenomenon is going on. So it's beyond just the tonsils and adenoids. There's more things going on. And, and this is why I love the concepts that I've learned from, you know, from you guys, from the dental world around, um... And we talked about it as well during my fellowship, and I look at that in my practice now absolutely. But we, there's a structure part of sleep-disordered breathing, and then there's the functional component too. So the box [00:52:00] itself, the skull, the structure of the face, the position of the m- of the, um, the maxilla, all of that matters. But there's also tone issues that can ensue from you just having this, I would say, relatively maladaptive way of breathing for a long time. So it's both. And I, and, and, and I agree. If you think about it, I've seen kids who, who, who come in, and I just say, "Just close your mouth and let's try to breathe through your nose for a moment." And man, five seconds later you could see they're pursing their lips because this is not j- this is not like, oh, they're just doing it because they're out of breath, because they ran. Dr. Mike: Right. Dr. Brown: They, they're just not able to because there's so much crowding. So Dr. Mike: Yep Dr. Brown: it tells a, it tells, it provides so much insight. But we have to look and pay attention and say, "Why? Why is this going on?" Dr. Mike: I completely agree. That's, that's so well said because it's, that's what I try to convey to people is [00:53:00] it's not normal for them to breathe that way. I think we could all agree, we're supposed to be obligate... We're supposed to be nasal breathers. So why are they doing this? And then to think that it is benign and causes no problems and like, "Oh, well, breathe through your mouth, breathe through your nose, snore at night a little bit, no big deal," uh, I think a lot of it is just, I hate to say this, but I think it's just ignorance. I think they just don't know. You know, I think people just, like you said, going back to the beginning of this discussion, none of us really learn anything about this in our training. We don't talk much about sleep. We aren't conscious of our own sleep. And also, if maybe our kiddos snored or we have family members who do, we don't wanna worry and think there is a problem. So I think that's a lot of it, too. I think a lot of it, too, with the... And you let me know if I'm wrong on the medical side, but, uh, I think for sure on the dental side, especially in the orthodontic world, it's just one more thing that we would have to worry about and dive into, right? And once you open that door, it's like, "Oh my gosh, now I've gotta start to look more in depth at these patients." It's why a lot of ortho colleagues don't want CBCTs, because it's just one more thing. They've actually... I've had orthodontic colleagues [00:54:00] literally say this to me, like, "It's, like, too much to look at." I'm like, "Too much to look at? Like, don't you wanna know why this patient comes to you in this condition? Or do you just wanna be a mechanical tooth straightener that's just like, 'My job's to line up the teeth, and why they got that way or what I can do otherwise to maybe prevent some of that or guide their growth and development differently, it's just more than I want to, to take on.'" Why providers avoid the topic Dr. Mike: Do you feel like there's some of that in the medical profession, too? Like, it's just if they went there, it'd be just more work and harder? Dr. Brown: 100%. And I think it's, there are multiple reasons. Number one, like you said, is lack of awareness, right? Like, I didn't even know this was a thing. I, I have even my own colleagues who say, "Oh, wait," you know, "I thought mouth breathing, some people just do them or do that," or whatever. That's one. Number two is time, and then number three is personnel. Who, who has that-- Who's gonna own that task of looking and asking those questions? And then number four is then what do we do about it? So when-- Let me [00:55:00] break that down. Awareness, right? Like you s- like, I'm telling you some of these things I'm just learning as I help more patients, and I've been working so closely with so many dentists and orthodontists. Like, literally, you guys are teaching me. That's number one, right? Number... Dr. Mike: I learn a ton from you guys too, but thank you. Dr. Brown: number two is time, right? If you think about the regular traditional practice, you'll have your pediatrician who's looking up your immunizations, your development, who's making sure that your, your blood work, everything is caught up to now say, "Oh, by the way, I breathe through my mouth. Help." They, they're like, "Uh, I don't know what to tell you, but that's not a priority right now," right? So they have a 15-minute slot to see you for all your issues. So if