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Episode 107 - Dr. Shereen Lim - "Breathe, Sleep, Thrive"

1:06

Hey there, it's Emma Cooksey here, and I'm your host.

So before we got on to today's guest, I just wanted to remind everybody out there.

With sleep apnea that if you would like to be featured on an upcoming episode of the podcast, you can e-mail me at sleepapneastories@gmail.com.

1:27

And ever since I started the podcast I've tried to have a balance between patients sharing their stories about their journey to diagnosis and treatment options for sleep apnea and then also.

Interviewing experts like dentists, doctors, surgeons, all sorts of people.

1:47

My functional therapists, you name it.

And and so I I like that balance where half of the episodes are from patients directly.

So if you're listening and you've thought about being on the podcast but you're not sure, now is your opportunity to take this as the sign and you can e-mail me.

2:08

And let me know a bit about your story and why you'd like to be on the podcast.

So that's that.

And then on to today's guest.

So today I'm joined by Doctor Shereen Lim and Dr. Lim is a Perth based dentist.

2:24

So as in Australia, not Perth in Scotland, just because I know we have Scottish listeners.

She has a postgraduate Diploma in Dental Sleep Medicine from the University of WA.

She's been involved in the.

Team management of snoring and Obstructive Sleep apnea for over a decade.

2:43

Dr. Lim is dedicated to promoting airway health from infancy as an alternative approach to minimize the development of these problems and their consequences.

And she's the author of the book, the excellent book Breathe Sleep, Thrive.

2:59

Discover how airway health can unlock your child's greater health, learning, and potential.

So I really hope you all will get a copy of that book and read it, especially if you're a parent.

There's so much information that you know is just not out there in the mainstream and pediatricians and pediatric dentists don't receive this training right now.

3:24

So it's really only people that have sought it out and done the extra training who know about it right and and the consequences of.

Leaving these problems untreated can be really serious, so I hope you'll listen to this episode and get a copy of the book.

3:41

Breathe, Sleep, Thrive.

And without further ado, here's my conversation with Doctor Shereen Lim.

So thank you so much for joining me.

Yeah.

No, fantastic.

I'm really glad to be here.

Thank you.

Yeah.

I am, I I love your book and I kind of.

3:57

I'd read it When?

When I first got it and then.

Today I was kind of going back through because I knew I was going to be talking to you and yeah, it's really great.

So I'm really glad you wrote your book.

It's going to be so helpful to everybody listening to dig into some of the stuff in there.

4:16

So do you want to just start by you're in Australia, Did you want to just start by explaining a little bit about your background, maybe a little bit about how you got into the whole realm of sleep in the beginning?

Yeah, well it was about 12 years ago.

4:34

It was my husband snoring.

It was really bothering me and I'm so frustrated.

One evening I decided to get up and look about the dental sleep appliances.

I knew that these were an option for obstructive sleep apnea and snoring.

And you.

Were already a dentist at this point.

Now.

4:49

Oh, that's correct.

Yes, yes.

So as a dentist, yeah.

So I am a dentist and I wanted to learn more about those dental sciences, cuz it's not something we're taught in dental school.

And I actually enrolled in a graduate diploma in Dental Sleep Medicine.

So for two years learning more about Sleep Medicine and how to become involved with it and work with sleep physicians.

5:10

And I started to realize that storing is not just a sound, but.

It is linked to increased health risk and how detrimental it can be for people.

And I became more involved in offering these sleep appliances, so they really are a compensation to actually Band-Aid the like to to deal with a jaw deficiency basically.

5:32

And so I was starting to wonder how come we can't deal with the underlying deficiency when children are young?

We taught that in dental school, you can do early interceptive orthodontics for children when they're 7 to 8 years old.

How come we're just watching and waiting a lot of the time and we're taking out teeth when children have stopped growing around the age of 12 doing braces?

5:52

Why can't we deal with this underlying problem early?

And so that's really why I wrote the book, to kind of help people understand what what are the benefits of early intervention, the breathing and the sleep?

And the more I looked into it, the more I started to realize that we can even do a lot of work much, much earlier on in childhood, because the way the jaws are formed is influenced by how the muscles are working from from infancy.

6:21

Yeah.

