Why Does Nasal Breathing Matter?

Transcription

1 Dr. Bill Martin & Dr. Peter Catalano Why Does Nasal Breathing Matter? Everything You Need to Know About Sleep Disordered Breathing in Children & Adults

2 Table of Contents 1. Why Is Nasal Breathing So Important? 3 Learn the benefits that come when you breathe through your nose instead of your mouth and the consequences of excessive mouth breathing. 2. How Do You Know If You Have Sleep Disordered Breathing? 5 Why do so many people never recognize their own breathing issues? What signs should you keep an eye out for in yourself and your loved ones? This section also includes... ¾ Symptoms of Sleep Deprivation in Adults 6 ¾ Symptoms of Sleep Deprivation in Children 6 3. Bruxism, Teeth Grinding & TMJ Can Also Be Symptoms of Nasal Obstruction & Poor Sleep 7 Your nose could be causing you to grind your teeth at night. Find out the link between nasal breathing and jaw-related disorders. 4. Extra Sleep & CPAP Are Not the Right Solution 8 Too many sleep doctors assign CPAP for sleep apnea without seeking the apnea s underlying cause. Learn why this is a mistake! 5. What Causes Nasal Obstruction? 9 You can t improve your nasal breathing until you know what s been holding you back. Read about the most common causes of breathing obstruction in the nose. 1

3 6. The Link Between Nasal Breathing & Dentistry 11 Enjoy a brief history of the scientific experiment that uncovered the link between breathing and jaw growth. Learn why breathing through the mouth can have serious negative consequences for a child s physical development. 7. Reversing ADD/ADHD & Behavioral Issues in Children 14 Recent evidence shows that mouth breathing during sleep can cause the same symptoms as ADD and ADHD. Before reaching for medication, make sure your child is breathing well when they sleep! 8. The Role of Head Posturing 16 Mouth breathing can lead to problems beyond jaw and facial growth. Find out how poor breathing can lead to issues with posture, back pain, and more. 9. What Are Your Treatment Options for Sleep Disordered Breathing? 18 There are numerous approaches to help improve nasal breathing in children and adults, but the RIGHT approach will differ from person to person. Learn about some of the common treatments available today. ¾ The Benefits of Palatal Expansion 18 ¾ What About Tonsils & Adenoids? 19 ¾ Correcting Nasal Obstruction with MIST New Data Supports Our Story 23 Learn about the incredible results coming from recent medical studies on nasal breathing. About the Authors 25 2

4 Why Is Nasal Breathing So Important? Breathing through the nose. It s a basic and critical function for your body, although most people don t give it much thought. Did you know, though, that proper nasal breathing influences the way a child grows and develops? It s true! If a child cannot breathe well through their nose, their daily life functioning will be negatively affected. Fundamentally speaking, nasal breathing provides four key functions: 1. It provides you with a sense of smell. 2. It improves the way your lungs absorb oxygen. (This is thanks to a chemical made in your sinuses called nitric oxide.) 3. It warms and humidifies the air you breathe before it reaches your lower airway. 4. It helps to filter impurities from the air. When nasal breathing doesn t happen correctly, far more can go wrong than just these four functions especially in children. Poor nasal breathing forces the 3

5 body to make compromises to get oxygen into your blood. In other words, the body stops performing other important functions in order to get oxygen. The result of this is a host of health issues caused by chronic or intermittent mouth breathing. One notable consequence of mouth breathing is an issue called Sleep Disordered Breathing (SDB). As the name suggests, this disorder arises when someone does not breathe properly when asleep. Sleep Disordered Breathing has been discovered to be a widespread problem in children and adults, and it can affect children s growth, development, intellect, school performance, behavior, and much more. 4

