The simple answer is yes! Yes, it can. But there is much more to the story than a simple yes.
It’s obvious that your airway is essential for you to live. Everyone is aware of this phenomenon! Normal well-developed airways assure normal breathing through the nose with the mouth closed. Nasal breathing is important because it is now known to be vital to good health. Research has shown that air breathed through the nose is quite different to the body than air breathed through the mouth.
The benefits of nasal breathing begin within hours of birth when nasal nitric oxide gas can first be detected. Nitric oxide is a key component of human health. Nitric oxide is produced in the nasal sinuses, secreted into the nasal passages, and inhaled through the nose. It is known to prevent bacterial growth. In the lungs, nitric oxide improves the ability to absorb oxygen. Nitric oxide is a strong vasodilator and brain transmitter. Furthermore, nitric oxide increases oxygen transport throughout the body and is vital to all body organs.
As in anything in life, the sooner you identify and deal with a problem, the better the outcomes. I like to call it early intervention. We don’t know what we don’t know. We need to look for signs and symptoms earlier. By earlier, I mean looking in utero before a baby is even born…early. Or better yet, Look at a woman and how she breathes before she even gets pregnant. If we diagnose and treat what we see early enough, we can use the growth and development of our kids. If we wait, it becomes a more invasive procedure to fix airway and breathing issues with orthodontics or surgeries to expand the upper jaw. Suppose I had known what I know now when my daughter was a toddler, I could have saved her a lot of time in braces and embarrassment from bedwetting. But I did not know until it became a bigger problem.
When you think of orthodontics, the first thing that probably comes to mind is straightening teeth.
Unfortunately, some orthodontics, when not planned properly, can lead to airway constriction. In some cases, tooth extractions or retractions due to overbites and protruding teeth can actually lead to the teeth and jaws falling back from their original position. This makes the tongue and soft palate fall back too, which narrows an otherwise normal and healthy airway. Many individuals assume that orthodontics only treats issues that involve the misalignment or the malocclusion of teeth. However, new studies have shown that orthodontics can also assist in treating airway issues. How is this possible?
There is a relationship between craniofacial development and airway development.
Craniofacial malfunction, such as a narrow palate, cleft palate, and low tongue position, can result in airway obstructions and difficulty breathing. This makes it harder for a person to breathe through the nose, resulting in chronic mouth breathing. Mouth breathing can lead to potentially serious health issues, such as sleep-disordered breathing and sleep apnea.
Perpetual mouth breathing can also lead to dental and facial deformity, especially in growing children, and can result in molar eruption and lower jaw rotation, along with other irregularities. It can also dry out the oral cavity, resulting in tooth decay, bad breath, and even gum disease. Luckily, this can be fixed by orthodontics. When identified early, orthodontics can limit mouth breathing by gently expanding the jaw, which widens the mouth and clears the sinuses. This will result in easier breathing through the nose.
There is even a new branch of orthodontics called airway orthodontics that specifically treats airway issues. We talked about this last week. These orthodontists look beyond the teeth to include the nose, throat, and muscles of the tongue, face, and neck to optimize airway passages.
Orthodontic treatment can ensure that a child’s mouth naturally closes at night so they can breathe through their nose. Orthodontics, such as braces and guards, can also treat the signs of mouth breathing, such as overbite and gummy smile. There are certain habits that can affect the teeth and airways of a child. Tongue position and posture are among them. Let’s start with a bit of history and what the jaws of our ancestors looked like.
Dr. Kevin Boyd is a board-certified Pediatric Dentist in Chicago. He teaches in the Pediatric Dentistry residency program at Lurie Children’s Hospital and serves as a dental consultant to their sleep medicine clinic. Dr. Boyd is a visiting scholar at the University of Pennsylvania Museum of Archeology and Anthropology, conducting research on the post-industrial evolution of the human face and airway-related structures. He lectures worldwide on pediatric OSA, evolutionary oral medicine, and early-age orthodontics. He, along with Dr. Marianna Evans, is a board-certified dual specialist in orthodontics and periodontics practicing in the greater Philadelphia area. She divides her time between private practice, teaching at the University of Pennsylvania Department of Orthodontics, and clinical research. She co-founded the OrthoPerio Institute and recently developed 4D Morphotropic OrthodonticsTM, an airway-focused preventive orthodontic technique. Dr. Boyd calls it Pre-orthodontic Intervention for Pediatric Sleep Disordered Breathing: A (R)evolutionary Solution to a Modern Problem. They have helped so many families!