So we're going to get all into that and I guess I'm quite interested in the differences between Australia and.

The United States, like I grew up in Scotland, but I've lived in the States for like 15 years since my kids were born.

6:37

And and I know that with some of the information in your book, like I've read similar things elsewhere.

And there's a lot of parents in the position that I find myself in, in northeast Florida where I'm not in like New York or California or somewhere.

6:56

So I find it very difficult to find.

Dentists who were really thinking about earlier interventions.

So I think for a lot of people they're taking their kids to, you know, I mean, I was going to say the pediatric dentist, but they're pediatrician as well.

7:16

And they're kind of saying there's some things going on with sleep and what can we do?

And a lot of them are told like.

We just need to kind of wait and see what happens and can you maybe speak a little bit to how urgent it is for for parents to, you know, get involved a bit earlier and really advocate for their kids?

7:41

Yeah, for sure.

Sleep is really critical in the early years of life.

We know that the brain development 90% of the adult size brain is attained by the age of three years.

And this is when we need to sleep the most.

And so we know that as important as it is to have the right number of hours of sleep, we need to be making sure the quality of sleep is good.

8:02

And typically, parents are pretty happy if their child is sleeping through the night.

They're not necessarily checking on their child's breathing, but there are things to look out for.

Whether it be mouth breathing, snoring, restlessness, tossing and turning, neck, hyperextension and and many more, that could indicate a child is not breathing really well.

8:22

And when that doesn't, when that doesn't occur, a child is going to be more at risk of problems like difficulties with emotional regulation, poor poor attention and concentration symptoms of a DHD.

When children are not getting restful sleep, they're not tending to be like adults.

8:39

Where we might get more sluggish, they may be more hyperactive or need to move, inability to sit still and have tantrums and things like that.

So I think it's really important that we address these issues when children's brain function really requires that sleep.

8:57

Can you speak a little bit to like really early like just infants when they're first born like kind of some of the things that?

Even then.

Or maybe being missed just because we don't have this focus about kids Airways, I guess they're checking for a bunch of other things and they sometimes will miss things like tongue ties.

9:21

And do you want to explain a little bit about how Jaws are developing?

You know, like from the moment kids are born and and kind of what's happening with that?

Yeah, so the first year of life is the most rapid period of jaw development.

9:38

That's when the jaws are growing the most.

And one of the biggest environmental influences of jaw development is how are the muscles working?

And so we we want to promote nasal breathing from the earliest years of life and we want to look out for ensuring that babies can sleep with their mouth closed, lips seal.

9:57

So sometimes it's as simple as just helping them to close their lips.

The other thing that's really important is the feeding.

We want to make sure we're a lot of parents.

They recognize that breastfeeding has many benefits, immunological and health benefits, but not really well promoted is the the the mechanical benefits of breastfeeding.

10:17

Because for breastfeeding we need to have good tongue suction where the tongue is elevating to the roof of the mouth and suctioning against the hard poet and then as it drops it creates a vacuum and that's how milk is extracted.

Really efficiently and so we we want to let parents understand that the way we feed our children in that first year of life is also going to influence how the jaws grow and we want to stimulate the muscles as much as possible through breastfeeding.

10:44

And sometimes yeah like you mentioned tongue ties, they can be a a barrier to getting effect good effect of breastfeeding because they don't allow the tongue to suction really well and a lot of the time people have these problems and.

11:00

It's very overlooked that because we're not really taught how to identify tongue ties or recognize those.

I think people just having been through, you know, breastfeeding to kids, like I think that there's not really enough support for breastfeeding mothers and and a lot of people will struggle on for a long time when you know they're they're having.

11:24

Things wrong with the latch and clicking noises and just stuff that's not going well and I guess like some support to kind of know what an effective breastfeeding looks like would be really helpful for a lot of women.

11:41

Yeah, for sure.

Even to see a lactation consultant.

But many parents aren't familiar with what a lactation consultant does.

But even when we see a lactation consultant, there's a difference in the knowledge of tongue ties as well.

So that's really important to recognize.

11:58

So it's not unusual to see people that have seen multiple different professionals that have been told there is no tongue tie and they've put on all different medications and told.

