Airway Support by Shirley Gutkowski, RDH, BSDH

The full-mouth-series of X-rays on the screen was of a person at least 60 years old, but the health history says she’s 27 years old. Who, at under 60, has three root canals and a flawless dental appointment history?

Nowadays it seems like everyone is getting on the oral-systemic link (OSL) bandwagon. By now, most dental practitioners are aware of the strong connection between periodontal disease and cardiovascular disease. The “Floss or Die” charge is on the tip of nearly every dental hygienist’s tongue. However, when practitioners look a little more posteriorly, they’ll suddenly become aware of the airway. Turns out the throat and airway are bigger players in the oral-systemic link than once assumed.

The knee-jerk reaction to airway problems usually revolves around snoring, however, it is just one symptom of an airway problem. Practices have cropped up focusing on snoring, branding themselves as “sleep practices.” They provide their patients with appliances that move the jaw to a position favoring the airway. The gold standard treatment for sleep apnea, sometimes confused with snoring, is not a very good option.

We all know people who hate continuous positive airway pressure (CPAP) machines. The CPAP blows air into the sinus with a force great enough to hold the soft palate and tongue away from the airway. Many are saved from this medical device by wearing a dental appliance, which studies show is as effective as the CPAP in nearly all instances. Both are a pill, a prescription that fixes a symptom.

When you look at sleep deprivation or sleep apnea and inflammation you’ll see the list of conditions are nearly identical. Many studies have shown the increase in inflammation from snoring in all age groups. While the housemate is not getting good sleep, neither is the one snoring. But the snorer has an increased inflammatory load that is likely more problematic than just sleep deprivation, exposing the snorer to greater risks for cardiovascular disease, diabetes and more.^1–4

Dr. Christian Guilleminault, a pediatric sleep apnea researcher, found that obstructive sleep apnea in nonobese children is a disorder of orofacial growth.⁵ Dental practices who appreciate this distinction are branded as airway practices.

Structures of a growing problem
Darwinian dentist Dr. Kevin Boyd explains current airway problems with studies of primal man and how large primitive people’s airways were. He points out that our food’s industrialization can be directly linked to evolutionary changes in the last century that would have normally taken more than 10,000 years. These epigenetic changes shrank the face. The midface is smaller, leaving little room for the sinuses, causing some people to breathe with their mouth open all the time, not just at night. Nasal volume in mouth breathers is smaller than those who are nasal breathers. No one says which came first, the smaller sinuses or mouth breathing. Mouth breathing also contributes to malocclusions that manifest in dentoskeletal and functional alterations. Surprisingly, mouth breathing contributes to increased or reduced overjet, anterior or posterior crossbite, and open bite.^{6, 7}

Today, fetal ultrasounds show pediatric sleep physicians not only a smaller midface, but an increasingly smaller mandible. Both are signatures of sleep apnea. Mouth breathing also leads to a host of conditions outside of dentistry. Studies of more than 3,000 children have found that those who breathe with their mouths open or snore have increased incidences of ADHD, behavioral problems at school and home, and learning disabilities. The most important concern is a stall in executive function development.⁸

No one can argue against the body’s need for air and this is where orofacial myofunctional therapy (OMT) comes to the rescue. Working with clients on the muscles in the snoring complex (nose, mouth, tongue, and back of the throat) can help with airway problems. A recent meta-analysis on OMT and sleep apnea in children and adults shows a 62 percent reduction in the apnea hypopnea index in children. A 50 percent reduction was seen in adults.⁹ Other studies show improvement in CPAP wear in those practicing OMT techniques.¹⁰ Practitioners can also identify and treat habits that accumulate in people who have airway obstructions. Some children are fine during the day but mouth breathe while sleeping because of a pet allergy. This habit then occurs in the daytime. Some exhibit allergy symptoms and cannot breathe through their nose at all. If a patient cannot breathe through their nose for 20 or more respiration cycles, an OMT referral is in order.

OMT takes longer than a minute. Clients must practice muscle movement techniques to build strength and neuromuscular pathways are altered. In the meantime, mouth breathing decreases oral pH and dries the tissue. The teeth are at a very high risk for breakdown. What to do? Two main office-adjuncts come to mind. To protect the teeth, we have fluoride and remineralization pastes. Both help treat airway conditions and work in harmony with other treatments. Fluoride varnishes lose value in a continuous low pH environment, but are the cornerstone of preventive treatments. The American Dental Association says, “fluoride varnish is effective in preventing caries in both primary and permanent dentition of children and adolescents.”¹¹ As of January 2007, fluoride varnish has its own code. Patti DiGangi, author of the DentalCodeology series, says “that an application of fluoride varnish at any age should be coded as D1206. There is no need for dual codes.”