they're not it, then who, who is it, right? So again, which comes back to the awareness, right? And then number four is who's taking on that role? Who's taking it? Is it the dentist? Is it the ENT doctor? Is it the pediatrician? Is it the sleep doctor? And the answer is yes. Whoever you can [00:56:00] get access to, advocate and find. I would definitely say for me what I've seen with a lot of dentists is, this is my thought about it. A dentist, a general dentist is seeing these kids at least twice a year. At least twice a year. Sometimes as they get older, even more frequently than the pediatrician is seeing them, and they're in that airway, so you're already seeing things. I think empowering our d- general, even our general dentists with information of, "This is what normal looks like. This is what abnormal..." Don't bypass abnormal and hope the pediatrician catches it because guess what? The pediatrician is like, "Well, you see the dentist, so hopefully the dentist catches it." And so we play tag, it doesn't work, and the child is suffering, and then we're putting them on meds. Again, don't get me wrong, I'm not against meds at all. If you need medications, you do. But oftentimes sleep issues mimic ADHD symptoms, so that's, you know... But I digress. The, the fourth thing is, now what? What do we do about it? So do we send them to, do we send them to [00:57:00] analogies? Do we send them to ENT? Do we go to the orthodontist? Do we do MRP? Do we... What, what, what do we do? Do we put them on CPAP? Whatever. So it, it becomes so overwhelming that now because of that, we don't make any, we don't make any progress. So I think it's, it's, it's so many multiple reasons. Dr. Mike: Yeah, it's so well said. It- they put... I feel like a lot of practitioners, they just put blinders on. It's just like, let me just stay myopic. This is what I was trained to do, and they kinda justify it by, well, I've heard a lot of people say, "Well, if it was a thing, I would've learned about it in school." I hear that all the time, you know, people... And such a credit to you for being, you know, it kinda sounds cliche to say this, but like lifelong learner, but I don't mean it in a, in a woo way. I mean in a, in a sincere way. Like you're, you're not content just being like, "I learned this in my training, and this is what I was trained to do, so I'm gonna stay in this box." And you've said it multiple times throughout this, this discussion of you're looking at your patients, you're evaluating your patients, you're looking at what works and what doesn't work. And then when you do that, though, Funke, and I can speak to it personally as well, it [00:58:00] does, and it's exactly what you were just saying. It does make life harder because the fourth one you said, doing something about it, it changes everything in your world when you then start to do something about it. Like here you are on a show with an orthodontist talking about these things. I mean, if you were in your sleep training and someone said you were gonna be this, right, immersed in the... For those who are listening and not watching, Funke's shaking her head, you know. But like be this immersed in the dental world, you'd be like, "What? For, for what?" Right? I mean, it's, it's a whole nother, it's a whole nother journey that you're Dr. Brown: Yeah. H- honestly, you're right. No, not in my wildest dreams, like five years ago would I. But I just knew there was more. We need more answers to gi- give these families. We need more answers. And really, as I see more, I'm understanding more. I'm like, "Oh my goodness, these kids are suffering." We owe it to them. This is the oath we signed, right? We owe it to them to look beyond that and say, "What else? How can I..." And honestly, I'm not saying take on [00:59:00] the burden of fixing all the issues that this child has. This is where collaboration comes in. I'm not... I, I have no idea what to do other than to sit in a dental chair. I have no clue. Like, all those tools you guys are using, no, I, I don't know. I just know what a CBCT looks like. I know when I need to refer, and that is critical because if I, if they come to me and I don't have that information or that education or that awareness, that child might suffer. That child might suffer, right? So, uh, the gravity of what we have in our hands of knowing these things, getting access to the tools or resources or collaborators or other specialties who can help, the onus is on us. It is on us to learn these things. Mm-hmm. Dr. Mike: I couldn't agree more. And you did mention on, um, the med side and, uh, the pharmacologic side of things and ADHD. That's another thing I would just like to pick your brain on. Um, uh, you know, I've seen studies [01:00:00] that upwards of 50% of kids who have an, a diagnosis of ADHD, uh, have