Breathing

Breathing and orthodontic treatment

  • It is imperative that mouth breathing be changed to nasal breathing for correction of orofacial myofunctional disorders which should result in more successful and stable orthodontic treatment.
  • There is evidence that mouth breathing adversely affects the development of the jaws and the bite (ref).
  • Chronic mouth breathers have been shown to have a more vertical growth pattern of the face than normal along with jaws that are narrower than normal (ref).
  • The mechanism that results in the vertical facial growth in mouth breathers is thought to be that the tongue is displaced from a rest posture in the palate.
  • Additional orofacial myofunctional disorders can result from mouth breathing such as abnormal swallow and lack of lip seal.
  • Poor growth of the jaws due to orofacial myofunctional disorders can result in narrowing of the nasal passages, which in turn can make nasal breathing more difficult.

Breathing and general health

  • Nasal breathing is the normal pattern for humans except during pronounced physical exertion when mouth breathing is required due to the volume of air required to provide sufficient oxygen for the body.
  • Nasal breathing ensures that air is warmed, humidified, filtered, and partially disinfected as it passes through the nasal passages and past the adenoids and tonsils through the pharynx to the lungs.
  • Mouth breathing allows cold, dry, unfiltered, and dirty air to flow across the tonsils and almost directly into the lungs.
  • Mouth breathing is associated with increased risk of respiratory infections (ref).
  • Mouth breathing results in decreased carbon dioxide in the blood which results in the following:
    • Spasm of all smooth muscle in the body
    • This causes all tubes in the body to be constricted.
    • As the blood vessels constrict, blood pressure increases
    • Airways constrict which can reduce airflow to the lungs
    • The smooth muscle around the bladder tightens and adds pressure to the bladder that can result in bedwetting at night (nocturnal enuresis)
    • The pH of the blood increases slightly which results in decreased efficiency of transfer of oxygen from hemoglobin to the cells due to the Bohr effect

Sleep

  • Orthodontic treatment can have a positive effect on sleep for all ages, although the impact for children is more pronounced than for adults.
  • It should be noted that treatment of sleep disorders with orthodontic treatment (often including orofacial myofunctional therapy) must always be done in collaboration with a sleep physician. An Otolaryngologist (ENT) is also often involved with treatment of sleep disorders.

Sleep Disorders in Children

  • Sleep disorders in children are often referred to as “sleep disordered breathing” (SDB) or “obstructive sleep apnea syndrome” (OSAS).
  • There are approximately 84 different sleep disorders in children although the most common one is OSAS.
  • OSAS can result from a small airway, enlarged adenoids, enlarged tonsils, constricted nasal passages, excess weight, or poor tone of the muscles around the airway including the tongue.
  • Constricted nasal passages can be due to enlarged turbinates, polyps, deviated septum, or simply enlarged nasal passage tissues due to allergies, infection or lack of use.
  • When the airway is constricted to the point that there is not enough air entering the lungs to provide sufficient oxygen to the body during sleep, the brain will either partially wake the body or completely wake the body to increase the breathing.
  • Heavy, loud, and strained breathing is a sign that the airway is constricted enough to be limiting the flow of air to the lungs.
  • Sometimes during sleep, the airway closes off completely and breathing stops. This as called an “apnea” (absence of breathing) or apneic episode.
  • After a very short time into an apnea the brain will wake the body sufficiently to start breathing again, usually with a pronounced snort or gasp.
  • Whether the body is partially wakened or completely wakened there is a dramatic interruption in the sleep cycles and the restorative aspects of sleep are diminished.
  • This can lead to fatigue, compromised development, and attention deficits.
  • SDB in children that is due to enlarged tonsils and/or adenoids can be effectively treated in the short term with removal of the tonsils and adenoids.
  • Unfortunately, it has been shown that within a few years the SDB returns following this surgery in the majority of cases, unless mouth breathing has been changed to nasal breathing and the orofacial myofunctional disorder has been corrected (ref – Guillenamault and multicenter T&A study).
  • SDB in children can also be effectively treated in many cases with expansion of the upper jaw.
  • This is a very common procedure in orthodontic treatment and has been shown in many studies to improve SDB effects in children.
  • The roof of the mouth is the floor of the nose so when the roof of the mouth is expanded, the floor of the nose is also expanded, with the result that the nasal passages are widened which improves the airflow through the nose. (long term results of RPE re SDB?)
  • SDB in children can also be improved with correction of orofacial myofunctional disorders.
  • When the muscles associated with keeping the airway open are poorly toned, as is the case when an orofacial myofunctional disorder is present, the airway is compromised to some additional degree.
  • When the tongue is poorly toned and not resting in the palate, it can more easily drop down and back towards the back of the throat, which can further block the airway.
  • This is more pronounced when a child sleeps on his or her back. Training a child to sleep on the side can improve SDB to some extent.

