Airway & Breathing

Reviewed By: Pat Pine, RDH, COM™

Date: June 23, 2019

Breathing

It matters how air gets into our lungs. The nose is designed for breathing, our mouths for eating/talking. Nasal breathing provides warm, filtered, moist air to our lungs, in an appropriate volume. In addition, nasal breathing incorporates nitric oxide (NO) into our breath, as NO is produced in the paranasal sinuses. Nitric oxide is a vasodilator and important for oxygen exchange.

Sleep-Related Breathing Disorders (SRBD) are often found in individuals that may be nose breathers during the day but have a compromised airway at night. The airway may collapse at night for a number of reasons. As RDH’s we are in a prime position to identify patients who are either mouth breathing day and night, or just at night. While it is not in our scope of practice to treat these conditions, it is important to recognize them and refer the patient for treatment.

Sleep-Related Breathing Disorders include: Snoring, Upper Airway Resistance Syndrome (UARS), and Sleep Apnea. Sleep apnea if further divided into central sleep apnea/hypopnea syndrome (CSAHS) or obstructive sleep apnea/hypopnea syndrome (OSAHS or OSA).

In 2017, the ADA wrote a policy statement regarding Sleep-Related Breathing Disorders. If a breathing problem is suspected, the patient should be referred to the Medical Doctor for evaluation and diagnosis. Dental oral appliances designed to improve airway may be a good alternative treatment, if the patient cannot tolerate a CPAP machine, with better compliance. You can find and read the policy here.

Some of the newer smart watches are able to monitor sleeping patterns. This may be an option to help make the patient aware of a Sleep Disordered Breathing Disorder.

It is important to recognize airway concerns via a valuable questionnaire/interview, which may help the patient recognize the airway problems, and be more receptive to a referral for assessment/treatment.

Professional members who may be on your Airway team:

Certified Orofacial Myologist (COM™): Provides Myofunctional Therapy to retrain  via neuromuscular re-education so the tongue and brain can work together and toning the tongue and facial muscles to eliminate tongue thrusts and other poor oral habits.

Orthodontist: May help expand the palate (sometimes as early as 3-4 years old) to create a larger airway. It will need to be an orthodontist who is aware of airway issues.

Ear, Nose & Throat MD (ENT): Assess/remove Adenoids/tonsils. Not all ENT’s recognize/treat an obstructed airway.

Primary Care Physician: Prescribe testing and diagnose Sleep-Related Breathing Disorders.

Pediatrician: May prescribe testing and diagnose Sleep-Related Breathing Disorders.

Dentist: When trained for Airway problems, a DDS may fabricate a  customized oral appliance when prescribed by a MD, after a sleep test.

Chiropractor or Craniosacral Therapist: Gently manipulates structures of the head and neck to relieve pressure and facilitate new movement.

Oral Signs & Symptoms of Airway Problems

  • Anterior gingivitis
  • Linea alba
  • Grinding
  • Scalloped tongue
  • Patient reports snoring
  • Premolar extraction (less room in mouth for tongue, so it falls back into throat during sleep)

How does mouth breathing affect our occlusion?

Can’t breath through your nose?

Then you can’t keep your lips closed.

Your tongue compensates and therefore doesn’t rest properly on your palate.*

Improper tongue positioning prevents you from swallowing correctly.

Soft tissue dysfunction develops from improper swallowing.

 The tongue and cheeks are the best retainer we have, if they are improperly positioned, our teeth cannot stay in proper position!

So, can your patient breath through his/her nose? Continue reading for the most common reasons for mouth breathing, and some possible solutions.

 

*Where should the tongue naturally rest?

Say the word “dad” a few times. (“dad, dad, dad”) Pay attention to where your tongue is when you say the “d” sound in dad. That is where your tongue should rest naturally. Just behind your incisive papilla. This is referred to as “the Spot.”

How do I assess the Airway?

Mallampati Scoring is a common way to assess how much of the airway is visible.

Class 1: The tonsil pillars, soft palate and uvula are all visible
Class 2: Tonsil pillars, soft palate and the upper portion of the uvula
Class 3: Base of the uvula and soft palate
Class 4:  Only the hard palate

For more information, check out www.sleepmedicineboardreview.wordpress.com

TONGUE TIE

There are a variety of signs/symptoms that may indicate a tongue/lip tie. They may be different through the ages, but there is some overlap.

If you suspect tongue tie and do not have an airway team to diagnose/treat, a great place to start is to refer to a Certified Orofacial Myologist (COM™). Find one in your area on the International Association of Orofacial Myology website.