Finding Connor Deegan is a Youtube video of one of the families Dr. Boyd helped.
The research they are doing is amazing, but not many people know about their work. Even though this information has been available for decades, we are just starting to realize the impact our mouth has on our health and certain diseases of the body. It is going to change the way we look at our kids, their breathing, and their future health.
When identified early, pre-orthodontics can limit mouth breathing by gently expanding the jaw, which widens the mouth and clears the sinuses. This will result in easier breathing through the nose. Early intervention with pre-orthodontics may even reduce the need for conventional braces.
We talked last week about a new branch of orthodontics called airway orthodontics that specifically treats airway issues. The problem is not everyone knows about these airway issues, what questions to ask, and how and when to look for them and treat them.
Based on their scientifically defensible research, Drs. Evans and Boyd have reason to believe these problems stem from subtle but significant changes to the human craniofacial structure—a smaller, more narrow palate, more slender skull, and weaker jaws, that have occurred since the beginning of the Industrial Revolution in the mid-19th century.
Besides affecting jaw structure and the way teeth fit in the mouth, these evolutionary changes can impede a person’s airway, causing other serious health problems, such as pediatric obstructive sleep apnea and even neurological issues, such as attention-deficit/hyperactivity disorder (ADHD) and lower IQ.
But why did these evolutionary changes occur?
The doctors suspect shifts in the human diet, such as artificial methods of infant nursing and weaning with commercially processed cereals and other “baby foods.” Centuries ago, humans in hunter-gatherer societies who gathered their food consumed a lot of fresh, tough, and fibrous foods, and they also used their teeth as tools. In other words, their jaws had to work harder, so the underlying muscles were stronger, and their facial bones were thicker and wider. Women nursed on demand until the child was three years old. Farming— specifically the introduction of cereal grains and dairy, changed everything.
A 1981 publication, Western Diseases: Their Emergence and Prevention, written by Hugh Trowell and Denis Burkitt, launched a new paradigm in medical education; many modern diseases are now better understood when viewed from an evolutionary perspective. A healthy circadian sleep cycling during childhood would have been absolutely necessary for our ancestors’ our human evolutionary history shows sleep-related breathing disorders such as obstructive sleep apnea (OSA) were likely not a part of the human experience until fairly recently and thus can be appropriately categorized as Western diseases (WDs).
Evolutionary medicine (EM), also known as Darwinian medicine, is a new approach providing a useful framework for understanding modern diseases from an evolutionary perspective. For example, one proposed explanation by Evolutionary medicine proponents for why humans have only recently begun to become vulnerable to many modern diseases such as type 2 diabetes and dental malocclusion. The current high prevalence of WDs in industrialized populations is at least in part due to exposure to modern feeding regimens and environmental conditions, which are vastly different from the Paleo/pre-agricultural diets and environments to which humans have adapted. Pediatric sleep-disordered breathing (SDB) is a pathological condition associated with a wide range of clinical symptoms, historical evidence, dentofacial physical examination findings, environmental components, and genetic and/or epigenetic factors. Recently published controlled studies indicate a close association between pediatric SDB/OSA and neurocognitive impairments such as ADD/ADHD and other behavioral disorders.
Consequently, the role of the orthodontist, pediatric dentist, general dentist, and myofunctional therapist as an integral member of every child’s comprehensive health care team has never been more important.
HISTORY OF MALOCCLUSION
Anthropological studies confirm that dentofacial malocclusion (poorly aligned jaws and teeth), a known risk indicator of SDB/OSA, was infrequently suffered by our pre-industrial ancestors. Skeletal malocclusion didn’t appear in humans until around the time of the Industrial Revolution of the mid-eighteenth century.
To understand the health problems known to be associated with untreated and/or inappropriately treated malocclusion, it would first be helpful to go back decades around the time of the Agricultural Revolution 10,000–12 000 years ago and more rapidly over the past 350–400 years. While there seems to be a definite observable trend toward the increased prevalence of malocclusion over the last three to four centuries, there is not yet a firm consensus amongst dental anthropologists as to precisely what happened, but there does seem to be a growing body of evidence that seems to suggest that feeding behaviors during infancy and early childhood are likely involved. Specifically, ancestral-type breastfeeding and weaning are known to be protective against certain forms of malocclusion, likely due to the physical challenges posed to the developing palatal– facial suture complex (P–FSC) during infancy and early childhood; as well as the highly processed/soft baby foods and artificial infant formulas/commercial nipples and pacifiers that are in so much use today were simply not readily available to children before the Industrial Revolution.
