Kids get hurt — a lot. But even when they “seem fine”, those facial traumas can have severe consequences on their growth and development. To help you detect those issues early, Kirk Behrendt brings back Dr. Drew McDonald, instructor from the Chicago Study Club, with advice for seeing the signs and asking parents the right questions about their child’s injuries. You can save children from a lifetime of pain and suffering! To learn how, listen to Episode 626 of The Best Practices Show!
Episode Resources:
Links Mentioned in This Episode:
Register for Chicago Study Club
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Main Takeaways:
Problems with growth and occlusion start early in life.
You need 3D and CBCTs to see and diagnose joint issues.
Even seemingly benign injuries can lead to severe growth issues.
Know where to look so you can get children the help that they need.
Ask parents good and thorough questions about their child’s injuries.
Quotes:
“One of the biggest issues that we run into as orthodontists is relapse. Why did everything we tried to accomplish — why are we watching it unravel? The topic we’re going to talk about today is one of the most important issues that I see, which is that a lot of things under the surface, especially joints, airway issues, issues with kids’ necks or adults’ necks, can really be the undoing of their bite, of their occlusion, of their growth — and they start early in life.” (3:16—3:45)
“I saw a little four-year-old guy yesterday. He’s not growing well. His lower jaw is extremely retrognathic. He’s very Class II. He also has a bilateral crossbite. He has extremely narrow development. This little kid’s jaws also click and pop. And as I’m doing my exam, I’m asking his parents, ‘Does he ever mention this to you?’ They go, ‘We thought that was normal. We thought everyone’s jaws click and pop. We didn’t know he was hurting, but he said it right here.’ My next question immediately is, ‘Do you recall any head or neck trauma? Any falls? Falls down the stairs? Normal, typical, kid stuff?’ And to a tee, a lot of parents go, ‘Well, we never had a car accident. He never had to go to the hospital or anything. But we do remember normal kid stuff.’ Well, “normal kid stuff” is pretty rough. I see it all the time.” (4:00—5:10)
“If you’ve ever been to a cheerleading camp, if you’ve ever watched kids in any summer camps right now in terms of how they play with each other, if you’ve ever been to a trampoline park, if you’ve ever literally just hung out, you’ve probably seen kids get whacked in the head, face, fall down, whatever it is. And those injuries, although they’re not needing to go to the ER, or they’re not bleeding, they’re not having a big issue where you think you have to take them to see somebody, those types of injuries can very often have effects on our facial growth, especially if there’s a whiplash type of incident. The biggest structures that get affected by this are our TMJ joints. Our nasal airway very often gets affected too.” (5:14—6:01)
“I see so many young kids with deviated septums and their parents go, ‘Yeah, he did actually break his nose. He got hit in the face with a bat. We didn’t take him in, though, because we just figured, nah, we’re not going to make this a bigger issue.’ But ultimately, that affects how our child breathes, which can affect growth. You hear this all the time from my friends, Becca Bockow, and other people. We talk about how we breathe and growth all the time. The other hidden gem — or hidden nightmare, I should say — is what happens when they have neck injuries to their upper cervical spine. These are super common, and they’re injuries that we think are benign: kids running into each other, kids bumping heads, hitting their chin on the swimming pool.” (6:02—6:50)
“There’s a really great Instagram account that I would urge everyone that’s listening to follow. It’s called Kids Getting Hurt. I would say that every dentist needs to follow this because these types of injuries you see on this, they all affect us, especially orthodontists and anyone trying to deal with facial growth and helping kids grow properly. These types of injuries, they look like everyday stuff. They create havoc on our facial growth, which creates orthodontic issues. We need to know how we got here to know how to treat it.” (6:53—7:27)
“On my intake for any new patient, there is a whole section that is, ‘Have you had any head or neck trauma? Have you had any injuries that affect that area?’ Most often, people skip over that and think they didn’t have a major injury or a cannon injury that they can go back on and go, ‘Oh, yeah. We had this car accident. He had to go see this guy.’ Ultimately, that leads to some gray area or more questions that I need to ask. As I do my exam, if I start to see signs of joint injuries, airway problems, neck issues, or kids holding their head asymmetrically and all of that, essentially, I need to ask more questions as to, were there any incidents that came along here? I really think that us as dentists need to be really good diagnosticians and ask really good questions about trauma because it’s there for most kids, whether the parents realize it or not.” (8:58—9:58)