Fluoride varnishes take less time to apply and achieve greater patient acceptance, especially in preschool-aged children. Too often adult patients opt out of fluoride varnish because of the flavor and how it feels on the teeth. For some clinicians, the flavor is the varnish’s least important feature. For patients, it’s the most important feature. A smooth application and great flavor improves patients opting for an application. Applying it to the occlusal surfaces, and tickling it in between molars is the highest priority, as those two areas are the highest risk for demineralization. While the labial of the anterior incisors may be at low risk for nasal breathers, they are at moderate risk for decay in people with airway problems. Of particular concern is a child with a low labial frenum attachment.

For some, there may be confusion about how much fluoride to apply. For small children with only primary dentition, a one-dip rule should apply. When applying varnish, incorporate any material that may be on the unit-dose package and mix and stir with the supplied brush. Then, load the brush once for three-year-old children. Using too much risks fluoride toxicity or clogged suction lines. All the applied fluoride should stick to the teeth. If the lines are clogging, the clinician is applying too much of the varnish.

A nanohydroxyapatite (NHAP) enamel remineralization cream can also be used. The cream can be used at the office after a fluoride varnish application, or applied to the teeth at night before inserting the mandibular advancement device. The cream will battle against the demineralization cycle giving teeth a fighting chance during treatments with dental sleep appliances or CPAP devices.

Looking ahead
Catching airway problems early is in the dental hygienist’s purview. Dental hygienists start their education learning that they are the prevention specialists in the dental office. Identifying airway problems to improve enamel and periodontal health is just the tip of the iceberg. A new way to look at the soft tissue during an oral cancer exam can make all the difference in a patient’s life. No one under 30 with a good dental history should present like a pre-fluoride elder with extreme damage to the teeth. While they’re in airway treatment, make sure the hygiene care is ramped up by providing remineralization options and a fluoride varnish treatment.

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  Figure 1: NORMAL

  During normal sleep, the muscles that control the tongue and soft palate hold the airway open.

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  Figure 2: SNORING

  When these muscles relax, the airway narrows. This can lead to breathing difficulties and snoring.

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  Figure 3: OSA

  If the muscles relax too much, the airway can collapse and become blocked, causing an obstruction.

References

1. Kelly A, Dougherty S, Cucchiara A, Marcus CL, Brooks LJ. Catecholamines, adiponectin, and insulin resistance as measured by HOMA in children with obstructive sleep apnea. Sleep. 2010 Sep;33(9):1185-91.
2. Bhushan B, Ayub B, Loghmanee DA, Billings KR. Metabolic alterations in adolescents with obstructive sleep apnea. Int J Pediatr Otorhinolaryngol. 2015 Dec;79(12):2368-73.
3. Shamsuzzaman A, Szczesniak RD, Fenchel MC, Amin RS. Glucose, insulin, and insulin resistance in normal-weight, overweight and obese children with obstructive sleep apnea. Obes Res Clin Pract. 2014 Nov-Dec;8(6):e584-91.
4. Thunström E, Glantz H, Fu M, Yucel-Lindberg T, Petzold M, Lindberg K, Peker Y. Increased inflammatory activity in nonobese patients with coronary artery disease and obstructive sleep apnea. Sleep. 2015 Mar 1;38(3):463-71.
5. Huang YS, Guilleminault C. Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. Front Neurol. 2013 Jan 22;3:184.
6. Grippaudo C, Paolantonio EG, Antonini G, Saulle R, La Torre G, Deli R.Association between oral habits, mouth breathing and malocclusion. Acta Otorhinolaryngol Ital. 2016 Oct;36(5):386-394.
7. Koutsourelakis I, Vagiakis E, Roussos C, Zakynthinos S. Obstructive sleep apnoea and oral breathing in patients free of nasal obstruction. Eur Respir J. 2006 Dec;28(6):1222-8.
8. Bonuck K, Freeman K, Chervin RD, Xu L. Sleep-disordered breathing in a population-based cohort: behavioral outcomes at 4 and 7 years. Pediatrics. 2012 Apr;129(4):e857-65.
9. Camacho M, Certal V, Abdullatif J, Zaghi S, Ruoff CM, Capasso R, Kushida CA. Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Sleep. 2015 May 1;38(5):669-75.
10. Diaféria G, Santos-Silva R, Truksinas E, Haddad FLM, Santos R, Bommarito S, Gregório LC, Tufik S, Bittencourt L. Myofunctional therapy improves adherence to continuous positive airway pressure treatment. Sleep Breath. 2017 May;21(2):387-395.
11. Professionally applied topical fluoride Evidence-based clinical recommendations http:/jada.ada.org/article/S0002-8177(14)64961-8/pdf Accessed June 29, 2017

Shirley Gutkowski, RDH, BSDH, is a career dental hygienist and the recipient of the World Congress of Minimally Invasive Dentistry Leadership award. Gutkowski is an author, speaker, Cross Link Radio host and CAREERfusion skills development coach. Her book series, The Purple Guide, is growing, while her new book, The New Dental Plate, is in development. She recently opened an orofacial myofunctional practice in Sun Prairie, Wisconsin, where she lives with her husband, Mark.
Contact: primalairomt@gmail.com.