a concomitant sleep issue, uh, a- and sleep-disordered breathing of some sort. ADHD and sleep-disordered breathing Dr. Mike: And I think a lot of... Uh, there's been some, uh, literature that's come out. Actually, they're opinion pieces. I wouldn't call them literature. There's opinion pieces in the literature that have come out in the orthodontic world saying like, you know, mouth breathing's not a thing, and this whole relationship to ADHD, you know, ADHD, sleep-disordered breathing doesn't cause ADHD. Eh, I'll give you my thoughts on it, and again, ple- feel free to correct me where you feel I, if, if I'm off base on this. I look at it as, okay, yes, can you have ADHD without a sleep problem? Yes. I think we can agree on that. That being said, there are a certain sequence of events that occur, a cascade of events that occur when you have disordered sleep, physiologic abnormalities that occur, and those tie into behavior, and it really doesn't take a big stretch to think about as an adult, let's just go with adults for a second, when you have a few nights in a row of disrupted sleep, you are not [01:01:00] yourself. You're not your best self, that's for sure. Um, your hormone levels are altered. There's prefrontal cortex impairment. There's all of these things happening in you that are not, um, the normal physiologic processes that should be going on because of your disrupted sleep, and that's what we've been talking a lot about to this point. So to think that that couldn't impact a child's behavior on the daily when, remember, if you're an adult who goes through a rough week or weekend or your kids are up sick or whatever it is, usually you can try to catch up at some point, and you said about the REM rebound before, and you can kinda get back on track. If you're a kiddo suffering from sleep-disordered breathing and you have, you know, s- significant obstructive hyperventilation or whatever it might be, when are you catching up? Uh, you're not. And so if you could talk a little bit about that and, and your thoughts on that if I'm, if I'm on track on that and, and how that then leads to potentially over-medicating, again, not saying these meds don't have a role, but over-medicating certain kids or, or medicating unnecessarily certain [01:02:00] children and the consequences therein. Dr. Brown: Oh, yeah. No, you're, you're really on point with that. So with children with neurodiverse conditions, right? Whether it's autism, ADHD, you know, um, dyslexia, all of that. I f- we'll focus on ADHD. Yeah, up to, you know, upwards of 50% of these kids have concomitant sleep disorders. So now what started it, right? The chicken or the egg? Was it the ADHD with the, maybe the impulsivity, the, you know, sensory dysregulation and emotional upturns and all of that that's impacting their sleep and impacting their sleep quality? Well, it's possible. But when we think about sleep and we think about the role that a good night of sleep, and we talked about what a good night of sleep is at the beginning of the, of the chat, right? What impact when you're deprived of that every single night for months, years, 10 years? It will catch up. And so we know that kids who don't [01:03:00] sleep well, right? Already they are more labile emotionally, right? They lack that ability to have that emotional regulation occurring in sleep. They're more likely to be sick. They are more likely to have hyperactivity, impulsivity, emotional dysregulation, all of that, right? What are the things we see? Lack of focus. They have difficulties with focusing, right? What are the symptoms we see with ADHD, right? Behavioral issues, difficulties focusing, emotional dysregulation, impulsivity, inattention. These symptoms mimic each other, right? And so here's what I always say to every-- 'cause I work with a lot of, you know, therapists and psychologists and behavioral pediatricians. Please do not, again, that's another thing if you're gonna take away, you're gonna take away from this talk. Do not make a full diagnosis of ADHD in a child when you're doing the [01:04:00] evaluation without doing a complete and thorough sleep assessment and making sure that you address the underlying sleep issues. Whether you refer them, you get them tested, whatever it is, this needs to be the case. Because when you put a child who is, who has poor sleep because they have maybe sleep-disordered breathing, maybe periodic limb movement index, which is, um, much higher in children with ADHD, or restless leg syndrome, which is much higher in children with ADHD, or circadian misalignment with delayed sleep phase, which again is much higher in children in ADHD. If you have a background or t- on that and you stimulate them, you put them on a stimulant, you're really just masking symptoms. And then the problem with masking the