Why Pediatric Dentistry Matters For Your Child's Airway Health

Hi everybody, I'm Dr. Sanda Moldovan, periodontist and nutritionist. Welcome to the Holistic Dentistry Podcast, the show that gives you the tips and tools to detoxify your mouth for a healthier body as we explore together the root cause of disease. Remember, you're not healthy until your mouth is healthy, so take care of it in the most natural way. Welcome to today's show on pediatric airway health. This is such an important topic because I feel a lot of these conditions go undiagnosed for many, many years and they result in having unhealthy children. And as parents, you really need to be informed of what you can do with your children at a young age in order to prevent some of the chronic conditions that come from an undiagnosed airway problem. With me today is Dr. Radhika Kapoor, who was born in New York City, raised in New Jersey, and she has extensive experience in pediatric oral healthcare, passionate about working with children and families. You have a practice now, Dr. Kapoor, in New Jersey, is it, or New York City?

New Jersey. New Jersey.

New Jersey. Yep.

Yeah.

So you continued at Columbia University to receive your DDS degree. And, uh, while at Columbia, you basically pioneered a lot of movements— the Give Kids a Smile Foundation. You received some academic awards for your work in ectodermal dysplasia. So welcome to the show. I want to definitely dive into this topic with you because you're so knowledgeable about it.

Thank you. Thank you for having me.

Tell us a little bit about ectodermal dysplasia. A lot of people don't know what that is.

Yeah. So it's a genetic condition that affects different glands, sweat glands, hair, skin, nails, essentially all the derivatives of the ectodermal layer in our, in our embryos. What actually probably sparked all of my future interest probably came from this project because it was working on a child that essentially was congenitally born with a condition, and we had to learn how to manage it. And so for me, you know, being able to provide care to such a young population and trying to figure out how to navigate with the various providers who were working on her case—prosthodontist, orthodontist, geneticist—it gave me that feeling of what I've had to do growing up, which is pretty much how do I navigate things for my family in a sphere that's less known to them in a, in a world that can be very scary when you're trying to put the dots together in healthcare. And so that, that was a very, very good example of that. Yeah.

So after that, you went into pediatrics and studied dental pediatrics, the residency. When did you start incorporating lasers? Is that something that you learned in residency or is that something you picked up afterwards?

So a lot of my attendings during residency had brought up lasers as a, as a, um, a novel technology to start using for very, very different modalities. So whether it was biopsies or, you know, just surgical procedures in a way that was less traumatic to the tissue, was more antimicrobial, sped up healing. To me, that was very interesting because I always feel like staying at the forefront of your specialty or industry is so important because then you're just bringing the latest and whatever is going to reduce discomfort, right? The level of trauma that's involved in pediatrics specifically, and especially with parents bringing their own kind of preconceived notions about dentistry. Anything that could make a movement in that was really starting to become important to me because I find that disease comes in abundance when you're avoiding, right? When you're avoiding the practitioners and you don't know who to go to and you don't feel like those types of exist. And so then it started to become my project that I would become a practitioner that would create that foundation that was more inviting so people felt more invested in their care and they were less scared, you know?

Yeah, absolutely. I love lasers. I'm a big laser user as well. Yeah, you'd be surprised how so many dentists don't use lasers. Yeah. And I think mostly because they're afraid of it. It's another thing you have to buy. But yes, definitely, definitely lasers are super important in dentistry. And how did you— was your program really focused on, on airway health for children? Was that something you picked up from your residency?

Yeah, no, it was not. It was very focused on children with medically compromised needs. I worked at Children's Hospital in, in DC. It was a very busy hospital, a lot of trauma experience, a lot of medically compromised special healthcare need patients. I found that I worked on a lot of children on the spectrum who were nonverbal, were having airway issues, feeding issues. But at that time, I had very little exposure to basically how my life unfolded afterwards, trying to start a family, meeting different providers, going through fertility challenges, health issues myself, where this became my niche and mission, I guess, because it is foundational, right? Breath is life. So For me, it became my thing, my area that I found most solace because it basically encompasses all the things I have an interest in, all the specialties I'm interested into, into one, right? I have an interest in functional medicine. I have an interest in gut health. I have an interest in immunity. I have an interest in prevention. And so if you're breathing well, if you're sleeping well, that's the foundation to being able to do all of the other things that your providers want you to implement.

