To Air is Human: To Breathe Freely, Divine

by Barbara Tritz, RDH, BS, MSB

Kissing tonsils, how do they breathe?

Breathing.  Why’s a dental hygienist writing about the airway!?  Again!  Because I want you to be healthy and live a life of wellness!  In my biological dental office, one of the most important, if not the most important thing we do, is evaluate your airway.  Repairing teeth is secondary to restoring the airway and getting oxygen to the body and brain.

Biological Dentistry

Let me quickly digress for just a moment and explain what the heck a “biological” dental office is and why I work there, instead of the traditional, usual type of dental office.  A biological dental office is focused on more than just addressing tooth decay or gum disease.  We look at (pardon the pun) the root of the matter, the cause(s) of your dental problems.  It’s a philosophy we practice with a commitment to health, helping you on your journey to wellness.  (And it is definitely a journey.)

We look at airway, nutrition, digestion, blood work, genetics, head and neck muscles, tongue rest posture, body posture, pathogen testing, and habits,  THEN we look at teeth and gums.  Does your dental office do all this??

Biological dentistry really gets down to “why” things are breaking down, and then, even more important, “how” we can help you stay healthy.  I have used a chairside phase contrast microscope since 1985, showing my clients their “bugs” even before I knew such a thing as biological dentistry existed!  So, in learning about biological dentistry, it was a natural fit for me.  Find and address the real cause (bacterial, fungal or otherwise) instead of just drilling, filling, and putting band aids on problems!  Most times it’s really not a cleanliness thing.  It involves what you eat, is heavily influenced by how you breathe, and then quite possibly your genetics.

Every dental office can drill, fill, and/or scrape plaque off teeth.  That’s not difficult, well, most of the time.  The mouth is a part of the body, though, not a separate universe, so let’s treat it in that context.

We want to preserve the patient’s “biological terrain.”   We use as safe a material as possible that mimics natural tooth structure but realize the very best is your own teeth and gum tissues.  Let’s preserve what you have!  Biology at its best.

Airway Heath

Too often, dentistry never even looks down the throat.  We seem to be too busy with whirring instruments or lecturing about dental floss.  It’s time to see beyond the base of the tongue!  If a person can’t breathe then it really doesn’t matter how great their teeth look.

So, to the airway we go!  How? you ask.   We look deeper!  With 3-D cone beam CT (computerized tomography) diagnostic scans of all our patients, we can see what’s going on back there.  It’s just better to see things in 3-D.

I wanted to share this CT scan of a new patient.  It’s a side view of the head and throat.  You can see the spine on the right of the photo.  It really caught my attention because this lovely lady (I will call Lady A) is a senior citizen and having other health issues.  Lady A’s throat is quite closed in the scan (see my arrow?) – and this is while she is standing upright.  How can she breathe at night with her tongue already blocking her throat (I.E. Airway!?) while she’s awake?  Her tonsils are moderately sized so no one has ever thought to look at her with this view before.  She is breathing through an airway the size of a coffee straw.  No wonder she’s tired all the time, and of course does not sleep well!

Night Time Breathing or the Lack Thereof

Airway? No airway!

The lack of good oxygen flow throughout the night creates a flight or flight situation in your brain.  Adrenaline surges.  Ever wake up and feel like you could clean the whole house at 2:00 in the morning?  (I have!  Well, not actually cleaned it, but felt wide awake and like I could clean it, if I really wanted to, which I did not… instead, I read dental stuff.)  Insomnia is actually part and parcel of a sleep disordered breathing called Upper Airway Resistance Syndrome (UARS).  It falls in there between snoring and Obstructive Sleep Apnea (OSA).

The problem (or one of the problems) with this adrenaline surge is that it increases blood pressure and heart rate.  It also messes with blood sugar.  Diabetics and pre-diabetics-I’m talking to you!  This heightened level of brain activity can increase your cortisol levels, which keeps blood sugar high and changes insulin levels.  These surges can occur hundreds of times an hour and cause serious damage to your heart, plus inflame blood vessels.  Sleep disordered breathing might cause glucose intolerance and insulin resistance which causes increased glucose levels in both the blood and brain.  The new research connects this inflammation and insulin resistance to what’s termed Type 3 Diabetes, and connects it to Alzheimer’s dementia.

Have a hard time losing weight?  Might be sleep disordered breathing because it causes weight gain!  The hormone that tell you you’re hungry – Ghrelin – is turned on, and the hormone that tells you you’re full – Leptin – is shut off.

Lady A has all these problems plus a few more.