Different things Shields and and talk Babies will grow out of the situation, so I think it is important for mothers to follow their gut when something is wrong and and seek out different opinions.

12:24

One of the really interesting things that you wrote in your book, and also I remember I kind of worked with a myofunctional therapist and I remember her saying this too, is that there's a lot of mothers who are told.

12:41

Like by, you know, healthcare professionals, but they'll just kind of like look at the baby and say, oh that tongue ties, not a problem or, but it's really to do with the function right of what what the tongue can do and what's restricted from doing because of the tongue tie.

12:58

Yeah, I think it's really important to pay attention to the symptoms and recognize that it is really important to have good tongue elevation.

It's the tongue elevation that is really critical for the good milk transfer, the good swallowing even later on for good articulation and good breathing and good tone that we need for good palate development and and sleep.

13:22

And another common thing that occurs with these tongue ties is the the misdiagnosis of reflux and colic.

Because babies cannot lift their tongue and swallow correctly and they're taking in lots of air.

And so I see that a lot in practice where babies are so unsettled, they're they're given these medications, which are not proven at all and no one has really inquired about that, sure.

13:45

How much air are they taking in?

So I think that's a really important thing to look.

For as well, really important.

15:22

So as far as encouraging better jaw development in kids so they can grow up super healthy and not develop sleep apnea, we hope.

And what things as you mentioned like keeping the mouth closed and nasal breathing and what are the other things, so chewing on hard things.

15:46

Yeah, for sure.

Chewing.

We we know that that is really important to stimulate the the the jaws and so that the muscles because.

So we want to also avoid dummies because what they do so pretty much for the tongue for the.

16:04

Fires for people in America.

I know what you mean, because we say dummies.

So I think for the upper jaw, the palette which is really the template, good palette development is the template for good lower development.

We really want to focus on good tongue.

Function.

16:20

And so that includes nasal breathing because when we close our mouth and we have that tongue resting in the roof of the mouth, that tongue is going to broaden or sculpt that palate.

And nasal breathing is important because that's where we spend all our time, you know, the majority of the day.

16:37

So that light, persistent force of that tongue up against the roof of the mouth is going to mold the pellet.

But then we also need to think about breastfeeding as I mentioned and also.

Pacify.

Use, which is lowers the tongue, so it lowers the tongue and then it so.

16:54

Pacifier.

Use of any kind.

Is there a particular one that's that or no?

Just just you think none.

Anything that lowers the tongue is going to interfere with that tongue position, and it introduces increased sucking pressures or inward pressures that distort the palate.

17:11

And because that jury is so malleable in the first year of life, it has an influence.

And those impacts are related to intensity, duration and frequency.

So obviously the least we do it, the less impactful it will be.

17:26

But a lot of people might say I just use it for sleep.

However, sleep is the time where babies spend the most time.

And yeah, so I just start educating people and there are some babies that will rely upon it.

But sometimes when babies rely upon it, there may be an underlying issue.

17:45

And I do think a lot of babies that do require it.

There is an underlying issue that, yeah.

I think, I think with the thumb sucking as well, like that there's a dentist.

I recently interviewed Jill Umbrella and she was talking about.

18:01

Because I was a, I mean, I just had every problem.

So we're trying to avoid people listening, have having kids turn out like me.

But I was a really serious thumb sucker for years and years and years.

And and Jill was saying, well, that's your way of like, you know, trying to kind of like bring the soft tissue out of your airway to breathe better.

18:24

That was kind of interesting to me.

I never really thought of it that way.

But so thumb sucking and fingers sucking aren't great either.

Yeah, I think, I think sucking habits are a compensation and usually I'm starting to think that it's a reflection of poor tongue function.

18:40

And there is some research from Italy which suggests that having the tongue in the roof of the mouth it it really needs to sit and hit that endless spot where we say in is that area is has the highest concentration of sensory receptors and.

18:58

When that tongue touches that spot and stimulates those receptors, it sends signals to the brain and and it's involved with neurotransmission.

So it it turns on pathways that release dopamine and serotonin and other feel good hormones.

And so when the tongue isn't on that spot, these type of sucking habits can also be a compensation to stimulate those receptors.

19:23

And so I think there is that neurotransmission aspects that we're missing and it's a way to the people to to feel good when they put their tongue thumb on that spot.