6 How Do You Know If You Have Sleep Disordered Breathing? Many patients with Obstructive Sleep Apnea or Sleep Disordered Breathing don t even realize they have problems with nasal congestion. The two most common reasons for this are 1. Often, nasal obstruction only occurs once you are lying down for sleep. It can take anywhere from 30 to 90 minutes for the nasal congestion to develop, and by that time you are already asleep and unaware of the problem. 2. You don t know what normal breathing feels like if you ve never had it. This is the reason we test children for hearing and visual loss in grade school. Children have no frame of reference for normal hearing or sight. Likewise, they have no frame of reference for normal nasal breathing, and unfortunately, there is no standard screening test for them at this time. As a result of these two factors, many children who suffer from Sleep Disordered Breathing go undiagnosed. To help combat this, it is up to teachers, parents, and guardians to watch for the signs and symptoms of Sleep Disordered Breathing. 5

7 One of the first lines of defense against Sleep Disordered Breathing is the ability to recognize its symptoms. Common symptoms of this disorder can vary from person to person, but any of the following should be considered a red flag. Symptoms of Sleep Deprivation in Adults: Snoring Obstructive sleep apnea (OSA) diagnosis Breathing stops during sleep Waking from sleep gasping or coughing Daytime fatigue Being overweight Increased risk of heart disease High blood pressure Stroke Diabetes Memory loss Trouble concentrating Reduced libido In children, obstructive sleep apnea (OSA) and sleep disordered breathing (SDB) lead to a very different set of signs and symptoms that are very commonly seen in children and are often overlooked or misunderstood. Symptoms of Sleep Deprivation in Children: Mouth Breathing Snoring Restless Sleep Frequent Awakenings Bed Wetting Lack of Focus Poor Attention Span Forward-Head Posture Disinterest in Eating or Difficulty Eating Neatly Hyperactivity (ADHD) Attention Deficit Disorder (ADD) Poor School Performance Anger Frank Aggression Headaches Teenagers can also sometimes show the daytime fatigue symptoms seen in adults. A key point to remember is that not all symptoms exist in every person, and the exact symptoms shown by each person can vary widely. Therefore, if you or your child shows any symptoms on this list, you should discuss your concerns with a doctor knowledgeable in Sleep Disordered Breathing. 6

8 Bruxism, Teeth Grinding & TMJ Can Also Be Symptoms of Nasal Obstruction & Poor Sleep One other key symptom to watch for is the way your jaw moves when you are sleeping. When you can t breathe through your nose and your sleep suffers, your sleeping body will attempt to improve oxygen flow by moving your jaw from side to side and back and forth. This jaw movement helps to widen your oral airway, so you can inhale more oxygen. Unfortunately, this jaw movement also causes your teeth to grind together. Over time, this wears down the enamel and flattens your teeth. It will also eventually cause health issues such as TMJ, arthritis, chronic pain, and locking of the jaw. As your teeth are worn down, they also get shorter, which causes the amount of space in your closed mouth to shrink. This, in turn, constricts your tongue further, forcing it to drop back and block your airway even more. Common signs that you grind your teeth at night include a creased tongue with a white coating and scalloped edges. A short lingual frenum or tongue tie may also contribute to this problem and must be corrected in early infancy or even later as an adult. If you suffer from this type of teeth grinding, then clearing your nasal airway and using an oral appliance will correct the problem. If your teeth have already been significantly worn down by years of grinding, you may also benefit from a special dental procedure that restores vertical height to your teeth and provides ample room in your throat for your tongue. 7