symptoms, especially with a lot of these sleep, um, stimulants, a lot of these medications, many of them are extended release, which now feeds into poorer sleep the following night. They lack the ability to, you know, really get that good sleep, and it just keeps going. [01:05:00] So this is so critical. It's, it's so important. I, in my practice, I mean, I would say my practice is more of a referred popu- population. I would say 80 to 85% of the kids that are referred to me have a diagnosed sleep disorder, one thing or the other, right? But of course, I'm, it's partial, it's refer-- I'm a re-- I mean, there's a reason, but I am not going back and saying, "No, no, no. It's okay. It's pure ADHD. This kid is fine. Just continue the meds." I'm, I'm, I'm not, I'm... And I've been doing this for 15 years. I haven't had that experience yet. Dr. Mike: Wow. I mean, that's a profound statement. And, uh, why do you think, uh, that... Why aren't physicians... I mean, I love what you just said, that it is incumbent upon the physician before placing this child on medications after a diagnosis of ADHD is made to evaluate sleep, and if you are not capable of doing it or equipped to do it, then refer them to the people w- who can. For the physicians out there listening, what, [01:06:00] if you don't mind, you don't have to go get super granular on it, but just kind of what does that look like? Because some of them might even be, be thinking, "I don't even know where to begin on this," like we were talking about before. Dr. Brown: Yeah. Excellent question. So when you think, I want you to think about, 'cause a lot of the parents when, even when they're talking to their pediatrician, for instance, or their, their psychologist or, or behavioral pediatrician, whatever, or developmental pediatrician, they say, "This child does not sleep." And the home is in chaos. There are no routines. So it's anything from even the bread and butter, let's establish consistent sleep hygiene, a, a sleep routine that is, um, that is affirming for the child, right? A lot of these children have a hard time winding down, so then we have to be more intentional. You don't just take a shower and put them in bed. They may need longer. Light exposure. It could be all of that basic stuff. Or it could be more, and I call them sort of the behavioral categories. It could be well, minimizing screen time up to an hour before bed, [01:07:00] making sure that you're eliminating, you know, the red dyes and the processed foods. It could be st- making sure they get enough physical activity. It could be stuff as basic as that, right? Or more commonly, it could be evaluating them for sleep-disordered breathing. You know, are they snoring? Are they mouth breathing? Do they have obstructive sleep apnea? Maybe potentially absolutely getting a sleep study. And I happen to be one of the few people that actually does home sleep studies for a lot of these kids because we need, we need access quickly. You're waiting on a diagnosis, and I'm telling you, "No, we need to do your sleep study," but it doesn't take six mon- it takes six months for you to get a sleep study. Like, what are we doing here? No, no, no. We can't Dr. Mike: that kid's suffering. That's what I was... I'm like, "That child is suffering that whole time," and so is the home. The family is suffering, yeah Dr. Brown: Be suffering. So it could be doing that. I'm very intentional about looking at holistic, you know, issues. A lot of these kids also have dietary restraints. They are not necessarily eating the, the wide array of foods they should be. So they might be deficient in, you know, some [01:08:00] micronutrients, vitamin D, magnesium, B12, zinc, some of those things that can actually impact sleep quality as well. So it could be looking into that. And then it could be a circadian rhythm issue. Again, you may-- most, many times we see a delay in their circadian phase, especially as these kids get older, where they, trying to force them into bed at 7:00 a-- 7:00 p.m. is creating insomnia because they naturally cannot fall asleep until later. So we also do some, sometimes we do some light exposure and melatonin, things like that. So there's just such a wide array of options available. It's not only sleep-disordered breathing. Many times it could be, but there's even the basic things, and sometimes it may be a lot to be able to handle and tailor to a kid with ADHD. Um, but that's where resources and, and, and things like that, and specialists, that's really why we exist. Home sleep testing and treatment Dr. Mike: Gosh, it's such great, such great information. Uh, and just kind of [01:09:00] to finish up here, I love... You talked about it a little bit there for a moment, but using, monitoring and monitoring devices, sleep home testing, uh, or home sleep testing, excuse