And so it's really common to I think a lot of people in that my functional therapy space will agree that when we have children that are older and they really want to stop sucking their thumb and we've got them on board, it's very predictable to get them to eliminate that thumb sucking habit within 24 hours if we're.

19:53

Teaching them where to put their tongue.

Right.

Yeah.

Similar feeling.

Yeah.

So, so there was a little bit where you were see if I've got a little note there.

I thought it was really helpful.

You had some questions that parents like.

20:12

If parents are listening to this and thinking, I really think my there's something going on with my child's sleep and I need to find.

A dentist just like you, but they don't live near you.

There was a list that you had of the kind of questions people can ask of a provider to kind of check if they just because you were saying like the training.

20:34

This is kind of a new developing area and the training among dentists and pediatricians is vastly different.

So you're going to go to some dentist who really won't know a lot of this about.

Facial and airway development.

20:50

So do you remember what those questions were?

Cuz I can tell them not.

As you were asking, I was.

Like, I hope you probably asked me.

You probably wrote it like a million years ago.

And you're like, what?

What did I write?

I think it's really important if you're seeing a dentist that they should understand that teeth grinding is actually a key red flag that a child might not be breathing well because a lot of the time in dental school we're thought it's something that they'll grow out of and.

21:17

Yeah.

So if they can understand that it is breathing related often, then that's a pretty good clue of someone that might have done some further learning.

And then we want to ask them, you know, do they refer to orthodontists for early intervention and how early do they go?

21:34

Because if they're involved with early treatment before the age of 7 to 8, they may understand that there's.

Reasons Functional Reasons for breathing and sleep that we might want to do early treatment, Or do they refer to a Maya functional therapist to address?

You're doing really well.

I just find it in your.

21:51

Or do they refer to ENT to an ENT specialist?

And to work because I think this is one of the things that it's really important to get across is, you know, treating these kind of issues with children really involves the team, right?

22:08

It's not about.

Just going to one person, usually.

It's like sometimes you'll then get referred to Myofunctional therapy, or you'll you'll go to an ENT or whoever ever happens to be.

So people should definitely expect that, right?

Yeah, absolutely.

22:25

Yeah.

So about the age that you can start working on kids.

Like I think at one part in the book you talked about it might have been Kevin Barder, it might have been.

Doctor Gamo, I can't remember, but they were saying like if you're waiting until the seven or eight, which is kind of like considered early orthodontics in the sort of mainstream, they're saying like that's kind of too late because so much of jaw development happens earlier than that.

22:58

So what kind of age are we, you know, really trying to find somebody to help us with this, like, especially as far as pallet expansion goes?

Yeah, well, Doctor Gimano, Christian Gimano, he actually says that 60% of jaw development is done before the age of 6.

23:20

And so we really need to be addressing that for development in that early in those early six years of life.

And so I've started to offer expansion in children around 4-4 years old, I've got 3 1/2 year olds as well.

23:38

And that's about the the earliest age that I can get really good cooperation and get them on board to do it.

But there are practitioners that are doing it from the age of two years when children have all their baby teeth.

It's a good time where we have something to anchor or support those appliances.

23:55

And you want to explain.

I always assume a lot of knowledge, but let's go back and explain what the pallet has to do with.

Nasal breathing and whether kids can can sleep well because of what's going on with their palate.

24:11

Do you want to explain all that?

Yeah, absolutely.

So with the palate, the palate or the roof of the mouth is actually the floor of the nose.

So when we have a narrow palate or any dental crowding with it, which indicates that the jaw is not growing well, what that means is we're going to have some degree of limitation of nasal.

24:33

Airflow.

And so we have researched to support that when we do pallet expansion, even a few millimeters increase in the width allows exponential increases in the nasal cross section, which means air can flow more easily.

24:49

So that's one aspect of it.

The other thing is that it is also the housing for the tongue.

And so we want good tongue to pellet seal the really good airway stability to keep the airway open.

25:04

And so when we open up the pallet, it makes more room for the tongue as well.

And so when we look at adult obstructive sleep apnea, what we know now is that typically in the past.

A lot of focus was given to the mandibular advancement devices that bring the lower jaw forward.