You know, definitely sleep has become also a big part of my practice, really screening for sleep and diagnosing and working with a sleep doctor on diagnosis and also finding treatment for patients so they could sleep better. It's hugely important. And a lot of people listening to this might not even know that their children have a breathing problem. Yeah. So, so for the parents listening, thinking, oh my God, maybe that's the issue with my child. Like, what kind of symptoms would would a child with sleeping, with airway issues have?

Yeah, so I treat babies as young as less than a week old because a lot of providers refer to me for infant tongue-tie procedures related to feeding, breastfeeding, bottle feeding. But what pivoted— this has almost been a decade in my career now as someone who does offer this procedure— is that that is a first insight into breathing. When babies can't stay latched on the breast, they can't do a proper suck, swallow, breathe maneuver as identified by the parent as an IBCLC. That is just a small indication that, you know what, this child has an uncoordinated system where they're unable to suck and swallow and breathe with a closed mouth posture. That's some of the first signs I start to see that their tongue is not properly positioned to actually expand and create a proper airway, because that's what the tongue's job is. It's supposed to sit in the roof of your mouth, which is the floor of your nose, and broaden your palate. In the first 4 years is actually the maximum growth of that maxilla, your upper jaw. So in infancy, feeding issues can actually be very much indicative of breathing issues. My baby wakes up, they're always congested. They sound like a little piggy when they're sleeping, or they have what I thought was reflux, and they're always spitting up after feeds, or they're bobbing on and off the breast or the bottle. These are just some of the ways where infants can start showing early signs of low tongue posture, low tongue tone, potentially a tie, and potentially something going on. And oftentimes a parent's family history is like the most remarkable in terms of my intake at this age, where it's 30 to 40-year-old parents start to talk about their snoring, about their mouth breathing, about their tossing and turning and grinding their teeth at night, which becomes a more relevant discussion that, oh, wow, this is not just screening for a breastfeeding, bottle feeding issue. We're talking about the fact that the tongue's job is to shape the airway, and that's somehow not able to happen anatomically. And we need to look further. And that's infancy. I mean, in children, the red flags for us as pediatric dentists should be so much more clear-cut. But the problem is now the environment has changed. Now those children are going into daycares and school. And so the parents don't know if they should just dismiss that time as my child was sick, that's why they were mouth breathing, or they were congested and that's why they were mouth breathing. And so that's why it's so important to have consistent dental homes during that, especially toddler time, toddler years, where you can rule out that, okay, no, this wasn't just when they had the cold or flu virus. This is something that we need to dive in deeper. This child is having is grinding, is mouth breathing, they're snoring, they're tossing and turning, they're having behavioral issues, they're having oral fixation habits, they're chewing on everything. There's so many different indications, large tonsils and adenoids and recurrent ear infections. I mean, the list goes on and on, but we really feel like pediatric dentists can really put a lot more into those first 4 years, those evaluations to help create a healthy foundation.

Absolutely. I think most people, when they say, oh my God, my child can't breathe, he's got a throat problem, let's take him to the ENT. Is that a normal thing that you see? 100%.

Yeah, I see that quite often. And do ENTs—

are as equipped as dentists to do these diagnoses? Are they even aware about the, you know, the treatments that you can do as a pediatric dentist, or not all of them?

I would say that my knowledge of kind of where their scope is. Based on my own personal experience with my daughter, for example, my daughter at 2 and a half years old, while I was doing my fellowship with Dr. Zaghi at the Breathe Institute, he was the one who helped me identify that that was my child who had sleep apnea. And he's an ENT, he's a sleep surgeon, he's from Harvard and Stanford. And he said, based on the level of scope and training, it is very limited to find ENTs who have the diagnostics and the tools that they need to properly evaluate, you know, children's airways. And with that, there's a lot of, I would say, at least in the New York City area, red tape along when you can have tonsils and adenoids removed, how many infections, what's the criteria, what's that level of standard of care. And as a pediatric dentist, I'm not too aware of what their guidelines are specific to being a board-certified your nose and throat doctor specific to pediatrics. But here we see a lot of variety based on the hospitals and their waiting lists. And it's very, very sad because, I mean, the number one condition that's bringing the kids to the hospital during this time of the year is viral or bacterial in origin, and it's compromising their airway. Had we understood what their baseline airway was and how important it is to have that just repertoire of how to keep up your airway health, they probably wouldn't be in that position, you know? And so, so often parents don't know if their kids were born with large tonsils and adenoids like my daughter was, or it became structures that became big because of the environment that we're in, you know?