“If a young child has a joint injury early in life, falls on their chin, has to have stitches, or hits their head on the bathtub, that can compress their TMJ. A lot of times, I see young kids as young as six years old, seven years old, when we do their MRI of their joints because they’re clicking and popping, they’ve got completely displaced discs. They’ve got really bad architecture within their joint because of those injuries. Essentially, what that does is it starts to stunt the growth of their jaw joints. If we have one jaw joint that’s not growing properly because of an injury, then we start to see facial asymmetry ensue. We also see a lot of kids with very retrognathic Class II mandibles. When I do their MRIs, which is a huge part of my practice — we’ve done close to 2,000 MRIs to this day on orthodontic kids, mostly — they don’t have discs in place when they have Class II growth, when they have asymmetries, when they have open bites. Those are the three big things that all point towards a joint injury. So, when you’re doing your exam — and even before I see that patient, I’ve got a good idea just from looking at facial photos, there’s probably something up with this patient’s joints . . . You can see signs of airway. You can see signs of neck injuries before you ever say hello to that patient in person. Those are things that show very easily with even photos, or watching the kid walk by on the way to your exam room.” (10:15—11:50)
“The growth center of the mandible or the lower jaw, one of the principle growth centers is our condyles, which is our jaw joints. If that growth center is injured, we see repercussions on growth of the face. And it’s not just the lower jaw. What I see over and over again is that if a patient has a displaced disc on one side versus the other, it doesn’t just disrupt their mandibular growth, but their maxillary growth on the same side of that joint injury gets affected too. If the mandible is not growing properly and it’s not interacting with the maxilla in the way it normally would on one side versus the other, I see this all the time where the maxilla is also asymmetric towards that side. We also get underdevelopment of the maxilla in a unilateral way. So, what does that look like in terms of the patient? That looks like a canted smile. Their smile is going up towards that shorter side. I see it all the time.” (12:11—13:09)
“Kids are much more active from younger ages and they’re playing a lot of competitive sports, or dance, or cheerleading, and things like that. And I don’t want anyone to misconstrue what I’m saying. Kids need to live their lives. They need to play sports. They need to get out there and be active. But sometimes, things that happen in those sports can have repercussions.” (15:00—15:20)
“In orthodontics, there’s this common term that comes up where, especially a teenage female, after their orthodontics, we’re watching them have a joint issue. We commonly allude to it as “cheerleading syndrome”. ‘Oh, that’s cheerleader syndrome. Pretty classic.’ That’s the verbiage that people use. Well, what is it, really? That’s not just, ‘It happened because they were a cheerleader,’ or a female, or they’re a teenage female — it just happens idiopathically. No. There is 100% correlation. If you watch some of these sports, or dance, or stunt routines, there are a lot of times where things have jarring impact or whiplash type movements that happen in the head and neck region. That can [cause] a lot of problems during ortho or afterwards and start to have jaw joint meltdown and problems because we’re displacing a disc.” (16:50—17:44)
“There are two parts to our airway. I think that we very often construe, ‘The airway world does only OSA,’ obstructive sleep apnea. What I find so often, or what I allude to is the two parts of airway, which is, one, the nasal airway, and two, the pharyngeal airway. So, why would an injury to the face affect either of these? I see a lot of kids that say they play football, play sports, a pretty common thing — back to soccer, they get hit in the face with a soccer ball. Basically, I’ve had several parents lately, I don’t know if it’s just me, say, ‘Oh, yeah. We knew he broke his nose. They told us at the doctor’s he broke his nose. But they’re not going to do anything at this point because he’s just a kid. So, we’re just going to watch.’ Well, then my next question is, ‘Can he breathe through his nose now?’ And a lot of times, what parents say is, ‘Well, he does sound pretty nasally after the accident, and he does breathe with his mouth open more. Yeah, I kind of see that.’ Well, that is the kid, orthodontically, that has the narrow maxilla, because when you breathe through your mouth, your tongue can’t live in the roof of your mouth. That can’t drive that maxillary growth the way it needs to, and we end up with narrow maxillas. We end up with a lot of crowding of our teeth, and we end up with what looks like just an orthodontic issue. But if we don’t look under the surface and ask questions, then we miss the point.” (18:16—19:43)
“How do we actually look at these injuries? We need 3D imaging. We need CBCT, at minimum, to see noses. We need CBCT, at minimum, to see joints. We need it to see necks. And so, ultimately, that’s a big consequence of facial injuries, is that if the nose gets involved in some sort of injury, that’s going to affect their breathing. And if they’re not breathing through their nose, that’s going to affect their growth, especially in the maxillary region.” (19:46—20:10)
“The other side of our airway, which is the pharyngeal side, doesn’t get talked about a lot. Which is that if we have a joint injury and we’re stunting our mandibular growth because of that, then if the mandible doesn’t grow forward, then it really hangs back, and our pharyngeal airway starts to get really impacted. There’s lots of research, lots of papers, that have looked at Class II or retrognathic patients, especially adults, that have very significant OSA type of issues because their pharyngeal airway is very collapsible because their mandible is not forward, it’s back. So, what if we could have caught this early rather than letting them get to 20, 30, 40 years old and having this significant pharyngeal airway issue? If we could have caught the joint injury early enough and been able to support that joint and the growth, and understood how to do that based off of the MRI imaging that we take, then we could have given this kid a shot at having a normal projected mandible and growing normally, which allows their pharyngeal airway to develop properly.” (20:11—21:18)