9 Extra Sleep & CPAP Are Not the Right Solution If you struggle with Obstructive Sleep Apnea (OSA), simply getting more sleep will not reduce your symptoms or your risk of additional health problems. By definition, apnea means you aren t getting any or enough breath into your lungs. When this happens, your heart, brain, and other organs become stressed from lack of oxygen. If you sleep longer, then you are increasing that stress on your body, not decreasing it. Your lack of oxygen is the central and key issue that needs to be addressed. Unfortunately, sleep doctors rarely take the time to seek out the underlying cause of your obstructed breathing. Instead, they jump straight into treating the symptoms instead of the cause, overlooking the fact that 85% of breathing obstructions are found in the nose. If you ve already been diagnosed with sleep apnea, you may have heard about CPAP (continuous positive airway pressure) machines. A CPAP machine uses a mask fitted over your face or nose, which tries to force oxygen past your nasal obstruction and provide adequate oxygen during sleep. CPAP machines are problematic for two main reasons. First, many adults simply cannot tolerate CPAP, and few patients can use it more than 4 hours a night. Second, CPAP is not appropriate for growing children, because the head straps can reduce proper facial growth and development. This happens when the straps push against the facial bones and prevent their forward growth. Ultimately, the best approach to combatting OSA or SDB is to go right to the source of the problem: correcting the nasal obstruction. 8

10 What Causes Nasal Obstruction? In general, these are the five most common reasons for compromised or limited nasal breathing 1. Deformities or irregularities in the anatomy of your nose. Some examples include septal deviation, a collapsed nostril, enlarged turbinates (structures that warm and humidify the air we breathe), or the presence of a concha bullosa (a large obstructing egg-like air balloon in the nose). These problems are typically genetic, but the first two can also be the result of nasal trauma. 2. Allergies. If you consistently suffer from allergies, your nasal tissues can become swollen. This, in turn, will limit your airflow. Many people turn to topical nasal steroids (nose spray) to treat their allergies, not realizing that the swollen tissues in the nose may actually stop the spray from getting into their body. 3. Nasal polyps. A nasal polyp is a small clump of cells that has grown inside your nose. Polyps can cause nasal obstruction, with symptoms that can include congestion, facial pain or pressure, headache, and a reduced sense of smell. 4. Adenoid enlargement. This is a very common condition in children that can completely obstruct nasal breathing. The adenoids sit in the very back of the nose and typically shrink after age 5. Adenoids, like tonsils, are part of our immune system and provide little benefit after age 2. In addition to breathing obstruction, enlarged adenoids can also lead to chronic middle ear infections and chronic sinusitis in children. 9

11 5. Vasomotor rhinitis (VMR). VMR is diagnosed when you suffer the congestion symptoms of allergies without being allergic to something. Perhaps the most challenging cause of nasal obstruction, VMR occurs when intermittent, excessive blood flow causes congestion on one side or in one part of the nose. With VMR, you may have clear breathing from time to time throughout the day, and your symptoms will almost always alternate from one side of your nose to the other. The symptoms of VMR are often worse when you are lying down. It is also possible to have more than one reason for nasal congestion. For example, you could have both allergies and a nasal polyp working together to obstruct your breathing. The most common causes of nasal obstruction differ between adults and children, too. In adults they are, in order of decreasing frequency: anatomic deformities, allergies, VMR, nasal polyps, and enlarged adenoids. In children, on the other hand, the order would be: enlarged adenoids, anatomic deformities, allergies, VMR, and nasal polyps. Regardless of the cause (or causes), however, nasal obstruction in adults and children leads to major changes in the body that can have serious health consequences. Large obstructing tonsils Large obstructing adenoids 10

12 The Link Between Nasal Breathing & Dentistry You may be surprised to learn that the most likely person to diagnose a child with Sleep Disordered Breathing is their dentist or orthodontist. This is directly related to the fact that nasal breathing has a tremendous impact on development of our facial bone structure, which in turn determines how our teeth fit in our mouth and how our jaws open and close. Over 90% of children with crooked teeth, signs of teeth grinding, or poor jaw alignment (called malocclusion) also have compromised nasal breathing. This important medical fact was first proven in the 1970s by a Norwegian orthodontist named Dr. Egil Harvold. Dr. Harvold noticed that many of his patients with these dental issues had nasal problems and were often mouth breathers. This observation prompted him to undertake a study, which he presented in In this study, Dr. Harvold took two groups of baby monkeys and secured silicone plugs into the noses of half of them. This forced those monkeys to breathe through their mouths. This in turn led to many changes in the way their facial skeleton grew compared to the monkeys who kept breathing through their noses. FAR LEFT: Healthy young rhesus monkey. MIDDLE LEFT: Monkey wearing nasal plugs. MIDDLE RIGHT & FAR RIGHT: Young rhesus monkey with adenoid facies after nasal blockage. 11