Bite Guard/Night Guard/Bad Guard

Do you wear an appliance at night to “help” with your clenching?  If you clench or grind,  it’s often attributed to “stress”.  Overall… false!  False and False!  It’s actually your body trying to get you to breathe at night.

The tongue tie contributed to the heavy wear into the dentin.

The scary part, your bite appliance may well be making your sleep disordered breathing even worse.  That appliance could be taking precious tongue space on the roof of your mouth (where your tongue is supposed to rest) so, OH-NO, your tongue falls back into your throat, closing off your airway.

Clenching and grinding is your body’s way of talking to you, trying to keep you alive.  When you stop breathing, your brain makes you clench/grind which pushes your jaw forward, opening your airway.  You breathe…tongue relaxes.. and bingo; repeat.  The problem is this may occur 40 to 60 times per hour!

Grinding and clenching at night is a huge red flag for sleep disordered breathing.  Quit stressing your brain and give it oxygen!  Bite guards are only band aids and do not address the real problem.  The real problem is little to no oxygen!  We have known this for a long time yet dentists still prescribe a “night guard/bite guard” for “stress.”   It’s oxygen deprivation.  Do you ever wake up with a head ache or jaw pain?  Again, these are symptoms of sleep disordered breathing.  A bite appliance will do nothing to fix the cause.   Dentistry still prescribes night guards,  but now you know to say no and address the real source of the problem.

Some Not so Fun Facts about Sleep Disordered Breathing

Brain Health

Our brains need a constant flow of oxygen, no surprise there.   When we sleep and have a constricted airway, our blood oxygen content plummets.  That’s called blood oxygen desaturation.  Blood oxygen levels should be no less than 97%.  In sleep disordered breathing it drops precipitously – 80% and below is severe oxygen desaturation.  For those already diagnosed with Obstructive Sleep Apnea (OSA), look at your blood oxygen levels from your sleep study.  How low did you go?   The constant dip and rise of the blood oxygen levels signal to the body that it’s in danger of dying, so it either wakes you up (this is called a microarousal) or keeps you in that lighter sleep.  The brain is in hyper-drive keeping you alive.  Thus, you wake up tired, groggy, and irritable.  Bet you know some folks like that…

When the brain’s not getting enough oxygen, you are stuck in phase N2 level of sleep, never getting that deeper N3 and REM sleep.  Your brain is then depleting serotonin and dopamine.  You need these neurotransmitters to feel good – it’s what helps you feel happy, relaxed and confident.  Have depression and/or anxiety?  Might well be a decrease in these hormones.

Then there’s another set of chemicals that become imbalanced- GABA (gamma-aminobutyric acid) and glutamate.  GABA slows the brain down and glutamte is the accelerator. These two chemicals need to work in harmony.  Again, think depression, and also brain damage.  Lack of oxygen has a severe domino effect not only in the brain but then throughout the body.  Because of this flight or fight response, the body then starts shutting down the extremities.  Got cold hands or feet?  How about chronic diarrhea, migraines or constipation?   Yup, all can be related to sleep disordered breathing.  Who knew?!?

True confessions- Until I acquired my cpap machine, I did not realize how tired I really was each morning.  It would take me over 20 minutes to finally, fully wake up and function. thank goodness for coffee…  I thought this was “normal.”  Life is so very different with oxygen, even if it’s from a machine.  I just didn’t know.

How does this impact brain health? This is important!

When the face and jaws are not big enough, then the cerebrospinal fluid flow within the brain is constricted.   This fluid flows for three seconds and then ceases for another three seconds.  It’s this fluid ebb and flow of the “glymphatic system” that at night cleans out the garbage in your brain, rather like a plumbing system.  When this fluid is constricted, toxic waste builds up -tau proteins and beta-amyloid plaques,  and neurodegenerative disorders (Alzheimer/dementia), stroke and brain injury can occur.  Definitely a big plumbing problem!  Or maybe an even better analogy is a garbage truck – and apnea is a driver on strike.

The bottom line– Intermittent hypoxia -inadequate oxygen – can cause brain damage.

Bad Breathing/Bad Body Health

In addition to this toxic waste buildup,  there’s a lack of oxygenation, and a restriction of hormone communication and nutrition to the whole body.  Human growth hormone is essential for muscle growth and repair.  This is released only after a body is in REM sleep.  Reaching REM sleep is the trigger for releasing human growth hormone (HGH).  We need HGH not only for children and teens to grow, but as adults to have the energy to do daily tasks.

Mouth breathing (snoring?!) creates arousals – momentary awakenings that you do not remember- that reduce or impede REM sleep, which we talked about above!  These constant arousals also reduce or prevent healing.   REM sleep is when you process memories, particularly short term memory.

