The Importance of Breathing Through Your Nose
The Connection Between Good Oral Hygiene and Sleep
By: Tamra L. Neugebauer, DDS
Well Beyond Dental – www.wellbeyonddental.com
TMJ & Sleep Therapy Centre of Reno – www.tmjsleepnevada.com
Noses are for breathing, mouths are for eating. When I ask most of my patients whether they breathe through their nose I often get a resounding “Of course!” Admittedly, it seems like a silly question. However, when I investigate a little further into the patient’s oral health I find that many, if not most, are not breathing through their nose; rather, they are breathing through their mouth because of nasal obstruction.
To underscore the importance of nose breathing, consider all the benefits it provides. The first point of entry for oxygen to enter our bodies is through the nose where it is warmed and filtered before being distributed throughout the body – this facilitates easy permeation into the tissues in the lungs. Oxygen also mixes with nitric oxide that resides in the sinuses and this mixture enhances the body’s defense mechanism against infection.
When the nasal passage is obstructed, mouth-breathing becomes the primary, yet incorrect, way of breathing. The mouth cannot warm and moisten the oxygen, and the oral cavity bypasses the sinuses thereby bypassing nitric oxide. The first line of defense for mouth-breathing is the back of the throat where tonsils and adenoids reside and because the oxygen has not been filtered tonsils and adenoids are susceptible to becoming inflamed and enlarged. Mouth-breathing also leads to such dental changes as decay, abfractions, broken teeth, dry mouth, and crooked teeth. When evaluating dental hygiene its imperative to consider mouth-breathing along with poor oral hygiene habits.
As a dentist, I am fortunate to be in the position to help people improve and maintain their overall health by treating the root cause of health issues that I can identify by routine oral examinations. When patients are evaluated with poor dental health it’s usually indicative of other underlying health issues rather than “just” poor dental hygiene. When I see decay, malocclusion (crooked teeth), gum recession, scalloped or coated tongue my first thought isn’t how often or long the patient brushes her teeth, but whether she is able to breathe through her nose.
The connection between good oral hygiene and sleep-related breathing disorders (SRBD) is one that is often undiagnosed because until recently sleep evaluations tended to stay in the medical realm and physicians would not correlate dental symptoms with sleep apnea. As the field of dentistry progressed over the last several decades, the dentist is now recognized as an integral part of coordinating treatment for SRBDs with medical physicians.
In 2017, the American Dental Association recognized the importance of the dentist’s role in identifying and treating SRBDs stating:
“The dentist’s role in the treatment of SRBD includes the following:
- Dentists are encouraged to screen patients for SRBD as part of a comprehensive medical and dental history to recognize symptoms such as daytime sleepiness, choking, snoring or witnessed apneas and an evaluation for risk factors such as obesity, retrognathia, or hypertension. If risk for SRBD is determined, these patients should be referred, as needed, to the appropriate physicians for proper diagnosis.
- In children, screening through history and clinical examination may identify signs and symptoms of deficient growth and development, or other risk factors that may lead to airway issues. If risk for SRBD is determined, intervention through medical/dental referral or evidenced based treatment may be appropriate to help treat the SRBD and/or develop an optimal physiologic airway and breathing pattern.
- Oral appliance therapy is an appropriate treatment for mild and moderate sleep apnea, and for severe sleep apnea when a CPAP is not tolerated by the patient. When oral appliance therapy is prescribed by a physician through written or electronic order for an adult patient with obstructive sleep apnea, a dentist should evaluate the patient for the appropriateness of fabricating a suitable oral appliance. If deemed appropriate, a dentist should fabricate an oral appliance.
- Dentists treating SRBD should continually update their knowledge and training of dental sleep medicine with related continuing education. Dentists should maintain regular communications with the patient’s referring physician and other healthcare providers to the patient’s treatment progress and any recommended follow-up treatment. Follow-up sleep testing by a physician should be conducted to evaluate the improvement or confirm treatment efficacy for the OSA, especially if the patient develops recurring OSA relevant symptoms or comorbidities.”
Snoring and Sleep Apnea
Snoring is one of the most common indicators of sleep apnea. Sleep apnea is a potentially serious sleep disorder in which a person’s breathing can start and stop repeatedly throughout the night. Imagine trying to breathe with a bag over your head. Sleep apnea can also cause decreased oxygen levels, similar to what happens to your body when you are at extremely high altitudes. So not only are you trying to breathe with a bag over your head you are also trying to climb Mount Everest. All of this happens during the period your body was designed to rest and heal itself. It’s easy to see why the combination of stopping breathing and lowered oxygen has high comorbidity with hypertension, heart disease, and mood and memory problems.
There are two main types of sleep apnea:
- Obstructive sleep apnea – blocked airflow during sleep usually occurring when the soft tissue at the back of the throat collapses blocking the airway. Health conditions such as obesity can be a contributing factor as well as diet, exercise, alcohol consumption, etc.
