About this transcript:
Dr. Barnhart was recently interviewed for an academic research paper on the prevalence, health ramifications and treatment of airway issues in children and adults. The full transcript of the interview has been added below and summarizes some of Dr. Barnhart’s observations about airway problems she frequently sees in patients as a practicing dentist, as well as her treatment philosophy on the topic. The interview is an informative read for anyone who might be suffering from airway problems or symptoms of sleep apnea.
In your opinion how prevalent is airway issues in dentistry?
I see it in most patients because of multiple factors. First there is low muscle tone, which impacts the patency of the airway and the ability for musculature to stimulate full development of the lower face and upper airway. This occurs when our diets are mostly processed foods, easy to chew. These days we even have food in liquid form, on the go, which doesn’t activate the muscles when consuming. This not only tells our brains we are still hungry because we haven’t been chewing our food because we’ve only been swallowing it, but we are also not exercising these muscles, which leads to low muscle tone. The weight gain increases one’s risk for obstructive sleep apnea and low muscles tone does as well. The tongue becomes lazy and falls back blocking the airway.
Second there is mouth breathing, which patients report they do for multiple reasons. They can do it because they have a deviated septum, which occurs when the maxilla is too narrow during one’s growth and development. As the maxilla grows horizontally it is increasing the base of the nose, which allows the septum to grow straight. If the maxilla doesn’t reach its full potential in its width the septum buccals to the side because it doesn’t have enough width or advancement. These noses tend to curve down.
Another reason someone would mouth breathe is nasal congestion, which may occur from allergies in the form of food or seasonal. Seasonal allergies tend to worsen if we mouth breathe aiding in nasal congestion, forcing more mouth breathing. This occurs because the nasal filter isn’t being used. Also, when you nasal breathe you release nitric oxide, which is a natural bug killer. You’ll get sick more often too when you mouth breathe too because you’re not releasing nitric oxide into your system to protect you for this.
Food allergies, such as dairy intolerance, causes a build-up of mucus production and is acidic, which aids in acid reflux. The mucus build-up narrows the airway and the acid reflux inflames the airway, narrowing it further. When the airway narrows it also causes negative pressure, which causes a vacuum effect that pulls up stomach acid while we are sleeping, which coats the back of our throat and goes into our sinuses and our ears (via the eustachian tubes). This causes a variety of ear problems (hearing loss, tinnitus, vertigo), clenching and grinding, hoarseness, troubles swallowing, nasal congestion, nausea, a sensitive gag reflex and possibly even vomiting in the mornings, the list goes on.
Mouth breathing, which causes inflammation in the upper airway, will cause tonsils and adenoids to enlarge as well as the turbinates in the nose, which closes the airway off further. Mouth breathing causes excessive vertical growth of the face because the nose isn’t being utilized so the mouth “hole” is overgrown in a vertical dimension to accommodate this change. The tongue also lives low in the mouth when one mouth breathes so the maxilla isn’t stimulated to grow out and forward. This causes the jaws to be narrow, which narrows the sinuses further.
Third there is frenum restrictions, which generally is not addressed at birth or after because we tend to accommodate and work around them. Frenum restrictions are genetic and are becoming more wide spread. A tongue ties limits movement of the tongue. This restriction limits the tongue’s ability to rest at the roof of the mouth stimulating proper growth and development of the maxilla and thus the mandible. In these cases, the tongue also doesn’t go up when swallowing, instead it may thrust forward or to the side causing an anterior or posterior open bite. Generally, malocclusion is caused from the tongue not living where it should, so the jaws aren’t stimulated to grow to their full potential causing a lack of arch for the teeth to grow into. The lips tend to compensate for poor swallowing habits and push the teeth back. A lip tie will make it difficult to have lip closure, these patients tend to become mouth breathers early on and develop upper airway resistance syndrome that turns into obstructive sleep apnea later in life. So in other words, airway issues are multifactorial and affect most people.
What ramifications to airway disorders are seen in dentistry?
When an individual has an airway disorder, they are more likely to develop TMD, caries, periodontitis, mobile, fractured, and sensitive teeth. TMD develops because the jaws didn’t fully advance, this causes the TMJ to be at a steeper angle, which can cause limited opening, dislocation of the joints, clicking/popping, lock jaw and/or pain, and make it difficult to undergo dental treatment. Also, with low muscle tone in the head and neck the TMJs are not stabilized in their positions and can more easily be moved out of place from being pulled on from other muscles that are trying to accommodate for the myofunctional disorder.
An increase in caries and periodontitis occurs because of a few reasons. One, mouth breathing changes the oral environment, making it stickier and more acidic. These patients generally have inflamed gingiva and caries in the anterior sextant from direct contact with air. Two, if the tongue is restricted, which caused it to live low in the mouth making it harder to keep the mouth closed causing the individual to have open mouth posture and become a mouth breather, the tongue can’t clean out the vestibule after eating. Food can become trapped in the vestibule when one doesn’t properly swallow and if they aren’t able to reach it with their tongue to remove it after eating then it sits there until they clean their teeth. Crowding, which is also generally caused by a myofunctional disorder, also makes it more difficult to keep teeth clean.
Tooth mobility, fractures and sensitive teeth occur from clenching and grinding. Clenching and grinding occurs from acid reflux as well as airway obstruction from the tongue. When the tongue collapses the airway, one will clench their teeth together to activate the tongue muscles to stimulate the tongue to move out of the airway. The tongue will thrust forward in these instances and can be seen by a scalloped tongue and/or wear on the edges of the teeth. When the teeth are being traumatized in one’s sleep it causes bone loss around them, which can appear that these individuals have periodontitis, but in these cases their pockets are generally shallow and healthy.