25:23

However, a lot of the time when we have a retruded lower jaw there, it is accompanied by some degree of constriction of the upper jaw.

And so the upper jaw is really key to actually get everything working well, you know, after your journey and like it's so much more difficult and more invasive.

25:45

And I just think it's really important for people to recognize this.

We can actually modify and mold it a lot more early, yeah.

You actually treat adults anymore or you mainly are just treating kids?

I do.

I do see adults.

OK, you know, someone a lot of the time they may come in for a tongue tie consult and it's they may have sleep and breathing problems or sometimes they come in for the dental devices.

26:12

What do you think about like, I just talked to so many people at this point who have done all sorts of surgeries.

And so I thought, I thought the section in your book where you're talking about some case studies of adults was super interesting and but so it seems as though if people are wanting to try and address this underlying issue.

26:37

Of like having a very narrow palette and you know like constricted airflow and their nasal airway and all that.

Then it seems like you're suggesting people look at surgically assisted like Dome you do you want to explain what Dome is?

26:54

Yeah, I think surgery.

It sometimes can be a very good intervention for people.

You know, a lot of the CPAP and the dental devices, they're really Band-Aid solutions.

They only work at nighttime and the ultimate goal should be to restore nasal breathing.

And sometimes that means developing that palette.

27:11

And traditionally we thought that you can't, the suture closes.

You can't do that for adults.

But now we know that you can use these mini implants or little screws that are placed in the bone next to the mid palate suture.

And what that means is you can put a little screw mechanism that applies the force directly against the palate directly across the palate suture.

27:33

So we can actually get that suture stimulate separation rather than move the teeth.

And sometimes it may involve a bit of surgery like the Dome technique which is really just releasing some of the other sutures.

To allow the bones to move more easily.

27:50

One of the people I interviewed really recently was doing surgitly assisted rapid pallet expansion and I can't remember, I think she was using MSE was the actual thing that she had connected up.

So she was talking about, I always thought that any sort of those kind of appliances that connected into the bone that you would have to like have the pallet will suit your.

28:16

You know, like surgically kind of cut.

But she was saying that it got to a certain point and it just kind of like almost like popped and like.

So is that what you're talking about?

Like it just kind of like gradually pulls apart until it separates.

28:33

Yeah, I think well, well as we age that the the joint or the the suture between the two halves of the palate is really fused.

Yeah, right.

So many implants is a way to in.

So previously they used to do a big cut in the middle of the color and then at the back as well just to allow things to move more easily.

28:53

Those many implants like the MFC, it actually allows that force to be placed very directly across the suture so it can be moved easily and often can be done without surgery.

Other things like the appliances and the acrylic appliances and different things, they may not get that same suture expansion and they may tend to move the.

29:15

Leaf more which can be, which can kind of tip the teeth and sometimes it's really not appropriate for people.

Some people it may that are they're severe, they may benefit from that improved tongue space.

But really at the end of the day if we want to improve nasal breathing, using predictable techniques involving many implants can be a good option.

29:34

Are you doing more like referring to Ent's for like septoplasties and all those kind of things?

Or are you trying this first and then if they still need?

Nasal.

Like, do you find that it kind of opens up people's noses so they maybe don't need as much surgery?

29:52

I do believe that pellet expansion plays a very central role.

If we can make sure that people's pellets grow it well, it it, it's really important for nasal breathing, really important for the tongue space and and for the whole support of that upper airway or throat.

When people underestimate as well.

30:11

How much nasal congestion and restricted airflow in your nose really plays into sleep apnea?

Like, I think that people kind of think of it as a as a sort of localized thing, but like if your nose doesn't work, then can you explain a little bit about.

30:30

I think you're explained in the book really well about how restrictions in nasal breathing it all almost causes like a vacuum.

And and makes it more lightly that things are going to collapse.

Yeah, for sure.

A lot of the time, adult sleep apnea, the roots are in mouth breathing and so if you try to breathe or snore with your mouth open, there's a snore with your mouth closed.

30:57

You will notice that when you close your mouth, it is less likely that you're going to snore because that and.

As that tongue is up and sealed against the roof of the mouth, it just flows really well and smoothly through the nose and down the back of the throat.