Mouth breathing is really over-breathing.  The body exhales too much carbon dioxide (CO2).  CO2 is what allows oxygen into the body, so without the proper level of CO2 there is not enough oxygen in body.  Low CO2 causes Trouble with a capital T!

Low CO2 levels contribute to: smooth muscle spasms, angina, high blood pressure, irritable bowel syndrome, bronchospasms, musculoskeletal  aches and pains, bed wetting, and asthma.  CO2 constricts artery blood flow so contributes to migraines, poor concentration, stress and nerve degeneration.  Think erectile dysfunction, cold hands and feet, phobias, as well as ear ringing, and numbness of the hands and feet.  Less CO2 means less O2, thus connections to weight gain, atherosclerosis,  heart attacks, strokes, gastrointestinal problems, chest pain, and less oxygen to the brain which then means dizziness, irritability, obsessiveness, panic attacks, and brain fog.

Yikes.

Lack of oxygen stresses and strains the body, brain, and heart.  We talked about brain damage- what is does is decrease the white and gray matter in the brain, thus contributing to cognitive decline, memory loss and dementia.  No surprise but it’s also connected to depression.  Want more symptoms? How about: fatigue or drowsiness, puffy eyes or hand tremors, as well as more serious physical symptoms like clumsiness, trouble coordinating movements, morning headaches, obesity, and even seizures. Then there’s reduced sex drive, intimacy, and infertility, and insomnia!   Not breathing properly at night has many, many severe consequences.

Breathing properly might not cure you completely… or it might!?

More true confessions:

For years I looked for a treatment for my tinnitus.  I never even connected my sleep disordered breathing issues to my ringing ears!  Sad fact though, neither did my docs…

Sleep Disordered Breathing is NOT Just for Old People!!

Does your child have crooked teeth?  Does your baby snore?  Does your toddler chronically drool, or have a pacifier or thumb in their mouth?  Do they have a stuffy nose all the time? These are all signs of a poorly growing face.

No room at the inn –  or rather jaw for 2nd or 3rd molars!

Upwards of 22 million people in the USA have sleep apnea and do not know it.  Eighty five percent of Westerners have an underdeveloped face and jaw bones.  (Me included, but working on changing that!)  Look at all the kids with braces.  It’s almost a right of passage in elementary school or middle school to have an orthodontist on speed dial.  Unfortunately, what that really means is the face is not developed properly, for one or multiple reasons.

As a result of this jaw underdevelopment, the teeth are crooked and there’s no room for third molars (you may know them as wisdom teeth).  Poor facial growth contributes to poor physical health.  When our airway is constricted, it reduces oxygen to all our cells, causing cellular dysfunction.  It affects the way we sleep, our daily performance, our IQ, and our behavior, not to mention our systemic health and well being.  Five hours of intermittent hypoxia causes brain damage, killing Purkinje cells which are responsible for motor coordination.  I know I mentioned this above, but it was so important, had to say it again.  Our children need well developed jaws.

Beauty and the Breath

With all these underdeveloped faces, it’s no surprise there is such a high prevalence of sleep breathing problems.  (I wonder what percentage these issues will rise in the coming years.)

There is a connection between beauty and health and it’s not just about straight teeth.  A healthy face

Crowded teeth, small airway

has a well developed facial structure.  High cheekbones, fuller lips, and a well defined jawline.  These are all signs of fuller, more forward facial growth, and they correspond to a well developed open airway!  It starts in infancy.  Read my post on growing healthy, good looking children. 

The younger we can correct, the better!  There are many ways dentists can widen and help grow proper jaws in children.  In our office we use something called a “Myobrace.”  Braces without the metal and wires.

Signs You Might be Breathing Incorrectly!

Do you or someone you love:

• Mouth breathe
• Sigh
• Sniffle
• Yawn often
• Breath with upper chest
• Take gulps of air while talking
• Audible breathing while at rest
• Have chronic tooth decay
• Have chronic gum disease
• Have bad breath
• TMJ dysfunction
• Dry Lips

All of the above are signs of mouth breathing, incorrect tongue rest posture and possible forward head posture.  There are many more signs.  Click here for more information on what to look for clinically.  Open mouth posture results in poor lip and tongue tone.  An un-

toned tongue results in a tongue that’ll fall back in the airway and -oh no- block that airway during sleep!  Untoned lips means floppy, droopy lip posture – not sexy.  Patients always tell me they never breathe through their mouth.  I know better (their dry lips give them away) but here’s your test.  Place a business card between your lips and go about your day.  See how long you can hold that card between your lips.  When it falls out, you are mouth breathing.