With every accumulating physical evidence from anthropological studies, combined with advances in the newly emerging scientific disciplines of epigenetics and evolutionary medicine, it can be stated with a reasonable degree of scientific certainty that malocclusion is not primarily a genetically determined disease. Rather, malocclusion is better described as a Western disease with environmental interaction that follows a fairly predictable pattern; most WDs are preventable so long as genetically predisposed individuals are identified before early expression of the disease is obvious.
Most western diseases are preventable and can be reversible, but only in the very early stages of disease expression and only when the precipitating environmental pressures (e.g., unhealthy eating, sleep-disordered breathing) have been eliminated. In many cases, however, the disease has advanced beyond reversibility; it can still be treated with accurate diagnosis and appropriate therapeutic measures (e.g., dietary changes, pharmaceuticals) if the disease state is not too far advanced. The advanced end-stage disease can be fatal if not accurately identified, reversed, and/or appropriately controlled. While a cause-and-effect relationship between malocclusion and of SDB/OSA is not yet proven, a relationship does indeed appear to exist between the two disease entities. Similar to what we now understand about why diabetes and periodontal disease often coexist in the same person.
Dentists who treat children are uniquely positioned to identify patients who might be at increased risk for SDB/OSA. Due in part to the successful implementation of the American Academy of Pediatrics and American Academy of Pediatric Dentistry’s (AAPD) joint effort to assure that all children establish a dental home by the age of 1 year, pediatric dentists now have a higher frequency of patient encounters than most other health professionals.
Chronic obligate mouth breathing from impaired nasal respiration can cause progressively worse abnormal craniofacial development and malocclusion beginning at a very early age. Chronic mouth breathing interferes with proper maxillary and mandibular arch development by disrupting tongue, cheek, and lip muscle forces. Chronic oral breathing causes a down and backward positioning of the lower jaw (mandible), a vertical long-faced growth pattern, and multiple abnormal growth patterns in the face, jaws, and dentition that are very interrelated.
Characteristics of chronic mouth breathing and respiratory obstruction include mouth breathing at rest, inflamed tonsils and/or adenoids, open-bite, crossbite, incompetent lip posture, gummy smile, narrow nose holes, V” shaped palate, and dark circles under the eyes (known as venous pooling), overjet, open bite, maxillary crowding.
Chronic mouth breathing has been shown to be 4 times more common in children with orthodontic abnormalities.
Oral–medical health history interviews are helpful and designed not only to obtain information about the child’s overall dental/ medical health status but also to inquire information about dietary/feeding history and previous dental and/or medical experience that might impact a child’s possible expectations about the dental appointment. When we ask better questions, we can get a better picture.
While this is not typical of a pediatric medical–dental health history, it is certainly easy, useful, and appropriate for dentists to incorporate into the parent/caregiver interview a short series of questions specifically designed to gain valuable information about a child’s possible risks for both malocclusion and/or SDB/OSA.
A typical list of questions asked might include, but are not limited to:
Was your child breastfed or bottle-fed? For how long?
What beverage does your child typically drink when thirsty?
Does your child grind his/her teeth at night?
Is your child a noisy open-mouth breather and/or snorer during sleep?
Does your child wet the bed?
Does your child ever wake up with a sore jaw, headache, dry mouth, and/or sore legs?
Is your child a restless sleeper or wakes with blankets and pillows all over?
Is your child at a healthy weight?
Does your child have night terrors or nightmares?
Does your child walk on their toes?
In addition to the detailed medical–dental health history interview, a comprehensive dentofacial clinical examination might show warning signs that a child might be suffering from impaired ability to breathe properly during sleep.
Dry, cracked lips, dark circles under eyes, crowded teeth, open mouth, low tongue, or forward posture, to name a few. By the age of two or three, subtle dental signs of nasal obstruction and mouth breathing can be seen. Some of the clearest signs include open bite, posterior crossbite, and excessive overjet.
Craniofacial growth is eighty to ninety percent complete by age twelve, so most formation and/or deformation occurs by that age. Unfortunately, age twelve is still the average age that orthodontic and orthopedic treatment starts for most children worldwide. We need to intervene sooner.
The maxilla and mandible are nearly 50% grown at birth, 70- 80 % by the age of 7-8, and about 90% grown by age 12. Therefore, about 80% of post-birth craniofacial growth occurs between birth and age 12. It is plain to see why earlier treatment makes sense. From birth to age 12, the majority of growth potential occurs and can better impact craniofacial growth and development if treated at a younger age.