13 Facial changes in mouth-breathing young male Facial changes in mouth-breathing young female After only a few months, severe changes developed in the jaw growth of the mouthbreathing monkeys. Their upper jaws got narrower. The roof of their mouths developed a high arch. Their lower jaws grew longer, rotated downward, and stopped aligning well with the upper jaw. In addition, the obstructed nostrils forced the facial 12

14 muscles of these monkeys to work differently, which further pulled the lower jaw out of position. Overall, the monkeys with blocked noses developed narrow faces and elongated jaws, a development that is known today as adenoid facies in children. When this occurs in a child with obstructed nasal breathing, their narrow upper jaw won t have enough space for all their adult teeth. This causes the teeth to crowd and grow in crookedly. While braces can straighten crooked teeth, they cannot fix the forces that caused the crooked teeth in the first place. This is why orthodontic patients must wear a retainer for the rest of their lives after their braces come off. Without the retainer, those same out-of-balance forces will push the teeth back out of alignment. Adults and teens frequently require a second and sometimes a third set of braces for this exact reason. On the other hand, when the origin of the problem (nasal obstruction) is diagnosed and corrected, the need for braces and retainers can be reduced and sometimes even eliminated altogether. Facial and dental changes in a young female 13

15 Reversing ADD/ADHD & Behavioral Issues in Children It is also known, and with increasing evidence, that approximately 50% of children who suffer from Sleep Disordered Breathing develop the symptoms of ADD or ADHD as a type of behavioral and/or learning disability. In truth, these children don t actually have ADD or ADHD; instead, the constant exposure to adrenaline during sleep causes the same symptoms, which can commonly lead to their being misdiagnosed. Adrenaline is a chemical produced by the body to combat an obstructed airway by stimulating breathing. When a child is repeatedly exposed to this stimulating chemical during sleep, they remain overly stimulated during the day and therefore cannot focus or concentrate like other kids. (In adults, this 14

16 same phenomenon can lead to hypertension, heart attacks, strokes, fatigue, and more.) If a child snores by the age of 8, there is an 80% chance the child will have a permanent 20% reduction in mental capacity. If they are diagnosed with Sleep Disordered Breathing in the first 5 years of life, they are 60% more likely to require special needs education by age 8. In these cases, the cognitive impairment may not be reversible. Unfortunately, the clinicians diagnosing these children and offering treatment are rarely considering nasal obstruction as a cause. In addition, these clinicians are unaware that this condition is likely reversible in these children without the need for medications or therapy. Our group is currently investigating the reversibility of ADD and ADHD symptoms in these children, and the early results show a significant ability to reverse the condition by providing normal nasal breathing and proper sleep. While the results of this study are not yet complete, we are extremely encouraged by our findings so far. A significant number of children have shown positive behavior changes after they reversed their mouth breathing tendencies and began to receive quality sleep. We are also currently reviewing our data to identify whether a child s age, gender, or severity of behavior symptoms will affect their degree of improvement. The ability to reverse or reduce the effects of ADD/ADHD in children is a major breakthrough with profound long-term implications for quality of life. To the astonishment of their parents and teachers, even children with mild autism, anxiety, or aggression have become highly functioning students after undergoing airway correction. 15