Baby

0-12 Months

 POSSIBLE SYMPTOMS

Difficulty breastfeeding (latching, clicking, inability to fully drain breast, dribbling milk during feeding, etc), Failure to thrive, Gassiness/colic/reflux.

Mom may experience symptoms related to breastfeeding: pain, clogged ducts, frequent nighttime feedings, depression.

Ages 1-6

POSSIBLE SYMPTOMS

Tongue cannot reach palate (when mouth is open, tongue should touch the hard palate and be able to slide back to the soft palate), Open mouth breathing, Frequent ear infections, Snoring, Frequent gagging, Diastema, Sinus infections, and more!

Ages 7-13

POSSIBLE SYMPTOMS

Open mouth breathing, Chewing disorders, Malocclusion, Allergies, Snoring/sleep apnea, Migraines/headaches, Compromised airway, Tongue thrust, and More!

Ages 14-Adult

POSSIBLE SYMPTOMS

Tongue thrusting, ADD/ADHD characteristics, Enlarged tonsils/adenoids, High palate/narrow arches, Malocclusion, Strong gag reflex, Crossbite/crowding, Restricted Maxilla/high palate, Tongue scalloping, Lisps, Allergic shiners, Forward head posture, Abnormal breathing, Eustachian tube dysfunction/tinnitus, and More!

Common Causes of Mouth Breathing

NASAL BLOCKAGE

(allergies, polyps, swollen tissue, deviated septum)

 POSSIBLE SOLUTIONS

Breath Right strips
Nasal saline irrigation
MFT referral
ENT Referral
ENT Probiotics
Decongestants (may cause dry mouth)

ENLARGED TONSILS OR ADENOIDS

POSSIBLE SOLUTIONS

ENT referral

IMPROPER POSITIONING OF MANDIBLE & TONGUE

POSSIBLE SOLUTIONS

MFT referral
Orthodontic referral
Occlusal guard
MyoBrace®
Healthy Start™

UNDERDEVELOPED NASAL PASSAGES

POSSIBLE SOLUTIONS

MFT referral
ENT Ref

Sleep Disordered Breathing in Kids

SYMPTOMS: ADD/ADHD symptoms, bedwetting, allergies, asthma, eczema, poor school performance, frequent nightmares​, snoring, stunted growth

ORAL SIGNS: Wear from grinding, cross bite, large tonsils, and more.

Upper Airway Resistance Syndrome

SYMPTOMS: Low blood pressure, fatigue, headaches, night time waking to urinate, cold hands, digestive issues (constipation or diarrhea). Often in skinny women who do not fit the profile for sleep apnea.

ORAL SIGNS: Wear from grinding, large tongue, premolar extraction, linea alba, scalloped tongue, and more.

Sleep Apnea

SYMPTOMS: Overweight (a risk factor or OSA), hypertension, stroke, atrial fibrillation, congestive heart failure, and many other adverse conditions including increased mortality.

ORAL SIGNS: Wear from grinding, large tongue, premolar extraction, linea alba, scalloped tongue, and more.

Current Research, Controversies, and Trends in Treatment

Premolar Extraction: What role does it play in SRBD?

Orthodontists: What age should a child be assessed? Some DDS’s wait until primary dentition is gone, others start around age 7. Addressing facial skeletal growth may be best around age 4 (or when symptoms begin to appear).

Many ENT’s are hesitant to remove tonsils/adenoids

Dentists and sleep medicine; many states are currently determining Dentist’s scope of practice in regard to treating SRBD.

If the tongue is tied, it may fall back and block the airway. Is there a relationship between SIDS and tongue tie? (Dr Ghaheri, MD, ENT is researching)

Certified Orofacial Myologist (COM™), Myofunctional Therapist; currently no states have laws regarding certification/licensing. The International Association of Orofacial Myology is trying to standardize the certification process and become a recognized entity by the states. Currently anyone can take any class that teaches Orofacial Myology, and practice anywhere. The IAOM’s goal is to allow only Dental Hygienists (and a few other medical specialties) apply for the training, and following specific testing, confer the title of Certified Orofacial Myologist.

 

Here are the three Organizations that provide training and certification

Coulson Institute

International Association of Orofacial Myology (IAOM)

Academy of Orafacial Myofunctional Therapy (AOMT)

Want to learn more?

Podcast // Breathe Better, Sleep Better, Live Better, by Steven Y Park, MD

Website // www.doctorstevenpark.com

Website // www.sleepmedicinereviewboard.wordpress.com

Book // “ Please Release Me. The Tethered Oral Tissue (TOT) Puzzle” By Patricia Pine, RDH, COM™