“Back to the two parts of the airway, injuries to our nose, injuries to our joints, they affect those two parts of the airway, especially. If we catch that early in life, we give this kid the best chance of growing properly, breathing properly, sleeping properly, having better attention at school. All the consequences of not breathing well and how they often begin is if we have a facial injury or a head or neck injury. So, if we know what to look for early, we’re going to give a better shot.” (21:19—21:50)
“Active kids — these are football-playing kids. We think of them as being in pretty good shape. We’re not really worried about them from a health consequence right now. But I can tell you, I see so many kids that are wrecked because they’re not sleeping well. I mean, how many of our professional athletes do we see or read about now that are sleeping in hyperbaric chambers, basically maximizing their oxygen while they’re sleeping because they know it affects their performance? Well, high school kids that aren’t sleeping well, they’re probably not getting the best rest. They’re probably not feeling that great whenever they go into school that day. And then, back to their football field performance, stuff like that, what could they have been?” (22:41—23:20)
“We think, often, of the airway people as adults that are sleep apnea, overweight, out of shape, whatever you want to call it. It’s quite the opposite. There are so many kids that don’t present that way at all, or adults that don’t present as overweight and with issues, that have the worst sleep. And when we look at their nose, their pharyngeal airway, their jaw structure, their retrognathic jaw structure, they are set up for this pretty early in life to have these problems. And again, if we could have caught that earlier, we could have made a difference in the trajectory of that kid’s life from a health standpoint, from a growth standpoint — all of it.” (23:23—23:58)
“Back to getting hit in the nose, or having a jaw joint injury, what’s connected to that? Our neck. And the upper cervical spine, especially the C1-C2 issues, it’s super common in kids — it’s frightening. And again, they’re not in pain, so we don’t sit there and go, ‘We take him to the chiropractor because his neck is hurting.’ Often, young kids don’t present with pain. But what I see on my CBCT images — and I always go through the slices of the upper cervicals because I see all the time C1 rotated posteriorly towards one side. C-2, very often, also rotated. And if those two in particular are rotated posteriorly on one side, the nerves in that area namely are ansa cervicalis, which those nerves exit between C-1 and C-4 . . . Those nerves control the sympathetic nervous system tone to our head, our neck, and our shoulder on each side of our body. And so, if we are rotated on our upper cervicals back because of an injury and that is compressing those nerves, what we see over and over again is that those nerves over-fire. If our sympathetic nervous system is over-firing, that means blood vessels are constricted. If our blood vessels are constricted, that means less oxygen to growing tissues. And so, if we think about these patients that have facial asymmetries, I often see neck issues that are rotated back towards that side, especially C1-C2 issues. And again, it comes from an injury.” (24:14—25:58)
“The other thing is that if our sympathetic nervous system is over-firing on one side more than the other, we see muscle tightness. This is the kid that if you’re a myofunctional therapist listening — which, I work with myofunctional therapists all the time — when you take your pictures, this is the kid that has one shoulder higher than the other side. They kind of lean their head towards that side. Sometimes, they have tighter facial musculature on that side of their body. And again, the dynamics of growth, if we see those things happening in a young growing kid and their muscles are tighter, they’re not getting oxygen. We see that side, especially, not grow properly and we get more and more facial asymmetries, more torsion. Cranial strain is another word that gets thrown out there. I see it. And again, we can dive back to a lot of neck injuries in these young, young kids. It’s sad to think about. And so, if we know where to look, we can get these kids help.” (26:39—27:38)
“I work all the time with what’s called an Atlas Orthogonal chiropractor. We’re fortunate to have one here in Albuquerque. She tells me all the time, ‘Thank you for sending the young kids,’ because she knows what these young kids become when they get older. If you have increased sympathetics on one or both sides, as you’re getting older, that starts to also present itself in other weird ways. People that have ringing in their ear, or tinnitus, people that have hearing or sensory loss on one side, or have headaches, very often have upper cervical issues driving that. I can’t tell you how common this is, and it’s frightening. I never thought about this before I met Mark Piper a few years ago. He said, ‘Sympathetics are it. Everything is driving sympathetics in the wrong way.’ If we’re not breathing well, sympathetics are bad. If we have a joint injury and we have neck injury things that are driving sympathetics, this is a problem, and we have to unwind these things as early as possible.” (27:38—28:37)