17 The Role of Head Posturing Another way that children and adults compensate for their nasal obstruction is to hold their head further forward. For optimal mouth breathing, the oral airway needs to be aligned with the trachea. This helps to produce a chin-up, extended head position. Many children will sleep in an extended head position for this reason. During the day, however, a child needs to drop their head forward in order to breathe easily through the mouth. Since the child can t see with their head in this position, they must compensate by lifting their head up and forward. This position, called forward head posturing, allows the child to see and mouth breathe at the same time. Unfortunately, additional physical problems can arise from forward head posturing. Holding the head in this position puts significant stress on the neck Sleeping child with open-mouth breathing and extended neck posture 16

18 and back muscles, leading to pain in the spine, neck, and/or lower back. Poor cervical spine alignment can also result, which can lead in turn to nerve root compression and mal-alignment of the lower spine. Thus, once the first domino falls, it is uncertain which will be the last domino to fall. Will forward head posturing affect cervical spine position alone, or will it result in lower back problems, gait issues, neck pain, a poor sense of balance, or more? The image on the left shows a young boy whose spine was curving badly due to forward head posturing. The image on the right was taken only 6 months after treatment. It shows the significant improvement to the boy s posture and spinal alignment. 17

19 What Are Your Treatment Options for Sleep Disordered Breathing? The Benefits of Palatal Expansion In the past, orthodontists would extract adult teeth to make room in a patient s mouth, and then they would use braces to straighten the remaining teeth. However, this treatment is now largely abandoned in place of what is called palatal expansion. By placing an oral device onto the teeth, orthodontists can enlarge the nasal cavity by separating the palatal bones within just a few weeks. Narrow and high vs. normal palatal arch The palatal expansion process is completely painless, because it is performed slowly and gently. It helps to widen a child s restricted jaw space, making room for all the teeth without extractions. Because palatal expansion also widens the nasal cavity, it helps to promote proper nasal breathing. It is important to treat children at an early age, because 60% of their facial growth occurs by age 4, 70% by age 5, and 90% by age 12. When a child is treated early enough, their nasal airflow can be increased by as much as 100%! The same can be done with 18

20 adults, although not as easily, because the palatal bone may have become fused. In short, a palatal expander does more than expand your child s jaw naturally and painlessly. It also helps your child s nasal airway to open, thus improving their ability to breathe through their nose. Today, palatal expansion in Palatal expanders children with Sleep Disordered Breathing and dental misalignment has become standard as the first step in modern orthodontic care. Wearing headgear or other dental devices designed to correct these orthodontic problems is actually counter-productive, because these devices constrict the upper jaw and inhibit its ability to expand and grow forward. What About Tonsils & Adenoids? In the 1980s, it was also discovered that enlarged tonsils and adenoids were responsible for Sleep Disordered Breathing, and at that time, it was considered the primary cause. Because of this, many children underwent removal of their tonsils and adenoids (T&A) with the hopes of correcting the symptoms of Sleep Disordered Breathing. Did we finally have a cure for Sleep Disordered Breathing in children? The answer is yes and no. Follow-up studies showed that while 33% of children 19

21 recovered from their Sleep Disordered Breathing, 67% of the children relapsed within two years of their surgery and began to suffer from SDB again. What went wrong? Unfortunately, this situation arose because the medical and dental communities weren t sharing their knowledge. The medical field knew about tonsil and adenoid issues, while the dental community had discovered the importance of nasal breathing for facial development. Because this information wasn t merged and looked at together, the larger picture was missed. Ultimately, removing one s adenoids and tonsils can improve nasal breathing in certain patients. However, if we ignore problems within the nose itself, we cannot expect better outcomes for all who are affected. Therefore, correcting nasal airflow often requires much more than removing one s adenoids. This fact, which was lost for years among medical specialists, is now coming back to light. What is the takeaway of these discoveries? It s that while removal of tonsils and adenoids may be appropriate in certain children, we must first consider whether other factors could also be blocking healthy nasal breathing. Only when all the information about a child s breathing is understood can the best course of treatment be chosen. Correcting Nasal Obstruction with MIST Previously, nasal surgery alone had been shown ineffective in correcting OSA. The cure rates were below 17%, and therefore surgery was primarily used to improve one s 20

