March 12, 2019
by Janice Goodman DDS, MS Oral Medicine and Orofacial Pain; Mark Webb, BSc
As humans, we are obligate nasal breathers but mouth breathing has become prevalent and almost the norm. The dentist can play an important role in reversing this trend by both diagnosing and treating.
Mouth breathing has been considered a factor in Sleep Disordered Breathing (SDB) especially in children. It may be present from a combination of obstruction and habituation and it can lead to both skeletal and muscle facial imbalances. Mouth breathing in children has been correlated with day time sleepiness (DTS) and DTS has been further correlated to ten times the risk of learning difficulties. Rhinitis, maternal smoking, and positive allergic skin tests were significantly associated with habitual snoring and mouth breathing. Pacheco et Al took a group of 687 healthy children with no complaints of poor quality of life. In the group he found that 24% were mouth breathers, 32% had severely hypertrophic tonsils,18% had Malampatis of III or IV,26% had excessive overbites, 17.7% had excessive DTS, 32.2% often sneezed, 32.3% had a stuffy nose, 19.6% snored, 9.4% reported feeling they stopped breathing while sleeping.
A delay in diagnosis and treatment of habitual mouth breathing could prolong and exacerbate morbidity. If dealt with earlier, we may be able to prevent pathologies and have more effective results. In this article, we will look at some of the possible reasons there is more mouth breathing and the how and why dentists can help, including some more novel suggestions.
1. Habitual mouth breathing. This could be multifactorial. For example, if a baby didn’t nurse properly or for long enough, that could contribute to an underdeveloped nasal airway; perhaps there was a bad cold and stuffiness and the person never converted back to nasal breathing naturally after an extended period of mouth breathing. A child learns many things at a young age by “mirroring” their caretakers and if the parents are also mouth breathers, it might appear to the child as the correct way to breath and they adopt the habit.
2. Smaller mouths make the tongue relatively larger in a more constricted space. This could be from our diets, as demonstrated years ago by Dr. Weston Price, iatrogenically by retractive prophylactic extractions, head gear, retractive orthodontics; or simply because the tongue sits low in the mouth instead of the palate and cannot act as the architect of the palate in such circumstances. In these cases, tell-tale signs are high arched and narrow palates, scalloped tongues, crowded and worn teeth. Although controversial at this point in time; tethered frenums such as tongue and buccal ties might be involved. Obese patients can have fatter tongues as well as genetic conditions, causing structural obstructions to the airway.
3. Many people have a chronic rhinitis and they have sensitized noses. They are more sensitive to weather changes, certain chemicals, scents and odours. This is the nervous system being on high alert and it is not an allergic response. There are new fairly simple ENT treatments to literally freeze the nerve involved which resolves many of these issues. It should be noted that these patients generally have poorer sleep and increased cortisol and stress levels.
4. Compromised structural issues in the nose including swollen turbinates, flimsy nostrils and deviated septum. If the nostrils “cave in as you inhale”, a referral to an ENT might be in order to check these things out. A new procedure to place a resorbable material in the lateral nasal walls can sometimes be reinforcing and is now available.
5. Infections and allergies will cause the nasal turbinates to swell up and the increased mucous production may not be able to drain. Tonsils and adenoids are in this category. In children, the tonsils are further aggravated by mouth breathing by both the lack of Nitric Oxide production to kill the bad guys and also the aggravation from dryness which can cause inflammation. In adults, the tonsils are full of actinomycosis and it is very difficult to fully eradicate this with antibiotics. (Dr. Catalano, ENT, Tufts University).
6. A congested nose can cause the soft palate and tongue to collapse during deep sleep due to muscle relaxation, this leads to more stomach acid being suctioned up to the throat and that irritation further leads to chronic swelling. That is the viscous cycle of GERD and sleep disordered breathing.
7. Diet and vitamins, including the pro hormone vitamin D., which affects teeth, brain, gut, skin, pancreas, bones, sleep and more. It has been suggested to not eat anything for three hours prior to going to bed to avoid GERD causing swelling and inflammation in the nose and oropharynx. Cessation of alcohol many hours before going to sleep also, as alcohol both irritates the stomach as well as relaxes the muscles of the oropharynx and exacerbates sleep disordered breathing (SDB).This topic is too large to be covered in this article but is very important and the dentist should have a good understanding. (Suggestions for patient resources to learn more about sleep and diet: are the book “The Dental Diet” by Dr. Steven Lin or consult the “RightSleep” Program at drgominak.com).