31:14

But the moment that the the tongue is mouth is open and the tongue is down and we've lost that tongue to pellet seal, it has more than one way to flow and we have to breathe a little bit harder.

And that's when we're going to get those instability of the airway and increased risk of collapse.

31:33

Yeah, and so.

The more and more I see adults snoring and obstructive sleep apnea patients, the more I'm recognizing that, you know, we really need to address this nasal breathing problem and a lot of mouth breathing problem.

And a lot of the time when I see people that have had obstructive sleep apnea and they're here for dental devices, they've had various nasal surgeries that haven't worked out.

31:56

And so we know from the team, doctor Stanley Liu and the team at Stanford, they have established that people that have.

Failed nasal surgeries.

The common link is a narrow nasal floor or a narrow palate, so we really need to address that.

32:15

Oh, I know.

What I wanted you to explain as well is you have a really good diagram in the book where you're talking about the continuum from open mouth.

Breathing and snoring right through to severe sleep apnea.

32:30

Do you want to like maybe talk a little bit?

Because I think that a lot, a lot of times people think, you know, like especially in our current system.

I'm sure it's similar in Australia where people are going for a sleep test and they're told even though they have a bunch of apnea events, they're told, oh, your AHI is really low.

32:54

And we're not going to do anything to treat this.

And so which frustrates me, like I'm not a really big fan of everything all being about the AHI, because I know that there's just such a broad spectrum of like not normal breathing that can get worse and worse.

33:10

So do you want to talk a little bit to that?

Yeah, absolutely.

Well, obstructive sleep apnea is the end stage problem, and it's a very arbitrary definition.

You need to have five.

For adults, 5 obstructions 10 seconds or more every single hour of sleep on average.

33:31

But what people don't recognize is that you know that those numbers 9 seconds, if you have nine second obstruction, it's not counted how low is the oxygen dropping during that time.

And I want people to recognize that if we look on the other end, these problems begin when mouth breathing starts.

33:50

And even mouth breathing in children, we know that it's linked to significant increased risk of behavioral and learning problems and and and ADHD like symptoms and then even if we have.

We we we may work harder to breathe, so we may not necessarily have 10 second obstructions.

34:08

The sympathetic nervous system is more alert and it's in final flight mode.

Every time it looks like the airway is collapsing, there's an arousal from sleep and increased stress response or things like teeth grinding to kind of keep the airway open and it protects against sleep apnea or those longer obstructions, but that leads to very fragmented sleep.

34:29

And so in children it it's linked to all those problems.

But then the other group that's under diagnosed or recognizes is young women, premenopausal women that they are tending to get more of the upper airway resistance syndrome where they're constantly in part of flight mode.

34:47

But that's linked to a lot of other problems like anxiety, you know irritable bowel fibromyalgia, all these other functional somatic syndromes where there's an increased response to to stimuli and.

It it it can be linked to this chronic stress of not getting good night's sleep.

35:07

So I do think that it is important that we look beyond the AHI and obstructive sleep apnea and try to achieve healthy breathing.

Yeah, yeah.

Because the more people that I interview who, I mean, I just if I had a dollar for every person that told me exactly the same story, they went to the doctor and they said you have an AHI of four.

35:30

But they had really bad symptoms and they felt terrible.

And, you know, they just kind of were sent away without an answer and eventually figured out that they have upper error resistance syndrome.

Yeah, like healthy sleep is not having any apneas, you know.

35:47

So I think that like the whole thing about, like, well, providing it's under 5.

Well, like if you're really easily arised from sleep like you could, you can be waking up multiple times an hour, you know, and just really never getting restful sleep.

Yeah, for sure.

36:03

OK, tell people where they can find you.

Probably my site Dr. shereenlim.com dot au or I'm very probably the most active on Facebook so I'm after using different cases and and information there.

Awesome.

36:18

And I'm gonna put links to.

Your book and also all those places people can find you in the show notes so people can get in touch.

Thank you so much for.

Your time, no, thank.

Thank you so much.

Thank you for what you do as well.

I think really it's that adult problems that are often the most despairing because we know, gosh, we could have actually resolved or or achieved a different pathway.

36:42

And so I really appreciate the opportunity to to talk to you today.


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