22 tolerance of CPAP. This has led sleep surgeons to pursue more aggressive and invasive procedures such as palatoplasty (UPPP), jaw advancement surgery, hyoid bone suspension, and robotic excision of the base of the tongue. These options are far from the minimally invasive goals of contemporary surgical practice. In recent years, however, we have acquired significant experience in improving the nasal airway in adults via a minimally invasive surgical procedure called MIST (minimally invasive sinus technique). MIST was originally introduced in the mid-1990s by Dr. Reuben Setliff, a superb surgeon with exceptional skills and intellect. His minimally invasive concepts have revolutionized nasal surgery and proven that less is often more when it comes to surgery in the nose. His techniques and philosophies have been validated in adults and children, and they have provided a safe and effective platform upon which we continue to build today. The MIST procedure takes about 1 hour to complete by an experienced surgeon. It allows patients to return home two hours after surgery, and they can then be back to work or school in one day. MIST does not leave any visible signs of surgery There are no incisions or scars, no nasal packing, no splints, and no sutures. Any discomfort from the procedure is minimal. Since 2002, we have continued to modify the MIST procedure based on the critical review of outcomes and feedback from our patients. Based on these collective advances, we now have the first reported results demonstrating that our minimally invasive nasal surgery, used alone as the sole intervention, can cure Obstructive Sleep Apnea (OSA) in 48.7% of adults, regardless of the severity of their apnea, body mass index (weight), and gender. An additional 43% showed improvement in their apnea, although they were not cured. 21

23 Computer-generated image of normal nasal airflow Pre (left) and Post (right) treatment 3D icat CT images of an adult male after nasal surgery alone. Notice the significant improvement in minimum cross-sectional area (56 sq mm to 118 sq mm) and throat volume (7.2 cubic cm to 19.3 cubic cm). 22

24 New Data Supports Our Story Since 2015, we have applied our minimally invasive principles to children with Obstructive Sleep Apnea and Sleep Disordered Breathing, and we continue to receive tremendous feedback from the children and their parents. With the use of a 3-dimensional CT imaging program, we have begun to measure the actual airway changes responsible for the subjective improvement in these children. We have found that both minimal throat area (a 2-dimensional measurement akin to the shape of a coin) and volume (a 3-dimensional space akin to an object like a walnut) have both increased an average of 46%, with every child studied showing improvement. We have also just completed another study measuring the volume changes in the nasal airway that occur after our modified MIST procedure, and the average child saw an increase in nasal volume of 42%. In other words, the average child s nasal airflow increased over 200%! 23

25 These ground-breaking results demonstrate that for the first time in medical history, we now can accurately do all the following Identify adults and children with Obstructive Sleep Apnea and Sleep Disordered Breathing, Pinpoint the cause of their compromised nasal breathing, Appreciate the breadth and variation in their symptoms, Implement an effective treatment strategy that combines palatal expansion with minimally invasive nasal surgery, and T&A in selective individuals. This perfect storm of understanding the science, appreciating unique differences among our patients, creating and adopting technical innovations, and fostering peer-to-peer learning between disciplines, has given us the unique ability to confront and treat the epidemics that are Obstructive Sleep Apnea and Sleep Disordered Breathing. We can finally improve the quality of life for most who suffer from these disorders. Our work is just beginning, but we are confident we have broken the code on a condition that afflicts millions of people worldwide, a condition that is responsible for a huge healthcare burden for society. With continued perseverance, we believe that burden can finally be lifted. 24