Yeah. So now we're all curious, what happened to your daughter? Did you end up removing tonsils or— Yes.

Yeah. So I actually had Dr. Zaghi. I flew out all the way to California during the third phase of my fellowship after we had our sleep study at Mount Sinai. And it was confirmed that she had sleep apnea. And this is my daughter who I already had released as an infant. So she was an amazing feeder, excellent breastfeeder. However, she got COVID within a year of her first year of life, and I believe that is what probably led to her tonsils and adenoids and airway condition to worsen because it was only shortly between 1 and 2 that I noticed that her tone of her tongue started to decrease. Now, this is COVID time, so we had no access to any myofunctional or oral motor therapy. She was drooling more. Her development started to seem like it was slow, slower. She was not really reaching her milestones in terms of like walking. And I noticed that she was always tired during the day and tossing and turning all night to the point where I started to take videos of her for a good 6 months to monitor her airway. And this, this baby was not breathing. My child was not breathing. I still went to 2 ENTs in the area. I went to Mount Sinai, I went to Columbia, and one said remove, one said don't remove. Dr. Saghi said, go for your sleep study so you have the data so you feel the most secure. So we went to a sleep lab and she had sleep apnea. She had many apneic events. And this was my 2.5-year-old. I flew her early last year and we had her tonsils and adenoids completely removed. Not only were they kissing, they were almost growing into each other. In the words of Dr. Saghi, who's done a million of these— of course, that's an exaggeration, but he's seen so many airways. He says he's probably one of the worst airways he's ever seen. And I Wow. You know, thank God for that, because she literally— my parents the next day were like, she's a different kid. And with that and relearning breathing and myofunctional, because, you know, it's all the things, right? A lot of times I have to explain to parents why you need a navigator. This is not a one time you see an ENT. Use me as your navigator so I can keep walking you through this. Because everything she does in the dental office, everything she does, This all has to do with one space. That's your mouth, your airway. That's your airway. That's right. So she's thriving. She's thriving. She's doing great. Early expansion at age 4, and it's her birthday this week. So I'm very grateful. I'm grateful for all the people that I'm working with and met along the way and can understand essentially who's walking into my office and how hard it can be.

Absolutely. Yeah. So you spoke a little bit about having a sleep test. So I want to ask you questions about how we diagnose, how you diagnose things, or do you need an ENT to diagnose? Or is this something that you can diagnose as a pediatric dentist?

I think my job is to identify red flags, and I do refer to a few ENTs in the area when I'm worried about a structural issue. So in terms of diagnosis, something as basic as videos are required for my pediatric visit. So I have parents send me videos of their children sleeping over a span of time, 1 to 2 hours into deep sleep, so I can understand like where they sleep, what does a home look like, what's the environment like? We go into a lot of detail about allergens, about what they're using to keep the air pure. We go into even feeding, like what are they doing during food, food time? What does that look like? Playing, postural. I want to basically understand body posture, tongue posture, and different types of scenarios. Those are just the very basic things in terms of additional diagnostics depending on the child's ability to cooperate. We have CBCTs, which is our dental 3D scan, which allows us to get a good visual on airway. and we send that to a radiologist who also works with the Breathe Institute. So we get a full report with the specific measurements that, that Dr. Zoghi's office would use to evaluate tonsils, adenoids, upper arch, you know, their jaw space, their tongue space, their airway space, all the things that we need to kind of create a treatment plan. And yes, that would probably— I refer to a few ENTs if I am concerned about something structural. And then our Home sleep tests also can be used on kids as young as age 2, and we work with a board-certified sleep MD office that reads all of the reports before procedures, after procedures, so they have all the data that they need so that if we recommend any treatment, home remedies or actual, you know, surgical treatment, parents can start gauging and seeing what's working, what's not working. Yeah, no, that's great.