Sleep Disorders in Adults

  • There are many different sleep disorders in adults although the most common one is obstructive sleep apnea (OSA).
  • OSA can result from a small airway, enlarged tonsils, enlarged adenoids, constricted nasal passages, excess weight, or poor tone of the muscles around the airway including the tongue.
  • Constricted nasal passages can be due to enlarged turbinates, polyps, deviated septum, or simply enlarged nasal passage tissues due to allergies, infection or lack of use.
  • The “ gold standard” for treatment of OSA in adults is CPAP (continuous positive air pressure), which is a machine that basically forces air in through a mask through the nose and mouth into the lungs during sleep.
  • CPAP is very effective at improving the symptoms of OSA although only around 35% of people using CPAP continue to use it long term.
  • Another very effective way to treat OSA is using a dental appliance called a “mandibular advancement device” (MAD). This device holds the lower jaw forward during sleep which effectively holds the tongue forward which helps to keep the tongue out of the airway which improves the size of the airway for better airflow. Compliance with the MAD is much higher than that for CPAP which makes it a good alternative to CPAP in many cases.
  • Long term use of a MAD will result in permanent changes to the bite that can adversely effect function and comfort.
  • Surgical options to treat OSA include reducing the pharyngeal tissue along the sides of the airway, and reducing the soft palate and the uvula. There are numerous reports of this surgery having complications of pronounced discomfort and in some cases regurgitation of food during swallowing.
  • Orofacial myofunctional therapy has been shown to improve OSA significantly and is a very conservative treatment with no reported negative side effects (ref).
  • There are Myobrace appliances that provide some of the action of a MAD which along with orofacial myofunctional therapy can be very effective at treating the symptoms of OSA.
  • There are also pharmacological treatments of sleep disorders including supplements such as melatonin.

Neurocognitive Deficiencies

  • Orthodontic treatment does not directly influence neurocognitive deficiencies such as ADHD or anxiety disorders.
  • Orthodontic treatment can improve sleep disorders, which in turn can improve neurocognitive deficiencies.
  • There is clear evidence that expansion of the upper jaw can significantly improve sleep disorders in children (ref).
  • There is clear evidence that improving sleep disorders in children can significantly reduce neurocognitive disorders (ref).
  • Primary treatment of neurocognitive deficiencies should always be under the guidance of an appropriate physician.
  • Orthodontic treatment can be a valuable adjunctive treatment for neurocognitive deficiencies.

Oral Habits

  • Oral habits are a significant contributor to orofacial myofunctional disorders and it is therefore necessary to correct all poor oral habits to successfully correct orofacial myofunctional disorders.
  • Correcting poor oral habits should assist in improving facial growth and the normal growth of the jaws and teeth.
  • Poor oral habits include, but are not limited to:
    • thumb or finger sucking
    • blanket or clothes sucking
    • lip sucking
    • tongue sucking
    • lip licking
    • lip biting
    • lip pursing or tightening
    • soother or pacifier use
    • pen or pencil biting
    • nail biting
    • abnormal tongue rest posture
    • abnormal swallow
    • mouth breathing
    • overuse of facial muscles with chewing and swallowing
    • overuse of facial muscles with speaking
    • open mouth chewing

Speech

  • Speech deficiencies are sometimes a sign of an underlying orofacial myofunctional disorder.
  • We often encounter patients that have some residual speech deficiencies in spite of having had speech therapy.
  • Sometimes these residual speech deficiencies improve as the orofacial myofunctional disorder is improved.
  • When these residual speech deficiencies do not improve when the orofacial myofunctional disorder is corrected, they are usually then easily corrected by a speech language pathologist.
  • It is thought that in some cases the poor strength and posture of the tongue due to the orofacial myofunctional disorder prevents the full success of speech therapy.
  • Once the orofacial myofunctional disorder is corrected, the speech therapy appears to be more successful.
  • Orofacial myofunctional therapy should never be considered a replacement for speech therapy, but it can be a useful adjunct therapy related to speech.

Posture

  • Poor posture can be a contributor to orthodontic problems and orthodontic problems can be a contributor to poor posture. In either case it is desirable to correct the poor posture.
  • In cases where the airway is constricted in some manner, there is a natural reflex to extend the head forward with an upward tilt of the head because this position opens the airway.
  • This forward and tipped position results in a backward pull on the lower jaw. This position also adds significant strain to the neck and shoulders with possible negative consequences to the joints and muscles of the head, neck and shoulders.
  • When there is poor posture such as can occur due to carelessness when using electronic devices, the head is often positioned forward and tipped downward often with the shoulders rolled forward and down.
  • This posture tends to constrict the airway and can trigger mouth breathing in some people.
  • Mouth breathing prevents the tongue from resting in the palate and an orofacial myofunctional disorder can develop.
  • This can adversely affect the growth of the face, jaws and teeth.
  • This position also adds significant strain to the neck and shoulders with possible negative consequences to the joints and muscles of the head, neck and shoulders.
  • A physiotherapist or postural therapist can be of assistance in correcting poor posture.
  • Improving the airway with expansion of the upper jaw or with orofacial myofunctional therapy can help improve posture in some cases.