- Central sleep apnea – this occurs when there is a problem with how the brain sends signals to the breathing muscles. The airway is not blocked; however, the brain fails to tell the appropriate muscles to breathe.
- There are several other sleep-related disorders that can contribute to poor/fragmented sleep. Sleep apnea and other related disorders must be diagnosed by a physician
More than 18 million American adults are afflicted with sleep apnea. Although sleep apnea can occur in men and women alike, there are several factors that increase the likelihood of sleep apnea:
- Adults over 40 years old,
- Being overweight,
- Large tonsils, large tongue, small jaw,
- Family history of sleep apnea; and
- Any kind of nasal obstruction due to a deviated septum, allergies, or sinus problems.
It is important to remember that sleep-related breathing disorders can affect anyone of any age or gender. Unfortunately, oftentimes these symptoms go undiagnosed and the symptoms are frequently treated with sleep medications or other modalities without getting to the root of the problem.
Sleep apnea is also common in children, with an estimated 10% to 20% being afflicted by all children who snore. It has been found that an estimated 70% of children who are diagnosed with ADHD have an SRBD. Symptoms for ADHD and SRBD in children often overlap and it can be difficult to make an accurate diagnosis. Common signs that children have an SRBD include:
- Trouble falling asleep
- Trouble staying asleep
- Trouble waking up in the morning
- Waking up screaming or in a panic
- Waking up coughing
- Labored breathing or pauses in breathing during sleep
- Strange noises during sleep
- Irritability
- Falling asleep in class
- Distractibility and difficulty paying attention
Connection between OSA, Sleep Bruxism, and TMD
Bruxism is a condition in which you grind, clench, or gnash your teeth. There are two types of bruxism, awake bruxism and sleep bruxism. Sleep bruxism is a reflex that occurs at night in response to a person’s airway collapsing. The natural reflex of any mammal is to protect its airway and if there is a collapse of the airway during the night the reflexive nature will initiate clenching and grinding to produce an increase in the airway. Clenching of the jaw at night is many times more powerful than during the day because humans are unaware of the pressure exerted on the jaw joint (imagine biting down on a grain of sand – your brain will automatically stop you from biting with more pressure because it can sense the grain of sand, but when asleep you don’t have the same sensory perceptions).
This parafunctional (nighttime) activity is greater at night and will start to wear down the jaw joint (TMJ) as well as the muscles and structures attached to it. This nocturnal activity will create structural changes to the skull, muscles, and nerves and will commonly lead to facial pain, headaches, migraines, and can lead to pain in other structures in the body.
The patient is now on a “pain cycle” and will often feel pain when they wake up and the pain will increase throughout the day. When the patient tries to go to sleep at night, the pain is so stimulating she can either not fall asleep, or will wake up due to the pain stimulation. This disrupts the patient’s sleep and her body does not receive the benefits of restful sleep (e.g. healing, memory retention, etc.). In addition, when the human body does not go through the natural cycle of sleep it will produce cortisol, a hormone that increases weight gain and makes it difficult to lose weight.
Excessive clenching can affect the jaw joint (TMJ) in several ways. The direct force that clenching applies to the TMJ can create structural changes and wear down the TMJ condyles and the articulator disc which is designed to absorb the impact of the TMJ. When these structures are worn down it is painful for the patient to clench or grind, even swallowing can exacerbate the pain. The articulator disc can become displaced causing the TMJ to be misaligned; this is commonly noted by patients as clicking or popping in the jaw as well being locked open or closed. This is a critical point for rehabilitating the patients TMJ because once the patient becomes locked open or closed the efficacy of treatment is greatly reduced.
The long-held standard of practice for treating sleep bruxism and TMJ symptoms was a nightguard to protect the patient’s teeth from clenching and grinding at night. Studies have shown that this single arch night guard approach actually increases apneic events in the apneic patient by up to 50% – 50% of the time. In other words, using an oral device that is only one arch will increase the symptoms you are seeking to prevent. This increase in apneic events pushes the moderate apneic into the severe apneic range and potentially places their lives at risk.
Next Steps
If you or anyone you know suffers from sleep-related breathing issues, snoring, fragmented sleep, daytime fatigue, TMJ symptoms, headaches, migraines, etc. the best course of treatment is to get a comprehensive exam to determine a diagnosis, treatment recommendations, and a team of providers who can offer the best overall treatment to treat the root cause of these symptoms. Our system is designed to find the root cause of these symptoms and create a treatment plan that treats the root cause rather than just focusing on improving the symptoms. My primary goal is to provide my patient’s freedom from pain so they can breathe, sleep, heal, and lead a quality life.
Please visit our website for further information at www.tmjsleepnevada.com, or call my office to set up a consultation at (775) 786-3472