These individuals generally also have buccal abfractions from the bone loss exposing the cervical region of the tooth, which is weaker. These abfractions and other fractures from clenching and grinding cause the teeth to become more sensitive and eventually break. The acid reflux from airway obstruction causes the individual to be more sensitive to taking x-rays and undergoing dental treatment due to a sensitive gag reflex. Also, with the tongue set back, lying the patient back into a supine position can cause them to have their airway closed off, making it more difficult to breathe during dental treatment. And if the person is also a mouth breather, they may really struggle with dental treatment because we are invading their ability to breathe while treating them. This can lead to dental anxiety preventing them from going to the dentist routinely, causing neglect and ultimately more dental problems down the road.
How often do you see and treat airway disorders in your practice?
I screen for orofacial myofunctional disorders (OMDs) every time I do an exam. I see OMDs, which are precursors to upper airway resistance syndrome (UARS) and ultimately obstructive sleep apnea (OSA), in most patients. If the patient has a medical history that supports sleep apnea, such as hypertension, atrial fibrillation, congestive heart failure, diabetes, acid reflux, anxiety/depression, asthma, allergies, hormonal imbalance, weight gain, memory loss, dementia/Alzheimer’s , Parkinson’s disease, fibromyalgia, and/or cancer, then I discuss referring them to a sleep center for further evaluation with a polysomnography (PSG), which is a formal sleep study that screens for UARS and sleep apnea. I also have my patients do the STOP score, which is located on their medical health questionnaire. This scoring system is very accurate in detecting if someone has sleep apnea. It asks the person if they snore, feel excessively tired/fatigued during the day, hold their breathe in their sleep, and/or have hypertension. If they answer at least two of the four is yes then they have a 50% chance of having sleep apnea. I also review their medications and if they are taking three or more medications for hypertension then they are also very likely to have sleep apnea. This is because the sleep apnea is making it difficult for the medication to treat the hypertension alone. Sleep apnea will make one somewhat resistant to blood pressure medication. I educate every patient I see that shows symptoms of sleep apnea about the potential of having it and offer to refer them for further evaluation. Once the PSG report is back then we discuss their treatment options.
What are your recommended methods of treatment for airway disorders?
There are many different reasons why someone may suffer from an airway disorder so it’s important to do a thorough screening to determine the proper method of treatment that suits them in particular. One diagnostic test I perform in my office is a Bolton Norm, which is a profile line that shows where someone at their age should be in their growth and development of their mid to lower face if they didn’t suffer from any OMDs. If the patient is an adult and falls short of this profile line, then a mandibular advancement device (MAD) is an option to treat their snoring and/or mild to moderate OSA. This brings their lower jaw forward in their sleep, which pulls the tongue forward and out of their airway. Alternatively, the patient could potentially “cure” their UARS/OSA with maxillary mandibular advancement (MMA) surgery, which surgical brings both jaws forward and a lot of the time moves them out horizontally too to enlarge the oral space for their tongue. To further confirm this is an option for them I then order imaging including a lateral cephalogram and 3D scan of their airway. This will prove their airway is being obstructed by their jaws being set too far back into their airway. Once this is confirmed an orthodontic consultation with panoramic image is performed to determine where the teeth need to move in preparation for surgery and how the bite and esthetics will look after surgery. If the patient suffers from severe obstructive sleep apnea or has a central sleep apnea component, then PAP therapy with continuous positive airway pressure (CPAP) or another type of PAP machine is indicated. In these cases, the sleep apnea is too advanced for the MAD to fully treat. If the pressure on the PAP is too high for the patient to tolerate the PAP therapy then a MAD can be done in conjunction with PAP therapy, called combination therapy. This allows the PAP settings to be lowered because the airway is being partially held open by the MAD. If the patient can’t tolerate the PAP therapy then a MAD can be done in its place, but in these cases may not fully treat the sleep apnea. If the patient has sleep apnea due to nasal and/or tonsillar obstruction, then I will refer to an ear nose and throat doctor (ENT) for consult / surgery to open the airway. In all cases the OMD must be addressed. This is accomplished by doing Orofacial Myofucntional Therapy (OMT), which I do in my office. This will prevent relapse after surgery, help the individual tolerate the MAD better and make the airway more patent by 50% in adults. This interdisciplinary approach allows for optimal treatment for the patient with the best long-term results.
How often do you see airway disorders in children? How often do you treat and course of treatment plan in children?
I see airway disorders in most children because environmental/food allergies, soft/processed diets, lip and tongue ties, and bottle feeding instead breast feeding is becoming more widespread. OMT is the treatment of choice in children, to change their negative growth pattern into a positive one. Depending on the severity of the OMD and degree of the narrow airway, orthodontic treatment with horizontal and/or sagittal expansion may also be indicated. This will prevent the child from needing MMA surgery once they are fully grown. I also check their tonsils to see if they are obstructive. If so, I refer them to an ENT for T&A consult / surgery and OMT in my office to prevent relapse of their symptoms post-surgery.
Is there anything else you would like to add?
Sleep disordered breathing including UARS, OSA and central sleep apnea, is very common and sometimes hard to detect. It is very important to be screened for these by a dentist that has a thorough understanding of the upper airway. If caught early enough it can prevent many health and dental problems and give you a longer, more fulfilling life.