Asthma

  • The primary treatment of asthma should be under the care of an appropriately trained physician such as a respirologist.
  • When we provide orthodontic treatment to asthmatic patients with Myobrace and associated exercises we sometimes receive reports back that the asthma symptoms have improved.
  • This is strictly anecdotal evidence and as far as we are aware there has not been research done in this area.
  • There is, however, research that shows clearly that Buteyko breathing therapy can significantly improve asthma symptoms (ref).
  • The basic breathing exercises that we provide with Myobrace treatment are adapted from the Buteyko method so it seems possible that some improvement in asthma symptoms could be occurring as a result of this breathing training.
  • We have recently started a more comprehensive breathing therapy program in our office for those patients that need additional assistance in changing a mouth breathing pattern to a nasal breathing pattern.
  • Four of our team members have taken the Buteyko breathing dental module that allows us to provide this extended breathing therapy.

Allergies

  • Primary treatment for allergies should be by a physician.
  • Allergies can be a significant factor in the development of mouth breathing.
  • Allergies can make it very difficult to breathe normally through the nose with the result of mouth breathing.
  • When breathing is through the mouth the tongue drops form its normal rest position in the palate and the development of on orofacial myofunctional disorder can occur.
  • This results in a compromise to the development of the face, jaws and teeth.
  • It is surprising how often we see children for orthodontic care that are allergic to the family pet and yet no changes are made to separate the child from the pet. This can make it impossible to correct the mouth breathing and the orofacial myofunctional disorder.
  • In some cases the allergy to the family pet is the primary cause of the orthodontic problems occurring.
  • It is also surprising how many children are allergic to or have a significant sensitivity to dairy or gluten products. Many parents have done a trial for the child with a dairy or gluten free diet for a week and have discovered a significant improvement in nasal breathing.
  • We regularly receive reports that following expansion of the upper jaw or the breathing training that a patients allergy symptoms have improved.
  • This is strictly anecdotal evidence and we are not aware of any research that has been done in this area. Where improvement has occurred, we suspect it is because with easier nasal breathing and more consistent nasal breathing, the nasal tissues are more robust and can resist allergens to a greater extent.

Bedwetting

  • Bedwetting, also known as nocturnal enuresis, is a condition that should be under the primary observation and care of a physician, as there can be many reasons for this condition.
  • We regularly receive reports that children who are receiving orthodontic care in our office with Myobrace and associated exercises, experience a significant improvement in bedwetting.
  • This is anecdotal evidence and we are not aware of any research that has been done on Myobrace treatment related to bedwetting.
  • In cases where the bedwetting has improved, one rational explanation is that the improvement is related to the change from mouth breathing to nasal breathing.
  • When breathing through the mouth, the carbon dioxide level in the body drops lower than normal values. This lower level of carbon dioxide triggers the spasm of all smooth muscle in the body and since the bladder is surrounded by smooth muscle, the bladder is somewhat compressed, leading to bedwetting.
  • It is common for children with some compromise to the airway to breathe reasonably well through the nose during the day but mouth breathe at night, possibly contributing to bedwetting.

Ear Infections

  • Some children have frequent ear infections and sometimes “tubes” are placed in the ears to help minimize the risk of infection. Tubes are designed as a bypass for a blocked Eustachian tube.
  • Infections in the ear are frequently due to the Eustachian tube being blocked. The Eustachian tube (auditory tube) is part of the middle ear and connects the middle ear to the nasopharynx. The Eustachian tube is necessary to equalize the pressure in the middle ear with the surrounding atmosphere.
  • Another function of the Eustachian tube is to drain mucus from the middle ear. If the Eustachian tube cannot open, fluid is trapped in the inner ear, which serves as a growth medium for bacteria, causing ear infections.
  • The Eustachian tube opens with normal swallowing by the action of two muscles of the soft palate (tensor veli palatini and levator veli palatini). With an abnormal swallow the soft palate does participate properly and the Eustachian tube does not open, fluid is not drained normally from the inner ear and there is a higher risk of an ear infection.
  • Correcting an abnormal swallow to a normal one through myofunctional therapy can return normal function of the Eustachian tube with a resulting lower risk of ear infections.
  • With a normal swallow, one can hear a click or pop in the ear from the opening of the Eustachian tube.

Digestive Problems

  • Along with an abnormal swallow there is often abnormal chewing and gathering of food in preparation for a swallow.
  • Sometimes the food is poorly chewed before swallowing which compromises the effectiveness of the digestive process. Food should be fully chewed to a consistency that allows maximum efficiency of digestion.
  • Open mouth chewing is fairly common with an abnormal swallow. This manner of chewing incorporates significant amounts of air in the food which is swallowed along with the food. This can result in bloating and gas.
  • The stomach is not designed to handle air in food which compromises the efficiency of digestion.