But I had no idea that you can even do sleep tests as young as 2. That's pretty incredible.

Yeah, it was very much requested because, as you can see, my experience, my own daughter, we waited a good 5 months and then I had to take a full day and a half off of work. And that's not always possible for parents. And, and so we don't think— I did a lot of research onto which companies follow the same types of protocol and technology as an in-sleep lab. But I would say parents are very happy because now they're in their own environment. So I find that it's less false negatives or false positives.

Absolutely. Yeah. What's the size of the jaw and location of the tongue have to do with breathing, especially in children?

Yeah. I mean, it's so amazing that we forget that the majority of our growth, especially in those first 4 years, is your head, is your baby's head. So a lot of parents will say, oh my God, my baby's head relative to their body. I'm like, well, that's That's what's forming their ability to breathe. If they breathe, they will grow, right? That's the growth that's happening is their cranial growth. And so the size of the jaw is determined by the position of their tongue. I mean, the tongue needs to sit in the roof of the mouth. That is what we call tongue space, or what we tell parents, the roof of the mouth is your palate. Your upper jaw has to be in front of your lower jaw because what's behind all of this is your windpipe. It's your airway. And so if your upper jaw is dictating growth, which your maxilla does, of your lower jaw, and they're growing in a forward posture, forward, you know, direction, then your airway will be as wide as you need it to be. But when, when it's not, instead it starts to grow down and long. And so now your tongue is kind of figuring out like, where do I live when I sleep? And when you lie down. And so if you think about a hose and you lie down, well, the tongue's only got one place to go if your upper jaw didn't form wide enough or forward enough. It goes in that windpipe and there goes your tooth, right? And so when we try to explain to parents, you know, when you're tossing around in bed, you're grinding your teeth, or you're like, I'm always getting those dental issues. I'm like, what do you feel like your quality of sleep is like? And a lot of times they say, well, when I'm on my back, I feel like I just can't sleep well. I just don't breathe well. I mean, it is amazing how good they are at clarifying that quality of sleep. And so a lot of times I see young people that I'm seeing in the 30s and Age 30 to 40, parents of babies that I've treated who actually I'm treating their tongue ties and airways, and they have positional sleep apnea where they might not meet what they thought was a typical example of someone who constitutes as someone with sleep apnea, but they have a format of a form of sleep apnea where when they're on a certain side of their body, their tongue obstructs their airway because of the size of their jaws. And even though their teeth look nice nice. Half the time they are telling me is like, that's because they needed 8 teeth taken out to, to make that nice straight smile on tiny little jaw.

Yes. Speaking about teeth being taken out. Exactly. That's something that was done a lot in the past. And, you know, from the studies that we do have, we know that actually causes— I mean, predisposes people to TMJ and sleep issues. Now, what is the orthodontic movement that's recommended today? I mean, or not taking out teeth if somebody has this discrepancy between the jaw size and the teeth.

I think that my goal, at least for 2025, is trying to have orthodontists in my area understand the importance of early orthodontics, especially the age group that I love to, you know, put myself through. I always say it's a challenging age, but the 4 to 6-year-olds, is who I'm treating with early expansion because I think that the orthodontic movement is still, let's, you know, shave down some teeth and do some interproximal reduction to accommodate, or let's remove some canines so we don't have a midline shift, or let's take out some premolars. Because what's happening is like, it's a funny analogy, but parents seem to get it. I said, if my office layout wasn't created properly and I tried to put all this furniture in, you know, after the fact, I'd have to cut walls and break things and, and, and really, you know, go backwards. But had I made the layout perfect from before and I then picked the furniture that was supposed to fit in that space, then it just fits seamlessly. So visiting your orthodontist at an age where really your potential to grow starts to decrease over time, you're only left with choices that are, are invasive. You know, and so getting in the right hands early and creating bone— you're a periodontist, you know this better than anybody— if we don't even have bone to begin with, well, Invisalign and braces can't create that bone. You're just trying to hope that that person has enough good bone health so they can achieve the smile that they want. But really, I find that this whole pediatric dentist role, I've been kind of reevaluating a lot of it because I can understand from a parental standpoint, their baby teeth are just going to fall out. But there's so much that can be done that is aside from just looking at teeth in terms of just information that if, if people start to think about being proactive and asking those questions and finding providers that can provide those answers and those treatments, a large part of the systemic— forget the dental— systemic issues can be prevented.