Open that Airway, and Breathe Lady A

Back to Lady A.  What should she do and in what order?

#1. Sleep study!   Before anything else, getting a diagnosis of sleep disordered breathing is important.  While our office is not beholden to insurance companies, we do our best for patients to maximize their benefits to the best of our abilities.  We need a diagnosis from a medical professional, then we can proceed.  Before we can start any type of dental therapy to widen her jaws, she needs oxygen immediately.   A machine called a c-pap (Continuous positive air pressure) will aid her in breathing by forcing oxygen and keeping her throat open.  It’s important we work with a sleep medicine doctor.  This is a collaborative venture.  We work with many different doctors, body workers, therapists and  breathing specialists.  Everyone brings wonderful tools to the table.  Getting Lady A to breathe and heal will go a long way to prevent a stroke or heart attack.

#2. Lady A  is in need of a new joint and will be undergoing a joint replacement surgery as soon as the pieces fall into place for her.  The anesthesiologist will need to know Lady A  has an airway issue in order to keep her safe during her surgery.  Breathing better will help speed healing.  Always tell your docs if you have or suspect you have night time breathing problems.

#3. Lady A’s small, underdeveloped mouth needs to be made bigger so there’s room for

Widen the jaws, create more room and breathe

her tongue on the roof of her mouth.  Our office uses a custom made appliance called the DNA to widen the jaws and grow bone.  This may be controversial but it shouldn’t be.  It can indeed be done, even for adults.  The palate can make new bone along the palatine sutures, and expand the mouth in three ways.   Forward, and then right and left.  We start with the upper jaw and if needed, can make another appliance for the lower jaw and grow it too.    In addition to the DNA appliance, there are many others such as the ALF, the Bioblock, and for children, there’s Myobrace.

#4.  Orofacial Myofunctional Therapy is the most unknown therapy but is vital to optimal health.  True health starts with good oxygen flow!  If you doubt me, see Bad Breathing  above!  Everyone with a sleep breathing issue would greatly benefit from a course in myofunctional therapy, even if they do nothing else to treat their breathing problems.  It improves OSA by 50% in adults and 62% in children.

Myo teaches the tongue where to go, works on lip seal, nasal breathing, and proper chewing and swallowing.  Lady A has a lazy tongue and poor lip posture.   Working with her to strengthen her entire oral musculature is important to total success in restoring her airway.   Therapy lasts for around a year.  Yes, that’s a long time, however, it takes that long to undo bad habits, create good swallowing patterns/nasal breathing/proper tongue rest posture and chewing food thoroughly.  You might not think it would take that long but to avoid relapse and failure, we need to get the tongue strong and in the right spot.  Athletes know it as muscle memory.

The “proper oral rest posture” is the tongue up on the roof of the mouth, teeth slightly apart, and lips resting together.  The tip of the tongue is then placed on what’s called the “N” spot- say the letter “N” and that’s the correct place for the tongue tip.  This spot is the end of the trigeminal nerve.  Rubbing this spot releases dopamine and serotonin.

Tongue up and strong means no sleep disordered breathing, which I’m working hard to achieve myself!

#5. Un-tether the tongue.  The tissue under Lady A’s tongue is short and tight.  This little, thin, tethered tissue is the root of many of her dental issues.  It kept her tongue down and

locked on the floor of her mouth, and restricted her jaw development.   A procedure called a frenectomy or frenotomy goes under the tongue and releases the fibers that anchor the tongue down.

I perused  the web to see what’s out there on adults and frenum release, not much.  Most of the research and posts center on infants and tongue ties.  Adults benefit every bit as much!  If your tongue is anchored to the floor of your mouth, you stand a huge chance of succumbing to sleep disordered breathing as well as many other complications such as digestion issues or a dowager’s hump.

This blog, written by a physiotherapist reviews all the very many health connections a tight frenum causes.  Worth reading if you have any head, joint,  neck or back pains.  He goes into much more detail and has great visuals too!

Lady A’s therapy plan consists of four phases-  sleep study, myofunctional therapy, palate widening and frenectomy.  Besides the above plan, she may also need physical therapy, cranial sacral therapy and perhaps a visit to an Ear Nose and Throat doc or allergist as well.  She needs a team to unravel what’s taken years and years to build and create.

Lady A has much work to do to get healthy but at least we have options and a great plan.   Oxygen is vital to health.   This wonderful lady will feel so much better.  Little did she know her body was on fire and teetering near death every night.  Let’s put out that fire and light up her life! Breathe well and freely.

Til Next Time,

Breathe like your life depends on it!

Barbara