Hygienists: First Responders for the Airway by Julia Worrall, RN

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Hygienists: First Responders for the Airway

by Julia Worrall, RN

At least 50% of patients in any health care practice are living with airway-centered disorders (ACD)1, that affect health, learning, performance and quality of life. Unfortunately ACD is often overlooked and not recognized. The dental hygienist is uniquely positioned, and with proper training, qualified to raise awareness, screen for and recognize this hidden problem.

Our brain is a complex machine of synapses and connections, working in unison with the rest of the body to keep everything running smoothly. But when a cog in this machine isn’t oiled properly, or neglected, negative effects can occur and spread throughout the rest of the body.

One of the best ways to keep the body “oiled” is through full, deep breathing. When our breathing is shallow, it affects our waking and sleeping hours and all physical aspects of our lives. As a member of the dental team, you have probably witnessed firsthand what a lack of oxygen and proper sleep can do. But did you know that there is a physical condition that is often overlooked when people are suffering? First coined by Dr. Howard Hindin, executive director of the Foundation for Airway Health, ACD is caused by abnormalities in the physical condition—that space through which oxygen passes in and out of our lungs. ACDs are structural and physiological conditions of the mouth, jaw, nasal passages, tongue, or throat that obstruct the upper airways, affecting your breathing throughout the day2 and, potentially, leading to sleep disordered breathing.

Why must you champion the recognition, diagnosis, and treatment of these ailments? Because unrecognized airway-centered disorders have been extensively documented as a significant contributor to almost every chronic health issue. The list includes excess weight, headaches, chronic pain, behavioral issues, allergies, blood pressure, asthma, cardiovascular disease, dementia and more. The lack of oxygen and poor sleep impacts other developmental, educational and performance problems. No age group is immune: the younger generation is actually more susceptible to the effects of poor airway health since their brains and bodies are still developing. In cardiopulmonary resuscitation, the first step is to establish an airway. If that is a crucial step in such a life-saving exercise, it stands to reason that it would be vital in daily life and function as well.

How does the airway become obstructed?

Flow physics and airway physiology have shown us that there are three main airway obstruction causes.3 First, if the airway is abnormally small, it can restrict airflow. However, helping the jaws grow forward, not just wider, is the bigger picture. As Dr. Barry Raphael said, “Altering these habits can begin to heal the dystrophy.” Processes that encourage forward growth have been finding measures of success in reducing sleep-disordered breathing.4 By widening the airway spaces, we assist our patients in breathing more deeply.

Second, if the airway walls cannot stand the turbulence from airflow, the surrounding tissue collapses. Some common contributors are lymphoid swelling, poor airway muscle tone and inflammation of pharyngeal tissue.5 If the smooth muscles of the diaphragm and upper airway are weak, sleep apnea can worsen in a negative feedback loop.7

Third, the airway can become obstructed due to changes of air pressure within the pharynx and thoracic cavity. Dr. Peter Litchfield noted that it’s not always the nighttime breathing that creates the biggest problem here, but daytime breathing habits that set people up for airway collapse at night.6 In fact, the relationship between daytime breathing habits and nighttime distress is so strong, the syndrome should be called “breathing disordered sleep” rather than the common “sleep-disordered breathing.”4

One of the most prevalent disorders is obstructive sleep apnea (OSA). Obstructive sleep apnea means your tongue periodically blocks your airway during the night. While you are sleeping, every breath moves your tongue slightly forward from your airway. However, poor oral posture and abnormal jaw structure means that the tongue is less able to move out of the airway. This disruption results in OSA.5

OSA can cause systemic inflammation, which damages tissue, brings oxidative stress and increases atrial fibrillation. According to dentist and author Carol Vander Stoep, it is also almost a guarantee that you will have high blood pressure. Patients find themselves fatigued and have difficulty concentrating and remembering information because the brain is starving for oxygen. Particularly affected by oxygen deprivation is the cerebellum, which is in charge of precise speech, attention, equilibrium, and motor learning.5

OSA also affects levels of B vitamins, such as B1, known as thiamine, and B12. Since thiamine ferries carbohydrates like breads and sugars into cells, OSA sufferers’ cells are less able to accept sugars from simple carbohydrates².

What can your dental team do?

  1. Assess nasal patency. Ask your patient to seal their lips and inhale through the nose. Do their nares remain open? Are they able to take a complete inhale and exhale through their nose, without any distress?
  2. Assess oral airway. What is the patient’s Mallampati score? What do their tonsils look like? Their uvula? Is the tongue scalloped? What is its resting position? How much free space exists in the oropharynx area for air to flow?
  3. Assess dentition. Is there evidence of bruxing such as attrition, abfractions or mandibular tori? Is there evidence of mouth breathing such as caries?

Neither dentists nor hygienists can diagnose sleep apnea and so the dental office may not seem like the first step for addressing a sleep disorder. But, dentists and hygienists are on the front lines of recognizing and helping those with airway disruptions. Narrow dental arches, tongue thrust, crowded teeth and recessive lower jaw are all possible indicators of airway-related problems.

The dental team can assess and prevent airway obstructions and disorders before they become crippling. These practitioners have a unique pathway with patients to help guide facial growth and even start proactive treatments such as orofacial myofunctional therapy. Effective education in the office can encourage patients in their endeavors to sustain healthy habits in breathing, sleeping and eating. These therapies yield results lasting well beyond the next dental checkup!

Alternatively, you can create a network of providers in your community for these patient referrals.. Knowledge is power. Arm your patients with the knowledge they need to ask the right questions, find the right provider and make informed decisions about their health and their family’s wellbeing. There is no greater reward than that feeling you get when you successfully intervene and save a life. You can start saving lives today!

1. https://www.who.int/gard/publications/The_Global_Impact_of_Respiratory_Disease.pdf
2. Bordoni, B., Purgol, S., Bizzarri, A., Modica, M., & Morabito, B. (2018). The Influence of Breathing on the Central Nervous System. Cureus, 10(6), e2724. doi:10.7759/cureus.2724
3. Chandra, RK. Diagnosis of Nasal Airway Obstruction. Otolaryngol Clin N Am,2009, 42, 207–225.
4. Raphael BD. Preventive Sleep Dentistry [Internet]. Dental Sleep Practice. 2014 [cited 2019Apr10]. Available from: https://dentalsleeppractice.com/the-bigger-picture/preventive-sleep-dentistry/
5. Vander Stoep C. Fragmented Sleep and Brain Death [Internet]. Primal Dentistry. 2015 [cited 2019Apr10]. Available from: https://primaldentistry.org/2015/03/fragmented-sleep-and-brain-death/
6. Litchfield, P. Respiratory Fitness and Acid-Base Regulation. Psychophysiology Today. 2010, 7:1, 6-12.
7. Macey P, Kumar R, Woo M, et al. Brain Structural Changes in Obstructive Sleep Apnea. Sleep. 2008 Jul 1; 31(7): 967-977.

Author Bio
Hygienists: First Responders for the Airway Julia Worrall, RN is the program director of the Foundation for Airway Health Airway Advocate Program. The foundation was created to help the public realize their maximum potential by championing the recognition, diagnosis and treatment of airway-related disorders. The foundation’s 15-50-20 campaign is dedicated to increase public awareness of airway issues from its current level of 15 percent to 50 percent national recognition and treatment of airway disorders by 2020. Worrall is a published author and member of many professional bodies. She lectures internationally and is an expert in applying sleep and craniofacial assessments in a nursing environment. Information: airwayhealth.org.


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