1. Your nose makes about two pints of mucous a day (Dr. Steven Parks) If the mucous is not draining properly it can lead to ear, and sinus infections as well as halitosis.
2. Nitric Oxide is largely produced by the paranasal sinus when you exhale from your nose. Nitric oxide does many things in the body which you will miss by mouth breathing, but specifically in the nose it is deadly for bacteria, viruses, yeasts, fungi and when inhaled into the lungs, will increase the oxygen deposition into body tissues by 10-25%.
3. Aspiration of oral bacteria can lead to serious medical conditions which include pneumonia.
4. Nasal airflow affects brain activity. It has also been demonstrated that asymmetric nasal breathing leads to asymmetric cerebral cortexes. In fact, Price and Eccles suggested that unilateral forced breathing exercises as often practiced in Yoga and Ayurvedic medicine could have an effect on sleep arousal, frequency, duration, right or left handedness, lateralization disorders such as schizophrenia and autism, although this remains controversial. The little hairs in the nasal airway are very sensitive and alert the brain if they are not feeling air pass over them.
5. Nervous system. Your nose is exquisitely connected to your brain and nervous system and affects to your lungs and heart and in fact the running of most of your body, including your autonomic nervous system.
6. Smell. Smell and taste buds are very much related. If your sense of smell turns off you can bet there will be an alteration in taste too. These can lead to decreases in quality of life, depression, appetite and weight issues.
7. Snoring. Although snoring can be benign, in a large percentage of snorers there is an aggravated lack of support of the oropharynx and upper airway resistance syndrome (UARS), as well as Obstructive Sleep Apnoea (OSA) may be present.
1. Many of the problems we as dentists treat, including basic cavities, periodontal disease, orthodontics, oral surgical issues are caused or exacerbated by mouth breathing and if one repairs the damage without addressing the underlying cause, they are likely going to see recurrent issues. If an orthodontist closes an open bite without looking after the tongue thrust, which came with the mouth breathing, the open bite is likely to return, even when we use fixed lingual wire retainers. If a dentist restores a carious lesion, chances of a recurrence or failure of the restoration increases if the mouth breathing was part of the etiology of the decay. The airway will always win when challenged or compromised.
2. There are several issues with mouth breathing that may only be addressed by a dentist such as palatal expansion, vertical oral dimension, and mandibular repositioning appliances.
3. Dentistry has begun to embrace in-office orofacial myofunctional therapy as a possible technique to correct some of these problems via neuromuscular reconditioning/re-education.
4. Dentists generally see their patients on a regular basis and are focused on looking at intraoral signs that a physician may not appreciate as well. These include high narrow arches, crowding, high malampatis, scalloped tongues, tongue thrust swallows, enlarged tonsils, open bites, TMJ issues.
5. Dentists will be able to help their patients reduce dental disease as well as more holistic health issues by assisting in converting their patients to nasal breathing.
1. Commit to understanding more about the airway so that you can better help your patients. There are so many avenues available these days. Patients can be recommended to read books and articles or check out YouTube videos. Some resources are “Close Your Mouth” by Patrick McKeown, “Gasp” by Drs. Michael Gelb and Howard Hindin, one of the YouTube videos we use is at: Airway and TMJ English
2. Since each situation is unique, a careful history and comprehensive exam are in order in order to determine what direction to take. Sometimes specialized radiographs or diagnostic tools can be helpful in sleuthing out the cause and location of the obstruction. A CBCT radiograph could be useful, an ambulatory or PSG sleep test may also be in order. The treatment must be related to the pathology. Treating these patients is bespoke and done on an individual basis.
3. Mouth breathing and its correction is often multifactorial so to start with have a team that you can work with or refer to. This may include ENT specialists, Oral surgeons, orthodontists, orofacial myofunctional therapists, sleep physicians, sleep dentists, respirologists, oral medicine specialist, radiologists, osteopaths, Buteyko and other breathing specialists, naturopaths +++. It will vary depending on your studies and beliefs. There is more than one path to successfully convertion to nasal breathing. Each person will respond differently.
4. Be vigilant – you can truly change a person’s quality of life and health simply by reminding them on a regular basis to CLOSE THEIR MOUTHS. Just by checking for issues like allergens, such as pets and reinforcing the harm that they might be causing might help someone.
5. We are including in this article some novel/alternative ideas and complementary methods that we have used to assist patients in clearing their noses and reducing mouth breathing. The ENT/surgical/medical solutions are beyond the scope of this article and we are assuming that the dentist uses our techniques as alternative medical suggestions.
1. Most obvious is the suggestion to blow/clear/clean the nasal passages frequently and making one consciously aware of the problem.