“We need to give our patients the best chance of having longevity that’s healthy and productive. Our job, really, we operate in this head and neck region all the time. We catch so many issues before they ever create a bigger problem — or we have the opportunity to catch them, I should say. But we have to know where to look.” (29:05—29:25)
“We have to have the tools to look at this stuff. You need 3D imaging. You need CBCT. You need an MRI to be able to see the joints and the injury of that disc and the displacement. You can’t go in blind. And sadly, especially in these areas, looking at under-the-surface things with the nasal airway, pharyngeal airway, neck, also our joints, we’ve traditionally gone in blind because we’ve said, ‘We don’t want to take X-rays whenever there’s not a big problem.’ But I’m going, ‘Every single orthodontic patient that walks in my office has these things under the surface, and it is making them an orthodontic patient where they have bad bites, where they have crowded teeth. We need to get to the source of this problem before we make our plan.’ And so, the hesitancy in orthodontics — especially right now, taking imaging on kids to adults — it’s going to go away. The wave is here. There’s so much evidence showing that those problems are so present. Our imaging technologies are so advanced now with less radiation than they ever used to be. We cannot live in a 2D world.” (29:28—30:34)
“That comes up all the time where it’s like, ‘Why do we need to take this 3D X-ray? I don’t see any problems.’ Well, the problems are underneath the surface. And if you don’t know what that problem is, whether it be an airway issue, joint issue, or a neck issue, and if you don’t understand how that’s affecting the growth of that patient or why it’s creating this bad bite, then yeah, you can hide in 2D world all the time. But if you understand these things and see them like I do, like you see in the research that is coming out over, and over, and over again, at this point, we can’t hide our head in the sand anymore with the 3D imaging, or even with MRIs. We have to be there as orthodontists.” (30:37—31:16)
“Ask good questions. If you see certain facial patterns like narrow maxillas, a lot of crowding of teeth, start to say, ‘Is there a nasal breathing issue here?’ and start asking questions about trauma. We also know that sometimes when maxillas aren’t growing well, that can also lead to a deviated septum. Either way, if it’s trauma-induced or growth-induced in terms of nasal issues there, we still need to ask these questions, and they come up all the time.” (31:36—32:08)
“If you see Class II asymmetric growth, open bites, I think we absolutely have to rule out that this is not a joint injury. And the only way to see is to image. We have to look at those joints with some imaging. We have to ask questions too. If parents mention any sort of, ‘I guess he had a concussion. He did run into Johnny. They smacked heads,’ or if you look at the kid walking in and he’s got a scar on his forehead or on his chin, dead ringer. We need to know that there’s probably a head or neck injury that happened, and we also need to know, what could this be doing to this child’s growth? And then, we have to know what imaging and what diagnostics we need to be able to see.” (32:10—32:52)
Snippets:
0:00 Introduction.
1:37 Dr. McDonald’s background.
3:46 Every-day injuries can wreak havoc.
8:39 Ask parents the right questions.
11:52 Repercussions of injured joints.
14:18 Injuries are more common than you think.
17:45 The two parts of airway, explained.
21:50 The importance of catching issues early.
23:59 Head and neck injuries.
28:38 You need 3D imaging to see these injuries.
31:20 Last thoughts.
34:29 More about Chicago Study Club.
Dr. Drew McDonald Bio:
Dr. Drew McDonald is a board-certified orthodontic specialist with a strong focus on airway and temporomandibular joint-focused treatment planning, surgically facilitated orthodontic treatment, and providing complex interdisciplinary care for patients. He lectures internationally on these topics and has contributed to literature and textbooks in these areas. He is dedicated to advancing the profession of orthodontics and dentistry as a whole.
Born and raised in Tucson, Arizona, Dr. McDonald’s love of baseball brought him to Albuquerque, New Mexico, where he played as a catcher for the Lobos from 2006 to 2008. While attending the University of New Mexico, he met his wife, Emily, a New Mexico native. He also fell in love with the Sandias, green chile, and the near-perfect weather. He graduated from the University of New Mexico in 2008 with a Bachelor of Science degree in biology and a minor in chemistry.
Dr. McDonald attended dental school at the prestigious Creighton University in Omaha, Nebraska. Known for its rigorous academic curriculum and intense clinical training, he received many academic accolades while at Creighton, including inductions into Omicron Kappa Upsilon (National Dental Honor Society) and Alpha Sigma Nu (Honor Society of Jesuit Universities). He also served in leadership positions as class president and student body president, and on alumni relations committees.
After graduating cum laude from Creighton, Dr. McDonald was accepted as one of only three residents nationwide into the University of Missouri-Kansas City Orthodontics program, a renowned two-and-a-half-year, full-time residency known for its clinical excellence. He graduated in December of 2016 with his certificate in orthodontics and master’s degree in Oral and Craniofacial Sciences.
When away from the office, Dr. McDonald is a “girl-Dad” to two daughters, a self-proclaimed grill master, and minimally talented yet enthusiastic golfer. You can find him taking in a Lobos game and spending time outdoors with his family.