You know, absolutely. I think that's a great idea. And that's one of the things I love about you, that you're, you know, at this forefront of changing dentistry and the way we look at things to question the status quo, because that's the only way we grow and come up with things that are better in terms of treatment. And you're right, at 4 and 6, that's when the jaws are still growing. So how do you— how do you expand the jaws at that age?

We use a combination depending on the kid's ability to cooperate. Again, this is all because we've created that relationship and understand what their home life is. We use myofunctional appliances, we use removable and fixed expanders. I'm currently using them on both my daughters. I've— I find that we don't experiment, we pivot. So what that means is not one appliance is going to suit another child. I have kids who have special healthcare needs, for example, that in my mind I would love to put someone who has a full crossbite in a face mask, but the parents are just happy that we were able to jump the crossbite with a combination of removable and fixed appliances. And so that has gotten her out of dental trauma. She's more, you know, able to wear her appliances at specific times to retain what we've done, and she's working with a myofunctional therapist. That's like a big, big component of what we do in our practice is everything is myofunctionally based. Movement from appliances is never going to be enough. It's again, it's on that tongue posture and that tongue swallow. So if your tongue doesn't know what to do and it's the strongest muscle that we have, it's only going to fight whatever work you put in. And I think we're starting to see a lot of orthodontists actually refer to us because they have relapse and they have open bites after such amazing Invisalign results and within a short few months that patient's like, my aligner doesn't fit or my bite is open or I feel like my teeth shifted. Do you guys do retainers that bond the teeth? I'm like, well, something in your body told it to unwind, so why would I tie it back together? You know, something's going on. And so I think it's bringing things like myofunctional therapy to the forefront, things that are more foundational and people understanding that this is not a product of today. There's no fad. It's epigenetics. Over time, our jaws have gotten smaller. Over time, wisdom teeth have become these types of vestigial structures because we are not creating that level of skull growth, right? We're not out in the wilderness and chewing bones and doing all those things and nursing our children until 6 years old. It's not happening. And so how do we accommodate the modern world you know, changes and, and understand that we're going to be more susceptible to certain things, but there's certain approaches we can take to hopefully minimize interventions.

Yeah. And for those listeners that, uh, want to know more about myofunctional therapy, we actually have two great episodes on The Holistic Dentistry Show with two myofunctional therapists talking about, uh, what myofunctional therapy is. So I highly encourage all of you to listen to those episodes because it's not just for children. We have a lot of adults that I refer to myofunctional therapy, and they're able to get rid of their headaches and tightness and clenching and all that. Excellent. Do you have any at-home tips for parents listening to improve breathing at home for their kids?