2. If a patient is able to nasal breath, they must understand that they have to exercise their noses! Nasal clearing/breathing exercises such as alternate nasal nostril breathing and Buteyko nasal clearing methods. Regular exercise of all types helps and can be done frequently throughout the day. Taping the lips using micropore paper tape can be effective.
3. Nasal dilators: Extra Nasal: Nasal dilator strips (e.g. Breathe-Rite); IntraNasal internal dilators (e.g. Mute, Nozovent, Breathwitheez, Nasal cones).
4. Nasal saline sprays with and without essential oils. There are several varieties of this including mists, sprays, Waterpik has something, Neti-pot. You can make a homemade variety with one cup of warm water and 1/2 teaspoon of sea salt with a pinch of baking soda. The saline is a mild decongestant and in addition if you use the full flow instead of mist you will get better results as you can clear out the mucous, allergens, fungus that hides on the posterior 90 degree turn area. I use the technique that I was taught by Lois Laynee (Restoringbreathing.com): Breath in while holding one nostril shut and inject the saline solution while inhaling until you have to swallow. This technique works well but be warned that there is often a rebound effect after chronic use of irrigation and you might actually induce nasal congestion.
5. The dentist can make one of many mandibular anterior positioning devices ( NLA’s, MAD’s, many options) which can be invaluable to convert mouth breathing to nasal breathing and being supportive in converting to a normal swallow and correct tongue position. An appliance that creates a stable, balanced, non-deflective stop will encourage the tongue to be drawn up and anteriorly to “the spot”, allowing for a better airway and proper function. The dentist can control the vertical dimension, allowing more space in the mouth for the tongue. Pads can also be strategically placed to lift the tongue out of the floor of the mouth.
6. Aromatic Solutions. Within the vast array of essential oils and other aromatics such as CO2 extracts there are some that are more suitable for respiratory and oral care than others. For inhalation blends creating a pleasing aroma is the primary objective after the therapeutic functionality is addressed. For oral dose forms, such as aromatic honeys, mouth gargles and the like, taste takes priority to aroma and plays a key role in patient compliance – if it doesn’t taste pleasant then people won’t use it.
Top Ten (10) Respiratory Aromatics:
6A. Aromatic Honey. Adding aromatics to honey for use against upper respiratory tract infections and irritations is an easy and safe way to venture into this, using aromatics for these conditions.
Aromatic Honey Blend
6B. Aromatic Inhalations. There are many inhalation dose forms and application methods available to use with aromatics to address upper airway conditions.
Aromatics that open the air-way and reduce irritation and inflammation include:
1,8–Cineole rich aromatics – The majority of Eucalyptus species, Niaouli, Rosemary CT Cineole.
Ketone rich aromatics – Peppermint Gum, Peppermint, Spearmint, Caraway, Dill, Rosemary CT camphor & verbenone.
Lemon-scented oils – Lemon Myrtle, Lemongrass, Melissa, Lemon Tea tree.
Wood Oils – Atlas, Texan & Virginian Cedarwood’s, Australian & Indian Sandalwood, Desert Rosewood (Buddawood).
7. Orofacial Myofunctional Therapy. Several organizations exist to help you locate trained practitioners who are adept at neuromuscular reconditioning to convert to nasal breathing, lips together, teeth apart and tongue up resting tongue posture. Orofacial Myofunctional therapist listings can be found at myofunctional-therapist.com.
8. Palatal expansion techniques which do not crowd the tongue and encourage nasal breathing such as ALF orthodontics (Alftherapy.com) vs. rapid palatal expansion in conjunction with myofunctional therapy/osteopathy.
9. Natural, herbal and homeopathic remedies are out there. Over the counter products such as colloidal silver nasal spray or White flower may give short term nasal relief.
The informed dentist can help their patients at all ages by diagnosing and treating pathological mouth breathing habits. By educating patients about the condition and presenting bespoke options for solutions they can increase quality of life and health. OH
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About the Author
Janice Goodman DDS, MSc. Janice completed her Masters of Oral Medicine and Orofacial Pain from USC in 2015. She has a general dentistry practice in Toronto with special interest in functional and sleep dental medicine. She serves as a member of the editorial board at Oral Health Dental Journal since 2000. Janice can be reached at firstname.lastname@example.org
Mark Webb BSc is the author of “Bush Sense – Australian Essential Oils and Aromatic Compounds” He is a world leader in aromatic formulation chemistry and consults and lectures Internationally. Mark is actively involved in the formulation of new products to promote oral health. He resides in Australia and can be reached at: email@example.com