me, for children. And, uh, again, kind of off-label, uh, but I, I, I think every physician I've had on that's in the sleep arena does it and says that, you know, they- there's a value therein. Where are we going in the future? I- where is this going? I mean, there- it's, there's so much information out there now, we're learning a lot more, which is wonderful. I feel like we understand a lot more about this, but We have a ways to go until we can really sort of dial it in as a society and start to figure this out. So what do you think the next 5 to 10 years looks like, both from a diagnostic standpoint and even a treatment and recognition standpoint, in, in your opinion? The future of sleep medicine Dr. Brown: Yeah, no, I, I definitely see us changing-- I see things changing very quickly when it comes to diagnostics because the, the, the polysomnograms, as much as they're the gold standard, is just really not [01:10:00] tenable in the real world we live in. So we need to provide, um, diagnostics that are easily accessible and, and shorten the time. You need-- From the time a child comes to see me and is already getting treatment for their sleep-disordered breathing, usually I will cap it at three to four weeks, and that's the way it needs to be because we know how much this impacts the child's learning behavior and growth and development. So when we think about home sleep tests, now even the American Academy of Sleep Medicine that I belong to, right now, based on the data that was available, the research that was available, I think the last time they made updates in the guidelines was over a decade ago , right? So since then, and at that time, there was just not enough, sufficient enough data to allow that home sleep test be the first line in making diagnosis of sleep disorders in children. And so the recommendation was to continue with the in-lab. But as we speak, there's a task force in place that's really looking at the [01:11:00] wealth. I mean, tons of research has been done, including a lot of work by a lot of my colleagues at the Children's Hospital of Philadelphia, where they're actually looking at the feasibility, um, and the reliability of home sleep testing, home sleep apnea tests in children as compared to the gold standard. And it is mind-blowing how just in terms of the correlation when you're looking for a diagnosis. Again, not sleep apnea. If you're looking for seizures or you're looking for narcolepsy, please go to the lab and get your sleep study done. But the data, and they presented some of this data at, um, the recent sleep conference in, in, um, in Maryland in, in, um, in, uh, June 2026. Dr. Mike: Mm-hmm. Dr. Brown: Strong correlation. So, and families of course prefer this testing because it's convenient, it's within the comfort of the patient's home and things like that. So those guidelines are really on their way to being updated, and I mean, uh, it's gon- you [01:12:00] will hear about them. You will absolutely hear about them once they come out. So these are things that we're gonna see really come to because we think about it. We, what are we doing here? We have children. We're saying sleep is critical. If you don't sleep well, all these bad things could happen. And then we're like, "Oops, but we can't help you until six to eight months." It's unacceptable. So I see that changing. I also see within even the wearable space, there now being roles of some of these, um, devices, um, that will be tailored towards children. I think in the right clinical context, this is really where you gotta ha- you have to be careful because we don't want parents thinking, "Oh yeah, the wearable said everything is fine, so everything is fine." Or, "Oh my goodness, the wearable said things are bad, so this child is about to die." Right? We, we gotta strike a balance. So I think some of those nuances are things that we're gonna have to walk through, um, with appropriate guidance. So, and in terms of treatment, I mean, I'm already seeing an uptick. There were [01:13:00] times when I was, I mean, I would say maybe 10 years ago, I could only give you two treatment options for your child with sleep-disordered breathing. And this is me being really, really vulnerable here to show how much the, the, the, the science is evolving, how rapidly it's evolving. The two treatment options were we take out your adenoids or tonsils and tonsils, or we put you on CPAP, or maybe a third option, we put you on a trach, a tracheostomy, right? There were times during my time in my training where if your sleep apnea was so severe and you didn't tolerate CPAP, you got a trach. That has evolved so rapidly now that it's so exciting. We're looking at, um, various modalities with, you know, optimizing of course the lifestyle things, the allergy optimization, optimizing any comorbidities. We're