More attention needs to be placed on routine craniofacial examination, diagnosis, and treatment beginning at birth. If we wait, it is harder to treat non-surgically.
NON-SURGICAL VERSUS SURGICAL TREATMENT OPTIONS FOR PEDIATRIC SDB/OSA
It is well established that surgical removal of the tonsils and/or adenoids is the most common treatment for pediatric OSA. For extremely severe cases of OSA for which adenotonsillar surgery might not be indicated as the best treatment, maxillomandibular advancement surgery (MMA) and/or tracheostomy placement are, on occasion, considered better surgical options.
Wherever feasible, collaborative efforts aimed at preventing and treating pediatric OSA non-surgically should be given the highest consideration. One commonly known implemented non-surgical medical interventions include inhaled nasal corticosteroids and the usage of a CPAP device. While correctly classified as a nonsurgical treatment option, long-term usage of CPAP facial masks can markedly reduce mid-facial development potential in growing children. Other common examples of non-surgical prevention and treatment options for pediatric OSA may include myofunctional training oral appliances (e.g., Infant Trainers, Myo-Munchies, etc.), oral myofunctional therapy (OMT)*, dietary counseling, functional orthodontic mandibular advancement appliances (e.g., Bionator), rapid maxillary expansion (RME) appliances (e.g., bonded Schwartz) To name a few both the mandible and maxilla may be treated with a series of removable acrylic mouthpieces.
Dr. Boyd calls it Craniofacial Mandibular Respiratory Morphology. He teaches about the maldevelopment of the craniofacial and respiratory complexes in early childhood as being a result of habitual mouth-breathing, sleeps disturbances (OSA, etc.), and possible co-morbid neurobehavioral cognitive deficits.
Often in conventional orthodontics, we do not ask the questions as to why the teeth are the way that they are; instead, we try to answer the question of how to move them to make them appear straight,” Dr. Evans says. “Research suggests that if we don’t address the function and the causes of these problems, the teeth will not be stable over the long term. We are not just straightening teeth in her practice, she says, but reshaping the structures that hold teeth. Good health comes from treating the function and foundation of a healthy bite, which is not only the ability to smile and be free from the jaw and tooth pain, but also chew, swallow and breathe, mostly through your nose, and especially at night. Once you put these puzzle pieces together, it will improve everything, including the beauty of your smile.
This means starting young, working with children and their parents to adjust everything from their posture and breathing habits to the muscle tone of their jaws.“Oral health is medical health,” adds Dr. Boyd, “We’re not just talking about healthy gums and teeth; we’re also talking about airway health and neurologic health.
We used to just look for cavities, which is still important, yet now we’re looking at the whole issue of airways as a vital component of our already established anticipatory guidance protocols.
Treating children as young as two years old when all 20 of the baby teeth have usually come in, though the focus on re-shaping craniofacial structures starts well before that age, according to Dr. Boyd.“A child’s first teeth usually start to come in at about six months old, but you can see signs that kids may have deficient jaw growth from day one, or even before then based on in utero ultrasounds,” he says. “Children need to be screened for jaw deficiencies, sleep apnea, and ADHD shortly after they are born. Often the inability to nurse is one of the indicators of this problem. That’s why, according to the American Academy of Pediatric Dentistry, it’s so important for all children to establish their dental home before their first birthday.”
Our teeth positioning and jaws are connected to sleeping disorders like snoring and obstructive sleep apnea, which are affecting millions of people today. Obstructive sleep apnea is a respiratory disturbance that creates many further health issues like high blood pressure, stroke attack, and depression. Improper breathing makes people feel drowsy during the day and has difficulty paying attention and breathing through their mouth. Think about how you feel as an adult when you are tired. Now think about your child that does not know they are tired. I knew when my daughter was tired, so when her behavior changed, I could tell by how she acted she was tired. She had most of the sleep-disordered breathing signs. I wish I had known this information sooner.
Each year, millions of U.S. children and teenagers require orthodontic intervention to “fix” crooked teeth and misaligned jaws—and, in many cases, the first intervention isn’t a long-term solution. Meanwhile, countless adults, each year have their wisdom teeth pulled as a way to eliminate mouth pain or prevent damage to surrounding teeth. The anthropological record suggests these kinds of dental problems didn’t exist 1,000 years ago or even 300 years ago.
We are passionate about not only addressing the problems these evolutionary changes have caused but also about understanding the links and connecting the dots. It is time for dental doctors and medical doctors to work together more in the areas of the airway, breathing, and orthodontics.
It all starts in the mouth. A healthy mouth is a healthy body and a happy, healthy life!