26 About Dr. Bill Martin of Martin Orthodontics & Martin Kids Dental Speaker, teacher, author, and orthodontic specialist Dr. Bill Martin has created over 30,000 beautiful smiles in children and adults since founding Martin Orthodontics in Dr. Martin has devoted his life to the health and well-being of children, and he puts his significant scientific and medical expertise to work in this regard. In 2013, Dr. Martin also founded Martin Kids Dental Health Team to provide comprehensive dental and orthodontic care for children in the Gainesville, Florida, area. Thanks to his unique expertise in childhood airway development, Dr. Martin regularly provides critical guidance and education to parents, helping them to transform their children into peak performers in school and at play. In so doing, Dr. Martin has cultivated an outstanding reputation in the Gainesville, Florida, area for his skillful and honest approach to children s health through orthodontic and dental medicine. Today, Dr. Martin stands as a pioneer in Airway Orthodontics, a revolutionary sub-specialty of orthodontic medicine. Airway Orthodontics follows an interdisciplinary approach to combating sleep breathing disorders, especially in children. Dr. Martin s notable expertise in Airway Orthodontics stems in part from his willingness to study and gain experience beyond the boundaries of the traditional orthodontic profession. In particular, Dr. Martin specializes in children s dentistry, breathing disorders, sleep disorders, and overall physical and cognitive growth in children. A firm believer in continuing education, Dr. Martin regularly supplements his medical knowledge both in and beyond the field of orthodontics. He achieves 25

27 this through numerous professional memberships, conferences, and continuing medical education courses. Dr. Martin is a current member of the American Association of Orthodontists, the Southern Association of Orthodontists, the Florida Association of Orthodontists, the American Dental Association, the Florida Dental Association, the Alachua County Dental Society, the American Academy of Pediatric Dentistry, the American Association of Sleep Medicine, and the American Association of Dental Sleep Medicine. About Dr. Peter Catalano of Breathe Easy Nasal, Sinus & Sleep Center of MA Peter Catalano, MD, FACS, FARS graduated with a BS from Columbia University School of Engineering, followed by an MD degree from The Mount Sinai School of Medicine (MSH) in New York City. He completed his Residency at MSH and became a full-time faculty member ( ), where he became an Associate Professor of Otolaryngology, Neurosurgery, and Maxillofacial Surgery. He then became Chair of Otolaryngology at the Lahey Clinic ( ), followed by Chair of Surgery and VP of Surgical Services at Caritas/Steward Health Care ( ). Dr. Catalano is now Chief of Otolaryngology at SEMC, Professor of Otolaryngology at Tufts University, Director of Rhinology fellowship (SEMC), and Medical Director of Research for Steward. He remains academically active, with over 287 invited lectures, 24 book chapters, and 90 peer-reviewed publications, and he is currently a member of the editorial board of 7 medical journals and the editor of 1 journal. Dr. Catalano is President and Founder of the Foundation for Innovation, Education and Research in Otolaryngology (2011 present), and organizer of two annual medical conferences, Open Forum and ENT Summit. 26

28 *The absolutely kindest, most fabulous staff out there!! The clinical side knows just how to make the patient feel comfortable and at ease, and the office staff is on top of things and stays familiar with the parents... a true family atmosphere!! Love them!! -H. Lambert *Awesome place with an awesome staff! They truly do love the kids and treat them like royalty! Our son, Trey, loves going there! Highly recommend them for all your kid s Dental and Orthopedic needs! We drive almost an hour 1 way to get there so that should tell you how great they are! -Suzanne T. *Love this team! They re the best and they make it so easy and fun for the kids and they love to go [to] the Dentist! My son Joshua has been in braces for a little over a year and looks forward to every visit! My youngest son can t wait till it s his turn to get his braces! Dr. Martin is truly a wonderful man, he s involved and gives so much back to the community!! -Amy G. *The reviews on this page are from actual patients of Martin Kids Dental. Individual results may vary. Reviews are not claimed to represent results for everyone. Dr. Bill Martin Martin Orthodontics & Martin Kids Dental W Newberry Rd #100, Jonesville, FL Dr. Peter Catalano Breathe Easy Nasal, Sinus and Sleep Center of MA 119 Mass Ave, Lunenburg, MA