looking at working with dentists and p- there will be space for palatal expansion, myofunctional therapy. Even for children with trisomy 21, we're looking at things like the hypoglossal nerve stimulator, which has been a game changer in that [01:14:00] space. So things have rapidly evolved. It's so exciting, and I can only imagine that this will continue to provide so many opportunities, so many options for families, um, that is not as invasive, intrusive, um, for them. So really excited about what's to come. Dr. Mike: it's so nice to hear the optimism because, um, I feel like now we're at that data information overload state, kind of all, and we're, you're right, we're trying, we're trying to figure out what to do with all of this. And then to hear that on the horizon are all... I mean, there, there's, there's so many things with AI and technology, and, uh, this is where it's just, it's just amazing, and I'm, I'm really excited too. I think we're going to start, we're going to look back on, um, this time, just like you said, you know, 10 years ago w- when you were so limited in, in your choices of what you could do to treat a patient and how that's changed now. I really think in five to 10 years we're going to look back and it's gonna be a whole new, new world and new field. Um, but I, I think one thing I've taken maybe more than anything out of this conversation is we need to clone you because [01:15:00] we need more Funkes out there, uh, advocating for children in the interdisciplinary relationships and breaking down those silos. You're just amazing. Um, uh, I really, I, I can't, uh, can't tell you how much I appreciate your time, your knowledge, your expertise, and, uh, your, your vulnerability too to admit, you know, that you don't have the answers and that you're continu- co- continuing to learn, but really you're just so knowledgeable on this. Your patients and your community are so fortunate to have you. Uh, I really, really mean that, uh, and I can't thank you enough for, for sharing that information with us all today Dr. Brown: Oh, thank you so much for having me. This has been so much fun, and I'm, I'm so just blown away by the work you do. You're an advocate of advocates, and I think this is so critical. And I love the fact that you're-- we're all now sitting at the same table. And this is also part of what I see us doing, like you said, five years from now. We all have this incredible multidisciplinary approach to the care of the child, um, with airway issues. So thank you, and thank you for, for having me on this show. This has been so much fun[01:16:00] Closing thoughts Dr. Mike: Oh, it's been my absolute pleasure. The time flew by, and I, I could sit here and talk to you forever, but I respect for your time and the audience's time. We'll, uh, we'll wind it down. But, uh, how can people reach you? If they wanna learn more about you, your practice, what you do, uh, how can they find you? Dr. Brown: Yeah, absolutely. So you can find me on my website. We, um, my website is, uh, therestfulsleepplace.com. So that's the website to my private practice. But also I have a blog, I have a YouTube channel. I'm also on social media @restfulsleepmd. So if you put that on, you'll, you'll find me where I share snippets of wisdom with, um, people as best as I can. So absolutely happy to help out in any way I can. Dr. Mike: Great. I will put links to all of those in the show notes, uh, and I'm confident there will be people reaching out to you as this show gets listened to and shared. Um, it t- whenever I do one of these with a, with a lot of providers, especially too with a physician, they tend to get a lot of people reaching out because people are so starved with answers, and they hear someone like yourself who's just so knowledgeable, uh, and so relatable and, and, uh, empathetic and, [01:17:00] and able to help these patients. It's just, um, I'm sure you're very, very busy. Very, very busy, very busy woman with what you're, uh, what you're doing for your community. So Dr. Funke Brown, absolute pleasure. Thank you so much for coming on the Doc Podcast and sharing with everybody today. Dr. Brown: Thank you. Thank you so much. Dr. Mike: All right, talk soon. Dr. Brown: All right, bye Dr. Mike: Bye. Outro Speaker 3: Thank you for tuning in to this episode of The Doc Podcast. Be sure to visit theorthocoach.com to get access to ADA CERP recognized CE courses or to schedule a private one-on-one coaching session with me. Also, if you know of someone who would make a great guest for this show, or if you'd like to be a guest yourself, please email me at drmike@theorthocoach.com. And be sure to join The Doc community on Facebook for more great content. Thanks so much for listening, and always remember, you have been blessed with the ability to do amazing things.