Yeah. So I guess through my personal experience, initially, a large part of what I do comes from my cultural experience. My entire background has always been in homeopathy and natural remedies. So I have a lot of natural remedies that I give parents based on what I find works in our home. So like anti-inflammatory foods, bone broths. These are just simple things that we'll say will help increase your gut microbiome, which will then also help your oral microbiome, which will also help combat any of these, let's call them pathogens in the air that are going to trigger our airway. So we talk a lot about food, food as healing. We also talk about the environment that we're sleeping in. I go into a lot about air purification, humidifiers, what kind of humidifiers to avoid using, cool mist humidifiers with distilled water, how often to clean them. Because the thing is, I mean, we're in New York City, but almost every demographic that I've ever spoken to, we have people who travel. The environment is changing everywhere. And so any of those things can start triggering mouth breathing, right? Your filter that you're born with, that's the best filter. Your nose is your filter. And so when that's not being used properly, then you're going to start breathing with your mouth, which is where your tonsils start to get big and your adenoids start to get big and your saliva starts to change and everything else starts to change. Right. And so we'll talk about different things they can do to fix that environment. We also talk about different things that they can use to clean their nose. We talk a lot about nasal hygiene. I think that we talk more about nasal hygiene than brushing now in toddlers. I love it. That's great. That's what they're coming in with. You know, they've got a stuffy nose. Parents do not want to go near that stuffy nose. Their kids scream whenever you blow their nose. And so I started taking videos of doing nasal washes on my kids in different postures to show them that it doesn't have to be very scary. It doesn't have to be traumatic, but it's so important. It's the only way. And you don't have to spend $50 on an electric gadget to remove boogers. But gosh, how much time and money you save. I mean, We've been able to stave off ear infections for my daughter, or the colds are not as prolonged. And also I'm not getting sick because if I shorten the amount of time that they are sick, then that's only going to help everyone else in the family. So I feel like there's a lot of things that we offer them, but we also show them how they can actually do it in their home. You know?

Yeah. Real. It's such a simple thing, but nasal hygiene, what an important topic for kids, especially Now, you know, we're going into the winter season where all these colds and flus get spread around. So, yes. What do you use for nasal hygiene for your kids?

So I actually use a bottle that almost looks like a Peri bottle. I put it on my— it's got a right angle hook to it, and it's the only thing that works well in my small hands. And I feel like it just— yeah.

So do you actually fill it with water and irrigate?

I fill it. So I actually— boil purified water in the morning. I keep it out to let it cool, and I put a little bit of sea salt in there, like Celtic sea salt. And then that's it. Yeah, that's a great tip. Yes. And there are times where we'll go into the remedies where I'll tell parents, like, I use clarified— instead of Vicks, we use clarified ghee in our home and put a little bit of salt, rub that between two hands, and rub the girl's chest from front and back. And The smell of that. And it just keeps everything lubricated. It's all about keeping things moving and clear. And sometimes we'll also heat a little bit of rice in, in a, like a little handkerchief and apply it to their cheeks so there's less swelling. And it'll also start making things. So oftentimes 2 or 3 days after I've done this, everything's clearing. I mean, they're spitting out the mucus, they're, they know how to blow through their nose, all of that.

Yeah. Awesome. Well, Dr. Radhika Kapoor, this was such an enlightening interview, and it's so nice of you. You're actually offering to anybody interested a complimentary 15-minute discovery call with your hygienist, who's also myofunctional therapist in your office. And if you're interested in taking advantage of that special, you can email wellness@hobokensmilespecialists.com. We are going to put the email address in the show notes below. I've learned a lot from this interview, and I'm sure everyone listening, not only like how you can diagnose children with airway breathing problems, but also simple things that, you know, we can do at home that sometimes we don't think about. Any last words that you want to add before we close?

Well, thank you so much for having me. I think that as a parent going through this and as a pediatric dentist, what I notice is A lot of times we don't know if we should bring something up with our provider because they may or may not understand how to deal with it, or is it something that's worth dealing with? But airway health to me is super essential for how your kids are doing in school, how they're eating, how they're behaving, all of the things. And I find that if your pediatrician's not asking, or the ENT that you're referred to is not asking, it's really, really important to understand that there's a whole host of pediatric dentists like myself who are really making this their mission because the airway and oral space are one. And, you know, be proactive, trust your gut. It's, it's, um, parents are extremely knowledgeable and very, very hyper-attuned to what's going on with their child. So just ask your provider, ask your provider and see how they can help.

Great advice. And with that, everyone, thank you for joining us, and I hope you enjoyed today's show. Join us next week for another enlightening episode on the Holistic Dentistry Show. Have an amazing day. Thank you so much for joining me this week. Please make sure you check out the show notes for any links mentioned in the show. If you like today's show, please invite your friends to listen as well. That would mean a lot to me. Do you have a question you'd like me to answer? Message me on Instagram @DrSandaMoldovan. This is Dr. Sanda Moldovan, and remember, your mouth is the gateway to your health. So take care of it in the most natural and best way possible.